eMedicine Specialties > Dermatology > Diseases of the Adnexa

Perifolliculitis Capitis Abscedens et Suffodiens

Author: Malgorzata D Skibinska, MD, PhD, Locum Consultant Dermatologist, Department of Dermatology, Basildon University Hospital, UK
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Mar 23, 2009

Introduction

Background

Perifolliculitis capitis abscedens et suffodiens (PCAS) is a therapeutically challenging suppurative scalp disease of unknown etiology. Spitzer first described the disease in 1903, and Hoffman named it descriptively in 1907 (suffodiens is from the Latin suffodio, meaning to dig under).1,2 It predominantly occurs in black males in their second-to-fourth decade of life. The clinical course is chronic and unpredictable with relapses, although spontaneous resolution may occur.3,4,5

Pathophysiology

Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) can be associated with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, with follicular blockage as the proposed common mechanism. As retention of material dilates follicles and causes them to rupture, keratin and organisms from the damaged hair follicles can initiate a neutrophilic and granulomatous response. Bacterial infection appears to be a secondary event, not an etiologic factor in the pathogenesis.3,6,7

Frequency

International

No data are available, but the disease is uncommon.

Mortality/Morbidity

Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) is not life threatening, but it is chronic and relapsing and can be complicated by squamous cell carcinoma.

Race

Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) is found most commonly in black men, but white persons are also affected.

Sex

Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) is found mostly in men, although cases in women are also reported.

Age

The most common age group affected is those aged 18-40 years.

Clinical

History

  • Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp)  begins as a simple folliculitis, most often of the vertex and/or occiput, with clusters of perifollicular pustules rapidly followed by abscess and sinus formation.
  • Nodules range from a few millimeters to several centimeters in diameter and may be firm or fluctuant.
  • Seropurulent fluid may be expressed from fluctuant nodules.
  • Lesions at different stages may persist for years, healing with a scarring alopecia.
  • Perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) has a strong tendency for recurrence.
  • No systemic symptoms are usually evident.

Physical

  • Vertex and occipital regions of the scalp are sites most often affected by perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp).
  • The main physical signs, depending on the disease stage, are perifollicular pustules, tender nodules (some discharging pus or a jellylike substance), intercommunicating sinuses between nodules, and patchy alopecia with scarring.8,9,10
Dissecting cellulitis in a black man. Painful cut...

Dissecting cellulitis in a black man. Painful cutaneous nodules and patchy alopecia.

[ CLOSE WINDOW ]
Dissecting cellulitis in a black man. Painful cut...

Dissecting cellulitis in a black man. Painful cutaneous nodules and patchy alopecia.


Side view of patient in Media File 1. Black man w...

Side view of patient in Media File 1. Black man with painful cutaneous nodules and patchy alopecia, characteristic of dissecting cellulitis.

[ CLOSE WINDOW ]
Side view of patient in Media File 1. Black man w...

Side view of patient in Media File 1. Black man with painful cutaneous nodules and patchy alopecia, characteristic of dissecting cellulitis.


A white patient with painful nodules. Image used ...

A white patient with painful nodules. Image used with permission from Medical Science Monitor, 2000, 6(3): 602-4.

[ CLOSE WINDOW ]
A white patient with painful nodules. Image used ...

A white patient with painful nodules. Image used with permission from Medical Science Monitor, 2000, 6(3): 602-4.


Same white patient as shown in Media File 3 after...

Same white patient as shown in Media File 3 after 3 months of isotretinoin treatment. Image used with permission from Medical Science Monitor, 2000, 6(3): 602-4.

[ CLOSE WINDOW ]
Same white patient as shown in Media File 3 after...

Same white patient as shown in Media File 3 after 3 months of isotretinoin treatment. Image used with permission from Medical Science Monitor, 2000, 6(3): 602-4.

  • Shedding hair from the surface of nodules and sparing in between the inflamed areas can be observed.
  • Regional lymphadenopathy is rarely noted.
  • Spondyloarthropathy has been reported in patients with perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp).11,12

Causes

The cause of perifolliculitis capitis abscedens et suffodiens (dissecting cellulitis of the scalp) is not known.

