Case study: Managing erosive pustular dermatosis of the scalp

An 85-year-old man who was wheelchair mobile was referred to the two-week wait skin cancer clinic with a three-month history of multiple scabs on his head. On examination, he had a dozen dry scabs up to 2cm in diameter on a bald, sun-damaged scalp.

This florid case resolved with the use of a very potent steroid (Dr Brian Malcolm)
This florid case resolved with the use of a very potent steroid (Dr Brian Malcolm)

They were removed in clinic with minimal discomfort and no tumours were discovered underneath them. The carer was advised to debride regularly and apply potent topical steroid to the inflamed skin, stopping once the visible redness had gone. The importance of preventing recurrence by preventing build-up of fibrin by careful scalp care was stressed. At review a month later the patient's scalp was completely better.

Erosive pustular dermatosis of the scalp apparently results from a combination of elderly sun-damaged skin and minor trauma, leading to erosion of the epidermis with inflammation and oozing of serum and pus.

It is typically seen in frail elderly white people with sun-damaged skin and in very elderly patients who are unable to self-care.

A clear history may not be available from the patient, as a result of memory loss.

A minor traumatic event, for example, a scratch, traumatised skin lesion, or reaction to treatment (typically 5-fluorouracil given to treat actinic keratosis or Bowen's disease) breaches the skin.

Trauma leads to discharge of fibrin and/or pus, which dries out and sets semi-solid, matting the hair.

Over time, this can develop into a 'bird's nest' structure, which retains exudate, debris and pus. Destructive elements in pus further erode the epidermis, creating a vicious circle. Small pustules developing on the scalp, temples and forehead progress to form crusts with moist and red skin beneath.

When the GP is finally called, a two-week wait cancer referral may result.

  • Dr Hayes is a retired GP, a specialty doctor and an educator in dermatology who lives in Botley, Hampshire

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