Impressive response of erosive pustular dermatosis of the scalp to lymecycline monotherapy

Abstract

We have read and much appreciated the article by Wilk et al., discussing clinicopathologic aspects and management of erosive pustular dermatosis of the scalp (EDPS) [1]. We wish to share our experience with a case of EPDS, which showed an impressive response to lymecycline monotherapy. The patient was a 75-year-old Caucasian man who presented for a painful scalp eruption of two months’ duration. He suffered from type II diabetes, metabolic syndrome, hypertension and chronic heart failure. Physical examination revealed multiple confluent erosions with erythematous borders and pustules on the frontal and parietal regions as well as the vertex of the scalp (Figure 1a). Differential diagnoses included bacterial or fungal infections, Brunsting-Perry mucous membrane pemphigoid, folliculitis decalvans and erosive pustular dermatosis of the scalp (EDPS). Histopathological examination of a skin biopsy from one lesion showed absence of epidermis and a mixed dermal inflammatory infiltrate comprising neutrophils and plasma cells. Direct immunofluorescence of perilesional skin, bacterial and mycological cultures were negative. A diagnosis of EPDS was made based on the clinical and histological findings. The patient was treated with clobetasol ointment once daily for four weeks, but there was no improvement. He refused other topical medications. Systemic therapies including prednisone, acitretin or dapsone were contraindicated due to the associated comorbid diseases. He was started on lymecycline 300 mg/day, which resulted in complete healing after four weeks of treatment (Figure 1b). Lymecycline was stopped and no recurrence occurred during six months of follow-up. EPDS is a chronic inflammatory dermatosis, mostly affecting the scalp and characterized by erosions, pustules and crusts, which may eventually lead to scarring alopecia [1, 2]. Diagnosis of EPDS is often challenging and requires the exclusion of various inflammatory and neoplastic skin disorders that also affect the scalp (Table 1). Regarding the pathogenesis, a Koebner-like phenomenon has been hypothesized since EPDS often occurs following skin damage, such as trauma, skin grafting, burns or herpes zoster infection; the association with autoimmune disorders such as rheumatoid arthritis is also consistent with a possible autoimmune origin of the disease [1, 2]. Clinical Letter