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October 16, 2018

Dissecting Cellulitis

SOCAH Center

Dissecting cellulitis (DC) also known as Perifolliculitis Capitis Abscedens et Suffodiens is an inflammatory scalp condition that can lead to scarring alopecia. DC primarily affects males that are between the ages of 20 to 40 years old and most commonly African Americans followed by Hispanics, then Caucasians. DC typically begins as a painful inflamed follicle (Acne-like bumps) involving the crown of the scalp or posterior neck that progresses into multiple boils. These boils can connect under the skin to form sinus tracts or canals which drain pus and/or blood.

At full development, the scalp will feel soft and boggy and pressing on one lesion may express puss at a distant lesion. The pressure of the fluid under the skin can crush overlying hair follicles destroying them and causing permanent hair loss. In studies, cultures were taken from numerous patients and found that the cause of DC was not due to a bacterial infection. However, because DC can lead to open sinus tracts and breaks in the skin the area is susceptible to develop a bacterial infection.

DC is diagnosed by exam and sometimes requires a scalp biopsy. When assessing for dissecting cellulitis, other systemic conditions must be ruled out that act similarly such as acne conglobata (bad cystic acne) or hidradenitis suppurativa (recurrent inflammatory boils). These conditions can all simultaneously occur due to hair follicles becoming blocked and causing an overactive inflammatory response. In addition, other scarring hair loss diagnoses must be ruled out, such as pseudopelade of Brocq, tinea capitis (scalp fungus or ringworm), or folliculitis decalvans (future article coming).

Medical treatment is aimed at stopping the inflammatory process. Interestingly, the condition requires follicles to continue. Oral antibiotics can be used to treat secondary infections but are also used for their anti-inflammatory effects. Steroid injections work similarly to reduce inflammation locally when injected into the scalp. Combination regimens can be administered for severe cases. When treated with laser hair removal or surgery the lesions improve if not completely resolve. I emphasize the importance of healing chronic open wounds because they can increase the risk of developing a skin cancer in the affected area.

DC is a condition of blocked follicles which lead to increased inflammatory response. There is no evidence that it was started by dirty clippers or a bad hair cut. While I tell patients they can still get their hair cut, I emphasize that caution should be taken to reduce the amount of trauma and irritation to the scalp. Without treatment, DC can wax and wane over a course of months to years and can cause the patient significant pain and psychological distress. Early treatment can prevent progression and more importantly prevent permanent alopecia and the formation of scar tissue over the scalp.

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October 16, 2018