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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 120-124  

Alopecic and aseptic nodules of the scalp: A new entity or a minor form of dissecting cellulitis?


1 Center for Dermatology and Hair Diseases Professor Trüeb, Wallisellen, Switzerland
2 Department of Dermatology, Universidade Federal Fluminense, Centro de Ciências Médicas, Hospital Universitário Antonia Pedro, Rio de Janeiro, Brazil
3 Department of Dermatology, Lusiada University Center, São Paulo, Brazil

Date of Submission09-Mar-2022
Date of Acceptance11-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Ralph Michel Trüeb
Center for Dermatology and Hair Diseases Professor Trueb, Bahnhofplatz 1A, CH-8304 Wallisellen
Switzerland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijt.ijt_33_22

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   Abstract 


Since the original report in 1992 and revised nomenclature in 2009, pseudocysts of the scalp and alopecic and aseptic nodules of the scalp (AANS), respectively, have been regarded as a new entity that is rare and not understood in its pathogenesis. We observed 26 cases of AANS. Except for the extent and severity of disease, we found no single feature that justifies distinguishing AANS as a nosologic entity in its own right from dissecting cellulitis of the scalp (DCS). The scarring alopecias represent a diverse group of disorders with the potential of permanent destruction of the pilosebaceous unit and hair loss. Within the maze of varied conditions leading to scarring alopecia, the most important is to keep a neat nosologic classification in mind, based both on morphology and a pathogenic understanding. We believe that AANS represents a minor form of DCS, so far predominantly observed in patients of non-African origin, and therefore, is a disease of follicular occlusion with a favorable prognosis.

Keywords: Alopecic and aseptic nodules of the scalp, dissecting cellulitis, follicular occlusion, pseudocysts of the scalp


How to cite this article:
Luu NNC, Uribe NC, Gavazzoni Dias MF, Rezende HD, Trüeb RM. Alopecic and aseptic nodules of the scalp: A new entity or a minor form of dissecting cellulitis?. Int J Trichol 2022;14:120-4

How to cite this URL:
Luu NNC, Uribe NC, Gavazzoni Dias MF, Rezende HD, Trüeb RM. Alopecic and aseptic nodules of the scalp: A new entity or a minor form of dissecting cellulitis?. Int J Trichol [serial online] 2022 [cited 2022 Dec 5];14:120-4. Available from: https://www.ijtrichology.com/text.asp?2022/14/4/120/351242



“As the true object of education is not to render the pupil the mere copy of his preceptor, it is rather to be rejoiced in, than lamented, that various reading should lead him into new trains of thinking.”

William Godwin (1756–1836)


   Introduction Top


In 1992, Iwata et al. originally reported 19 Japanese patients with pseudocysts of the scalp with inflammatory granulation tissue presenting as solitary painful subcutaneous tumor associated with alopecia.[1] It was not until 1998 that Chevallier reported three cases of noninfectious abscesses of the scalp with alopecia on the occasion of the French Federation of Continuing Medical Education in Dermatology and questioned whether it represented a new nosologic entity.[2] In 2005, Tsuruta et al. reported four additional cases of the so-called pseudocysts of the scalp under the assertion that there were no reports of such lesions in the Western literature for lack of familiarity with the French language.[3] Ultimately, Abdennader and Reygagne coined the term alopecic and aseptic nodules of the scalp (AANS) for the condition in a retrospective review of 18 cases seen over a period of 12 years at the Saint-Louis Hospital in Paris.[4] Subsequently, Abdennader et al. reported a prospective study of 15 cases of AANS and demonstrated that the disorder affected predominantly young men of Caucasian origin.[5] The main location of the nodules was occipital. Microbiological cultures of material from the puncture were negative. The histopathology showed a deep granulomatous inflammation. Pseudocysts were not always present. The condition responded well to oral doxycycline therapy with the recovery of hair. Subsequent single case reports and case series did not add any new insight of pertinence to the nomenclature and nosology of the condition,[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] including Heymann's latest comment in Dermatology World Insights and Inquiries.[17] Under the line, the authors state that the condition is rare, probably underreported, and its etiopathogenesis poorly understood.

