Pemphigus Vulgaris of the Scalp 

presented by

Henry Foong MRCP (UK)

Ipoh, Malaysia

on December 31, 2000

History:
The patient, a 54-year-old Chinese man, presented with a 6-week history of a crusted patch on the right temporal area. It had started off as a "10 cent coin" lesion and gradually increased in size. It was not painful. He was otherwise well and had no constitutional symptoms. He denied keeping any pets at home. In 1997 he had pemphigus vulgaris and had since been stabilised on prednisolone 10mg daily. His other medications were glibenclamide for adult onset diabetes mellitus. He noted that his pemphigus started off as a patch at the same area of the scalp years ago before spreading to the trunk and extremities.

Examination:

There was a solitary superficial erosion 6 by 5 cm on the right temporal area. The surface appeared raw and crusted. The hairs within the lesion apparently were not affected. His regional nodes were not enlarged. No blisters or erosions were noted elsewhere.

Oral cavity and nails were normal. Hairs were sent for fungal culture. He was given an initial therapeutic trial of griseofulvin for 3 weeks but there were no improvement. A skin biopsy was done on the lesion.

Diagnosis:
Pemphigus vulgaris of the scalp

Some of the differentials would include tinea capitis and squamous cell carcinoma. Biopsy showed an intraepidermal blister with acantholysis. Though immunofluorescence studies were not done, this histological findings would be sufficient to make a diagnosis of pemphigus vulgaris.

Comments:

Victoria P Werth, M.D., Associate Professor of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

It is not unusual to see relapses of pemphigus. From the history and photo, that would be my first diagnosis. Since there are implications for therapy, I would repeat a biopsy and meanwhile treat with intralesional kenalog and intermittent pulse topical steroids (2 days a week). If new lesions develop or this one doesn't heal, then I would consider increasing prednisone. You should treat with calcium and bisphosphonates (consider getting DEXA scan) for bone prophylaxis.

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