Peer Reviewed

What's Your Diagnosis?

Pustular Scab on an Elderly Woman's Head

Michelle L. Gallagher, DO
Casey Schukow, BS 
Meghan C. Grossmann, BSc, BS
Volume 63 - Issue 6 - June 2023

  • AFFILIATIONS:

    1Department of Pediatrics, Michigan State University College of Osteopathic Medicine

    2Michigan State University College of Osteopathic Medicine

    CITATION:

    Gallagher ML, Schukow C, Grossmann M. Pustular scab on an elderly woman’s head. Consultant. 2023;63(6):e4. doi:10.25270/con.2022.11.000003

    Received March 8, 2022. Accepted August 22, 2022. Published online November 16, 2022.

    DISCLOSURES:

    The authors report no relevant financial relationships.

    CORRESPONDENCE:

    Michelle L. Gallagher, DO, Michigan State University College of Osteopathic Medicine, 965 Wilson Road, East Lansing MI 48824 (docmlg@msu.edu)

    Abstract. An older adult presented to our clinic with chronic sun damage. She had history of several actinic keratoses, one of which was removed by electrodessication and curettage. This resulted in a plaque with pustular exudate and was diagnosed with erosive pustulosis of the scalp (EPDS). Our patient was treated with topical clobetasol. The patient was counseled on sun protection and the risks associated with chronic sun exposures.

    Key words: Dermatology, Erosive pustular dermatosis, Sun damage

     

    An 82-year-old woman presented to our clinic with a “pus-filled scab” on her scalp that had progressively enlarged over the past several weeks. The patient reported having a hypertrophic actinic keratosis around the scab that was removed by electrodessication and curettage about 1 month earlier. She reported a history of chronic sun exposure with inconsistent use of sun protective measures (eg, sunscreen) and actinic keratoses in other locations on her face and scalp treated with liquid nitrogen cryotherapy.

    Skin examination of her vertex scalp revealed a 1.6 cm by 1.3 cm ovoid plaque with pustular exudate and golden-brown crust on an erythematous base (Figure 1). Sparse hair around the plaque was seen. Approximately 2 inches anterior of the plaque was a scab from another hypertrophic actinic keratosis treated with electrodessication and curettage. No pus or erythema were noted within or around this scab.

    Figure 1

    Figure 1. An ovoid plaque with pustular exudate and golden-brown crust is seen on the patient’s vertex scalp.

    The patient described the plaque as mildly painful and itchy but denied any numbness, tingling, or constitutional symptoms (eg, fever, chills). Otherwise, she appeared well-nourished, alert, and oriented.

    What is the most likely diagnosis?

    1. Dissecting cellulitis
    2. Ecthyma
    3. Erosive pustular dermatosis
    4. Folliculitis decalvans
References
  1. Karanfilian KM, Wassef C. Erosive pustular dermatosis of the scalp: causes and treatments. Int J Dermatol. 2021;60(1):25-32. doi:10.1111/ijd.14955
  2. Wilk M, Zelger BG, Hauser U, Höpfl R, Zelger B. Erosive pustular dermatosis of the scalp: reappraisal of an underrecognized entity. J Dtsch Dermatol Ges. 2018;16(1):15-19. doi:10.1111/ddg.13387
  3. Burton JL. Case for diagnosis. Pustular dermatosis of scalp. Br J Dermatol. 1977;97 Suppl 15:67-69. doi:10.1111/j.1365-2133.1977.tb14339.x
  4. Pye RJ, Peachey RD, Burton JL. Erosive pustular dermatosis of the scalp. Br J Dermatol. 1979;100(5):559-566. doi:10.1111/j.1365-2133.1979.tb05581.x
  5. Piccolo V, Russo T, Bianco S, Ronchi A, Alfano R, Argenziano G. Erosive pustular dermatosis of the scalp: why do we miss it? Dermatology. 2019;235(5):390-395. doi:10.1159/000500909
  6. Robles DT. Erosive pustulosis of the scalp. Medscape. Published November 8, 2021. Accessed December 29, 2021. https://emedicine.medscape.com/article/1404360-overview
  7. Laffitte E, Kaya G, Piguet V, Saurat J. Erosive pustular dermatosis of the scalp: treatment with topical tacrolimus. Arch Dermatol. 2003;139(6):712-714. doi:10.1001/archderm.139.6.712
  8. Starace M, Iorizzo M, Trüeb RM, et al. Erosive pustular dermatosis of the scalp: a multicentre study. J Eur Acad Dermatol Venereol. 2020;34(6):1348-1354. doi:10.1111/jdv.16211
  9. Cuellar TA, Roh DS, Sampson CE. Dissecting cellulitis of the scalp: a review and case studies of surgical reconstruction. Plast Reconstr Surg Glob Open. 2020;8(8):e3015. doi:10.1097/GOX.0000000000003015
  10. Ecthyma. MedlinePlus. Updated May 2, 2021. Accessed January 5, 2022. https://medlineplus.gov/ency/article/000864.htm
  11. Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis decalvans. Dermatol Ther. 2008;21(4):238-244. doi:10.1111/j.1529-8019.2008.00204.x