Treatment of dissecting cellulitis of the scalp in adults

DCS: dissecting cellulitis of the scalp; TNF: tumor necrosis factor.

* We typically try minocycline prior to proceeding to oral isotretinoin based upon personal experience that suggests some patients exhibit greater improvement with minocycline than doxycycline. However, proceeding directly to isotretinoin is a reasonable alternative, particularly for patients with severe DCS.

¶ Longer treatment courses may be necessary for patients who are responding well to doxycycline but who have not achieved disease control after 6 months.

Δ If relapse is infrequent (less than or equal to once per year), we often prescribe a 3-month course of the previously effective antibiotic. Subsequently, for relapses treated with doxycycline, we often continue doxycycline at a reduced, subantimicrobial maintenance dose rather than stopping therapy. For patients with more frequent relapses (>1 relapse/year) or rapid relapse (relapse within 3 months of cessation of antibiotic therapy), proceed to Box A.

◊ To minimize risk for pseudotumor cerebri, oral tetracycline antibiotics should be stopped prior to isotretinoin therapy.

Combination therapy with oral clindamycin and rifampin or treatment with a biologic TNF-alpha inhibitor is an alternative for patients who cannot receive or prefer to avoid oral isotretinoin.

§ The optimal duration of isotretinoin therapy is unclear. In our experience, this treatment duration seems to reduce relapses.

¥ In our experience, mild relapses (few relatively small nodules) after cessation of isotretinoin can often be managed with a course of doxycycline and intralesional corticosteroid injections. For relapses of greater severity, we typically proceed to a biologic TNF inhibitor. Long-term, low-dose isotretinoin may be an additional alternative. Refer to additional UpToDate content on DCS for details.