A Case for diagnosis

presented by

Dr. Hamish Dunwoodie  FRCP (C)

Moncton,  New Brunswick

February 11, 2009


Abstract 30 yo man with scalp cellulitis, plaques on legs and biochemical abnormailities
30 yo man
2 years
scalp, legs

This 30 year old mental health counselor has been seen in our dermatology clinic for a number of problems over the past two years. Initially, he had a mild folliculitis of back and shoulders. This progressed to an inflammatory cystic process on the scalp and bearded area. Here is the patient's anamnesis:

July '06 Mono like illness-- severe fatigue, prolonged diarrhea (lost 30 pounds), upper abdominal pain, swollen neck lymph nodes, fever, folliculitis breakouts on face and back.

Jan '07 glazing crust on back of scalp, crunchy, crusty, and full of pus/blood, Oral thrush (no confirmatory tests were done), repeat of joint pain, cont mild fever

Mar '07, Back of scalp cleared up, clinical diagnosis of tinea by primary care physician (no tests)

May '07 Diagnosed with dissecting cellulitis of the scalp.

Dec '08 Painful erythematous plaques on lower legs

Dec'08 Dx chronic low grade pancreatitis based on scans and lab tests.

The patient has been seen by GPs, internists, dermatologists, gastoenterologists, psychiatrists and is awaiting a consult with a “pancreatologist” at a renown tertiary care centre.

Physical Examination

Patient is chronically depressed and sad-looking.

Scalp: covered with cysts and sinus tracts. Hairs not easily pulled. Areas of alopecia where inflammation is marked. Similar inflammatory lesions on face.

Scattered indurated plaques on both lower legs. These come and go over a period of weeks and measure 3 – 6 cm in diameter.


Pictures taken from the scalp

Picture taken from the leg

Laboratory Data

Mostly normal with these exceptions:

ESR elevated at ~ 30 mm Hg (normal is up to 20)

Serum Insulin level: slightly elevated 32 mU/L (nl 3 – 28)

Serum lipase ~ 360 U/L on 3 occasions (nl 114 – 286)

Serum alpha 1 antitrypsin: normal

Addendum: The patient has had numerous tests for HIV over the past few years and all have been negative. ( Feb 11, 2009)


Biopsy taken from the leg

A sparse superficial and deep perivascular and interstitial inflammatory infiltrate of lymphocytes and neutrophiles with a focus of neutrophilic microabscesses in the deep reticular dermis.


Dissecting Cellulitis of Scalp, Atypical Kerion, atypical panniculitis.

Reasons Presented

Dissecting cellulitis of the scalp. Persistently elevated serum lipase and ESR. This patient is depressed and focuses on his pain and his illness. He is afraid he is going to die.


Diagnostic and therapeutic suggestions are welcomed.  Do you think the inflammatory process of the leg is related to the scalp inflammation?  How does persistently elevated serum lipase levels fit in?


cellulitis of the scalp, kerion, pancreatitis,

Comments from Faculty and Members

Lionel Bercovitch MD, Clinical Professor of Dermatology, Alpert Medical School, Brown University, Providence, RI, USA, on February 11, 2009

Was the biopsy sample adequate to rule out pancreatic fat necrosis? Is this clinically a panniculitis or is it thought to be a neutrophilic dermatosis?

Parveen Kumar MD, Assistant Prof, Dasmesh Institute of Research and Dental Sciences, Faridkot, India, on Febrauary 11, 2009

This case needs HIV test since it seems to be a case of HIV +ve case.

Bhushan Kumar MD, Consultant Dermatologist, Chandigarh, India on Feb 12, 2009

Dissecting cellulitis of the scalp is the only likely possibility. Kerion is least likely. Any chronic inflammation like the nodulocystic acne triad can have symptoms pertaining to bones and joints. Non specific plaques with neutrophilic infiltrate are also likely in chronic inflammation. A course of oral isotretinoin (40mg/day) combined with doxycycline (100mg/day) given over a period of 4 weeks will be a good therapeutic trial. If response is good then the treatment has to be continued for 4-6 months.

Richard Sontheimer MD, Professor, Dept. of Dermatology University of Oklahoma Health Sciences Center, Oklahama City,OK, USA on Feb 12, 2007

Presumably this pt was not treated with isotretinon (Accutane) for his dissecting cellulitis resulting in hypertriglyceridemia that caused pancreatitis and pancreatic panniculitis. If not, the cause of his pancreatitis should be further addressed and he should have a full thickness excisional biopsy of an area on the extremities displaying the subcutaneous inflammation to better address broad differential diagnosis of panniculitis.

Haitham Al-Qari MD, Assistant Prof, Arabian Gulf University, Bahrain on Feb 12, 2009

A case of Perifolliculitis capitis abscedens et suffodiens is a therapeutically challenging suppurative scalp disease of unknown etiology. I have good success with these options:

1. Oral isotretinoin (1.5 mg/kg/day (usually 1 mg/kg/d) PO) may be considered the treatment of choice.
2. Intralesional corticosteroids (eg, triamcinolone acetonide at 5 mg/mL) can be injected into boggy nodules and sinus tracts.
3. Oral zinc sulfate at 400 mg tid and 135 mg tid for 3 months can help too.

Nidal Obaidat M.D. Dermatologist/Dermatopathologist, King Hussein Medical Center, Jordan on Feb 12, 2009

I believe a few histology slides are needed to help reach a diagnosis, esp there is no comment about the subcutis. Also, I think imaging studies of the abdomen (pancreas) are due.

Fadi Hajjaj MD, Dermatology, UK on February 15, 2009

The diagnosis is Perifolliculitis capitis abscedens et suffodiens based on clinical picture. My own approach as follows:

1- Systemic antibiotics treatment (Minocycline 100mg once daily for 3-4 months)

2- regular Intralesional steroids for cystic lesions (i found it very effective and improves the patient quality of life).

3- Isotretinoin is worth trying as possible option , but i dont expect excellant results in Perifolliculitis capitis.

Nico Mousdicas MD, USA on March 3, 2009

This clinically is dissecting cellulitis of the scalp. I consider this condition similar to Pyoderma Fulminans a form of Rosacea. This comes on in patients very acutely due to severe stress.
I treat them with Rifampicin 300mg daily, Clindamycin 300mg bid for 1 to 3 months. I also prescribe Prednisone 40 mg daily for 2 weeks with no taper and re-assess them at this time. The condition literally melts away. I also look to try and find out what has caused the distress and treat appropriately with counselling and SSRI's

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