The condition received its designation based on the clinical presentation with either one or few dome-shaped, firm, fluctuating, or soft, alopecic nodules of the scalp on the vertex or occipital area [Figure 1] that when punctured drain a sterile purulent or blood-tinged fluid. Histopathology shows a nonspecific mixed inflammatory infiltrate in the deep dermis; however, a granulomatous infiltrate with multinucleated foreign-body giant cells and pseudocyst formation may be found.[5],[10] Dermoscopic features are black and yellow dots, fine vellus hairs, and broken hair shafts, with none of these being pathognomonic for the condition.[11] Bourezane and Bourezane reported the “Eastern pancake sign” referring to dilated follicular orifices and comedo-like structures [Figure 2]a and [Figure 2]b.[18] Ultrasonographic studies demonstrated well-defined hypoechoic or anechoic subcutaneous nodular lesions.[11] The course of the disease is chronic relapsing with partial or total regrowth of the hair. Doxycycline 100–200 mg/d for 8–12 weeks was the most used treatment, followed by intralesional triamcinolone acetonide injections.[19]
Figure 1: Clinical presentation of alopecic and aseptic nodules of the scalp. Dome-shaped alopecic nodules on the scalp vertex of a Caucasian man

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Figure 2: The eastern pancake sign-on dermoscopy: (a) Eastern pancake, (b) dilated follicular orifices and comedo-like structures

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   Case Observations Top


At our hair disease clinic, we observed 26 cases in 10 years with the all-inclusive features of AANS [Table 1]. Again, the majority of our patients were male Caucasians, and the age ranged from 18 to 48 years. The patients responded well to either oral doxycycline or low-dose isotretinoin, associated with intralesional triamcinolone acetonide 20–40 mg/mL, with complete or partial regrowth of hair. In contrast to the former authors, we interpreted the condition as the minor manifestation of dissecting cellulitis of the scalp (DCS). The condition seemed to us obvious to the extent that we did not find it necessary to perform biopsies in our cases.
Table 1: Patient characteristics, treatment regimen, and outcome

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   Discussion Top


DCS, also known as perifolliculitis capitis abscedens et suffodiens, or Hoffmann's disease, is a distinct dermatological disease potentially leading to scarring alopecia. It most probably occurs because of follicular occlusion through hyperkeratosis, having the same pathomechanism as acne conglobata and hidradenitis suppurativa. These dermatoses may be associated, although isolated scalp disease occurs more frequently. Most of those affected are young males of African origin. Deep inflammatory nodules develop on the occipital scalp or vertex and evolve to extensive confluent boggy plaques with sinus tract formation, particularly in patients of African origin. Dermoscopic findings in DCS include broken hair, short regrowing hairs, black dots, follicular pustules, peri- and interfollicular erythema, and empty follicular openings.[20] What is characteristic for the histopathologic picture of the disease is the deep inflammatory infiltrate placed at the reticular dermis or hypodermic level. The initial perifolliculitis evolves toward forming profound abscesses and the destruction of follicles with granuloma formation, usually lymphoplasmacytic and accompanied by multinucleated foreign-body giant cells that may be related to denuded hair fragments.[21]

Indeed, due to peculiarities of hair anatomy and hair grooming habits, environmental factors, and maybe genetic factors,[22] a number of inflammatory scalp conditions tend to be more common or severe in patients of African origin, such as folliculitis keloidalis nuchae, central centrifugal cicatricial alopecia, discoid lupus erythematosus,[23] and DCS.

