Disorders of the face and scalp

Acneiform eruptions

• Includes acne vulgaris, pyoderma faciale, dissecting cellulitis of the scalp and acne keloidalis nuchae
• Androgen stimulation sebum production with keratin and sebum accumulation in hair follicle, host inflammation and proliferation of Proprionibacterium acnes with intensified inflammation
• Acne fulminans
  • Mostly males aged 13-16 with acute onset of suppurative cysts and nodules with ulcerations and haemorrhagic crusting. Foremost facial.
  • Often on chest/back as well
  • Can suffer osteolytic bone lesions of clavicle and sternum, fever, arthralgias, myalgias and hepatosplenomegaly
  • Acute treatment is oral prednisolone 1mg/kg OD and isotretinoin

• Pyoderma faciale (rosacea fulminans)
  • Inflammatory cystic acneiform eruption on central face of young women
  • Treat the same
• Dissecting cellulitis of the scalp (perifolliculitis capitis abscedens et suffodiens)
  • Mostly young men of African descent with boggy tender nodules in scalp and neck
  • Nodules suppurate and develop sinus tracts
  • Hair loss occurs over site
  • Rx – Antibacterial washes and isotretinoin via dermatologist

• Dissecting cellulitis of scalp
  • Not a true cellulitis 

• Acne keloidalis nuchae
  • Perifollicular papules and pustules in neck region
  • Individual keloid papules coalesce to form keloidal plaques with scarring alopecia
  • Topical clindamycin, topical steroids and oral doxycycline are all effective +- isotretinoin
  • Refer to dermatologist 

Seborrhoeic dermatitis

• Infantile form = cradle cap
• Adults with AIDS and Parkinsons are predisposed to adult form
• Common dandruff is a mild form
• The yeast Malassezia furfur (Pityrosporum ovale) may play a role
• Clinical
  • Mild pruritis, dandruff, can extend onto chest/axillae, symmetric eyebrow/nasolabial folds and retroauricular areas
• Treatment
  • Antidandruff shampoo containing zinc pyrithione, selenium sulfide 2.5%, salicylic acid or tar
  • Ketoconazole shampoo 1% is available
  • Topical corticosteroid to skin and scalp in severe cases (hydrocortisone 1% max)

Tinea capitis

• Dermatophyte infection of scalp, mostly in children
• Trichophyton genus
• Patchy, non-scarring alopecia with broken off hairs and scale at periphery
• Occasionally get boggy, tender, indurated plaque with superficial pustules and inflammation = kerion
  • May lead to permanent scarring and alopecia
• Can suffer id reaction with treatment commencement at distant sites with widespread, symmetric, monomorphic eczematous papules
• Treatment
  • Oral griseofulvin

Tinea barbae

• Dermatophyte infection of beard due to Trichophyton
• Predisposing factors include contact with infected pets, topical steroid use and DM
• Sycosis barbae is deep folliculitis of beard area due to S. aureus
  • Hairs not broken off or loose (unlike tinea barbae)
• Treatment
  • Tinea barbae – Oral griseofulvin
  • Sycosis barbae – warm compresses, mupirocin ointment or systemic antibiotics to cover S. aureus

Head lice (pediculosis capitis)

• Usually children 3-11yo but can occur at any age
• Due to Pediculus capitis louse (2-3mm in size)
• Limited to scalp, behind ears and back of neck
• Intense pruritis is a feature
• Treatment
  • Permethrin cream 1% or 5% applied to hair, left overnight, washed out and repeated in 1 week

Allergic contact dermatitis

• Two types are common:
  • Aerosolised allergen
    • Burning of poison ivy/oak
  • Direct physical contact
    • Toothpastes, nickel, nail polish, preservatives in makeup, contact lens solution, eye glasses, hair care products
• Clinical features
  • If aerosolised – Diffuse, upper and lower eyelids
  • If direct contact – Eyelids and sensitive skin areas
• Treatment
  • Must identify and remove offending agent
  • Topical or oral steroids + oral antihistamines are helpful
  • 3-5 days of medium to high potency topical steroids are safe on the face

Sunburn and photosensitivity

• Photosensitivity occurs in SLE, dermatomyositis, porphyria cutanea tarda, pellagra and HSV
• Exogenous photosensitivity arises from topical application or ingestion of an agent
  • Phototoxic – Occur quickly like sunburn
    • Chlorpromazine, frusemide, tetracyclines, thiazides, coal tar, amiodarone, isotretinoin, fluoroquinolones
  • Photoallergic – Occur later with eczema-like changes with vesiculation
    • NSAID’s, griseofulvin, sulfonamides, sunscreen, promethazine, sulfonylureas, fragrances, dapsone
• Typically spares the upper eyelids, upper lip, submental anterior neck and posterior auricular neck + clothed areas

Last Updated on October 13, 2021 by Andrew Crofton