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Use of an 800-nm pulsed-diode laser in the treatment of recalcitrant dissecting cellulitis of the scalp.

A 35-year-old black man with adult-onset diabetes mellitus presented to our clinics in July 1999 with a 2-year history of alopecia and a boggy scalp with cysts and pustules. He had been previously treated with 40 mg daily of isotretinoin for 3 months (Accutane; Roche Laboratories Inc, Nutley, NJ) and 25 mg daily of dapsone for 2 months with minimal improvement. Oral antibiotic administration was ineffective. The patient complained that in addition to being unsightly, his condition was continuously uncomfortable. Physical examination of his scalp demonstrated patchy cicatricial alopecia on the crown, vertex, and occiput with variable dyschromia (Figure 1). Numerous pustules, cysts, and erosions were noted. A punch biopsy specimen was taken, which demonstrated a diminished number of follicles with scarring, follicle rupture (Figure 2), and aggregates of neutrophils (Figure 3). These features are compatible with dissecting cellulitis of the scalp. The patient was treated with 100 mg of isotretinoin per day for 5 months, which resulted in diminution of the condition but not complete remission. Three months later, the condition flared, and he was treated again with isotretinoin for an additional 2 months with little improvement. Colchicine treatment, 0.6 g twice daily, was begun but discontinued after 2 months because of gastrointestinal adverse effects. Modest improvement was noted. After the treatment with medications was discontinued, however, the cysts and erosions returned. Over the ensuing 6 months, the patient’s condition worsened and was associated with increasing discomfort. He was treated with azathioprine, methotrexate, dapsone, ketoconazole, cephalexin, and clarithromycin for the cutaneous disease and celecoxib and gabapentin for the associated pain.