Therefore, we do not consider AANS a disease entity in its own right but a disease manifestation of DCS at the minor end of its clinical spectrum. Apart from the lesser degree of severity and extent, AANS does not present any features distinct from DCS, except for those related to the severity and extent of disease and ethnicity [Table 2]. With respect to pathogenesis, in fact, the dermoscopic feature of comedo-like structures suggests the potential role of follicular occlusion.[11] Finally, also treatment is the same, with oral doxycycline or low-dose isotretinoin[24] associated with intralesional triamcinolone acetonide being effective. While large-scale surgical excision in combination with reconstructive surgery may be necessary in severe cases of DCS, surgery is not warranted in AANS because of its favorable prognosis [Figure 3]a and [Figure 3]b.
Table 2: Features of alopecic and aseptic nodules of the scalp and dissecting cellulitis of the scalp

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Figure 3: Favorable prognosis (a) before and (b) after treatment with low-dose oral isotretinoin and intralesional triamcinolone acetonide

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   Summary and Conclusions Top


The scarring alopecias represent a diverse group of disorders with the potential for permanent destruction of the pilosebaceous unit and irreversible hair loss.[25] They feature some challenges: some have neither a known cause nor reliable clinicopathologic findings. There exists an inconsistent use of terminology with different terms denoting the same entities or single terms denoting different conditions.[26] Since structural changes in the course of disease usually are irreversible, there is a clear need for early intervention. With the expanding understanding of the basis of disease, there is hope for appropriate therapeutic strategies versus the currently proposed trial and error algorithms. Within the maze of varied conditions leading to scarring alopecia, the most important is to keep a neat nosologic classification in mind, based both on morphology and a pathogenic understanding. As a general rule, whatever condition targets the follicular stem cells or destroys the whole hair follicle with the extent and severity of the inflammation being determinant will result in scarring and irreversibility of hair loss.

Except for the extent and severity of disease, and possibly ethnicity, there is no single feature that justifies distinguishing AANS as a nosologic entity in its own right from DSC. We believe that AANS represents a minor form of DCS and therefore a follicular occlusion disease amenable to oral tetracyclines, oral retinoids, and intralesional corticosteroids. Since we cannot exclude a geographical bias in our and the so far published cases of AANS, it remains to be elucidated whether AANS is also observed in patients of African origin, who are known to be prone to DCS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Iwata T, Hashimoto T, Niimura M. A pseudocyst with inflammatory granulation tissue on scalp – Pseudocyst of scalp. Jpn J Clin Dermatol 1992;46:9-16.  Back to cited text no. 1
    
2.
Chevallier J. Non-infectious abscess et al. Scalp opecics: New entity. New Dermatol 1998;12:181.  Back to cited text no. 2
    
3.
Tsuruta D, Hayashi A, Kobayashi H, Nakagawa K, Furukawa M, Ishii M. Pseudocyst of the scalp. Dermatology 2005;210:333-5.  Back to cited text no. 3
    
4.
Abdennader S, Reygagne P. Alopecic and aseptic nodules of the scalp. Dermatology 2009;218:86.  Back to cited text no. 4
    
5.
Abdennader S, Vignon-Pennamen MD, Hatchuel J, Reygagne P. Alopecic and aseptic nodules of the scalp (pseudocyst of the scalp): A prospective clinicopathological study of 15 cases. Dermatology 2011;222:31-5.  Back to cited text no. 5
    
6.
Lee SS, Kim SY, Im M, Lee Y, Seo YJ, Lee JH. Pseudocyst of the scalp. Ann Dermatol 2011;23:S267-9.  Back to cited text no. 6
    
7.
Eisenberg EL. Alopecia-associated pseudocyst of the scalp. J Am Acad Dermatol 2012;67:e114-6.  Back to cited text no. 7
    
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Fischer-Levancini C, Iglesias-Sancho M, Collgros H, Sánchez-Regaña M. Aseptic and alopecic nodules of the scalp. Actas Dermosifiliogr 2014;105:208-11.  Back to cited text no. 8
    
9.
Gargallo A, García O, Molina E, Schoendorff C. Alopecic and aseptic nodules of the scalp. J Am Acad Dermatol 2015;72:AB110.  Back to cited text no. 9
    
