A 26‐year‐old man presented with 1‐month history of abscesses on his neck. He reported recurrent abscesses for 6 years, on his scalp and posterior neck. The lesions periodically enlarged and partially regressed, emitting a purulent discharge. The first episode required hospitalization and surgical drainage. On examination he had numerous fluid‐filled sinus tracts on his scalp, from the vertex to the bilateral parietal areas, occiput and posterior neck. Seropurulent fluid oozed from the areas. Extensive alopecia was present with scarring between sinus tracts. Repeated cultures of the discharge were sterile. The patient was not immurtocompromised.AmultilocJjIated fluid collection in the posterior soft tissues of the neck was revealed on CT, as was extracranial soft tissue swelling in the right posterior occipital region, with enhancement of the soft tissues. Fibrinopurulent exudate was revealed on cytology. Acute xanthogranulomatous inflammation with adjacent chronic inflammation and fibrosis was revealed on scalp biopsy. Special stains of the biopsy specimens for fungus and microorganisms were negative.
Dermatologic disorders are frequently encountered by hospitalists. Most cases of apparent abscess are responsive to antibiotics, but the hospitalist should be able to identify the differential diagnosis of abscesses unresponsive to antibiotics. These should be distinguishable from entities like necrotizing fasciitis by negative cultures and the lack of systemic symptoms. The prompt recognition and treatment of dissecting cellulitis are imperative to halt progression of the disease and prevent disfigurement. Dissecting cellulitis is a subtype of cicatricial alopecia. These scarring alopecias involve destruction of hair follicles, replacement by scar tissue, and hair loss. Scarring occurs subcutaneously, but significant disfigurement can occur. These disorders are distinguished by clinical characteristics and by the type of inflammatory cell involved in active destruction of the follicles. Dissecting cellulitis is characterized by neutrophilic infiltrates; there may be conversion to a lymphocytic predominance. The disorders are thought to be secondary to cellular infiltration of follicles, with subsequent dilatation and destruction. Fluid‐filled, communicating sinus tracts develop in dissecting cellulites Isotretinoin is the treatment of choice for dissecting cellulitis. Other treatments are modified external beam radiation, intralesional corticosteroids, and laser ablation. Disorders of neutrophilic predominance can be treated with antibiotics for associated bacterial infections. Surgical excision of affected areas with skin grafting may be appropriate in severe or poorly‐responsive cases.
The differential diagnosis of dissecting cellulitis includes acne keioidalis nuchae, pseudopelade, and folliculitis decalvans, all subtypes of cicatricial alopecia. As with our patient, it may be misdiagnosed as recurrent infectious abscesses
E. Brant, none.
To cite this abstract:Brant E. Disfigurement Is More Than Skin Deep. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 222. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/disfigurement-is-more-than-skin-deep/. Accessed May 23, 2019.