10.
Seol JE, Park IH, Kim DH, Park SH, Kang JN, Kim H, et al. Alopecic and aseptic nodules of the scalp/pseudocyst of the scalp: Clinicopathological and therapeutic analyses in 11 Korean patients. Dermatology 2016;232:165-70.  Back to cited text no. 10
    
11.
Garrido-Colmenero C, Arias-Santiago S, Aneiros Fernández J, García-Lora E. Trichoscopy and ultrasonography features of aseptic and alopecic nodules of the scalp. J Eur Acad Dermatol Venereol 2016;30:507-9.  Back to cited text no. 11
    
12.
Rodríguez-Lobato E, Morgado-Carrasco D, Giavedoni P, Ferrando J. Alopecic and aseptic nodule of the scalp in a girl. Pediatr Dermatol 2017;34:697-700.  Back to cited text no. 12
    
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Lázaro-Simó AI, Sancho MI, Quintana-Codina M, Viladomiu ED, Millet PU, Redonnet MS. Alopecic and aseptic nodules of the scalp with trichoscopic and ultrasonographic findings. Indian J Dermatol 2017;62:515-8.  Back to cited text no. 13
    
14.
Fischer-Levancini C, Gompertz M, Guglielmetti A, Opazo H. Alopecic and aseptic nodules of the scalp: First report in South America and second in America. Skin Appendage Disord 2018;4:78-81.  Back to cited text no. 14
    
15.
Gupta I, Dayal S, Kataria SP. Aseptic and alopecic nodules of scalp: A rare and underdiagnosed entity. Int J Trichology 2018;10:231-3.  Back to cited text no. 15
    
16.
Al-Hamdi KI, Saadoon AQ. Alopecic and aseptic nodules of the scalp with a chronic relapsing course. Int J Trichology 2019;11:244-6.  Back to cited text no. 16
    
17.
Heymann WR. Humbled again: Alopecic and aseptic nodules of the scalp. Dermatol World Insights Inquiries 2021;6:44.  Back to cited text no. 17
    
18.
Bourezane Y, Bourezane H. Two new trichoscopic signs in alopecic and aseptic nodules of the scalp: “Eastern pancake sign” and comedo-like structures. Ann Dermatol Venereol 2014;141:750-5.  Back to cited text no. 18
    
19.
Bellinato F, Maurelli M, Colato C, Gisondi P, Girolomoni G. Alopecic and aseptic nodules of the scalp: A new case with a systematic review of the literature. Clin Case Rep 2021;9:e04153.  Back to cited text no. 19
    
20.
Melo DF, Slaibi EB, Siqueira TM, Tortelly VD. Trichoscopy findings in dissecting cellulitis. An Bras Dermatol 2019;94:608-11.  Back to cited text no. 20
    
21.
Brănişteanu DE, Molodoi A, Ciobanu D, Bădescu A, Stoica LE, Brănişteanu D, et al. The importance of histopathologic aspects in the diagnosis of dissecting cellulitis of the scalp. Rom J Morphol Embryol 2009;50:719-24.  Back to cited text no. 21
    
22.
Malki L, Sarig O, Romano MT, Méchin MC, Peled A, Pavlovsky M, et al. Variant PADI3 in central centrifugal cicatricial alopecia. N Engl J Med 2019;380:833-41.  Back to cited text no. 22
    
23.
Semble AL, McMichael AJ. Hair loss in patients with skin of color. Semin Cutan Med Surg 2015;34:81-8.  Back to cited text no. 23
    
24.
Melo DF, Trüeb RM, Dutra H, Lima MM, Machado CJ, Dias MF. Low-dose isotretinoin as a therapeutic option for dissecting cellulitis. Dermatol Ther 2020;33:e14273.  Back to cited text no. 24
    
25.
Harries MJ, Trueb RM, Tosti A, Messenger AG, Chaudhry I, Whiting DA, et al. How not to get scar (r) ed: Pointers to the correct diagnosis in patients with suspected primary cicatricial alopecia. Br J Dermatol 2009;160:482-501.  Back to cited text no. 25
    
26.
Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol 2000;136:235-42.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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