  • The hypothesis is that blockage of follicles, retention of contents, and subsequent rupture leads to inflammation. Acne conglobata, hidradenitis suppurativa, and pilonidal cysts are frequent concomitant diseases, often referred to as the follicular occlusion triad or tetrad.
  • Bacterial infection is probably secondary in the course of the disease because most bacteriological cultures are negative. The most frequently isolated pathogens are Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus albus.
  • Keratosis-ichthyosis-deafness syndrome has been reported in association with the follicular occlusion triad in 2 patients.13,14

More on Perifolliculitis Capitis Abscedens et Suffodiens

Overview: Perifolliculitis Capitis Abscedens et Suffodiens
Differential Diagnoses & Workup: Perifolliculitis Capitis Abscedens et Suffodiens
Treatment & Medication: Perifolliculitis Capitis Abscedens et Suffodiens
Follow-up: Perifolliculitis Capitis Abscedens et Suffodiens
Multimedia: Perifolliculitis Capitis Abscedens et Suffodiens
References
[ CLOSE WINDOW ]

References

  1. Hoffman E. Perifolliculitis capitis abscedens et suffodiens: case presentation. Dermatol Zeitschrift (Berlin). 1908;15:122-3.

  2. Spitzer L. Dermatitis follicularis et perifollicularis conglobata. Dermatol Zeitschrift (Berlin). 1903;10:109-20.

  3. Varshney N, Al Hammadi A, Sam H, Watters AK. Perifolliculitis capitis abscedens et suffodiens in an 18-year-old Aboriginal Canadian patient: case report and review of the literature. J Cutan Med Surg. Jan-Feb 2007;11(1):35-9. [Medline].

  4. Williams CN, Cohen M, Ronan SG, Lewandowski CA. Dissecting cellulitis of the scalp. Plast Reconstr Surg. Mar 1986;77(3):378-82. [Medline].

  5. Stites PC, Boyd AS. Dissecting cellulitis in a white male: a case report and review of the literature. Cutis. Jan 2001;67(1):37-40. [Medline].

  6. Chicarilli ZN. Follicular occlusion triad: hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of the scalp. Ann Plast Surg. Mar 1987;18(3):230-7. [Medline].

  7. Zisova L, Sakakushev B. Acne tetrad in a family. Folia Med (Plovdiv). 1994;36(4):51-7. [Medline].

  8. Benvenuto ME, Rebora A. Fluctuant nodules and alopecia of the scalp. Perifolliculitis capitis abscedens et suffodiens. Arch Dermatol. Aug 1992;128(8):1115-7, 1118-9. [Medline].

  9. Moyer DG, Williams RM. Perifolliculitis capitis abscedens et suffodiens. A report of six cases. Arch Dermatol. Mar 1962;85:378-84. [Medline].

  10. Ramesh V. Dissecting cellulitis of the scalp in 2 girls. Dermatologica. 1990;180(1):48-50. [Medline].

  11. Salim A, David J, Holder J. Dissecting cellulitis of the scalp with associated spondylarthropathy: case report and review. J Eur Acad Dermatol Venereol. Nov 2003;17(6):689-91. [Medline].

  12. Libow LF, Friar DA. Arthropathy associated with cystic acne, hidradenitis suppurativa, and perifolliculitis capitis abscedens et suffodiens: treatment with isotretinoin. Cutis. Aug 1999;64(2):87-90. [Medline].

  13. Maintz L, Betz RC, Allam JP, Wenzel J, Jaksche A, Friedrichs N, et al. Keratitis-ichthyosis-deafness syndrome in association with follicular occlusion triad. Eur J Dermatol. Sep-Oct 2005;15(5):347-52. [Medline].

  14. Montgomery JR, White TW, Martin BL, Turner ML, Holland SM. A novel connexin 26 gene mutation associated with features of the keratitis-ichthyosis-deafness syndrome and the follicular occlusion triad. J Am Acad Dermatol. Sep 2004;51(3):377-82. [Medline].

  15. Sperling LC. Scarring alopecia and the dermatopathologist. J Cutan Pathol. Aug 2001;28(7):333-42. [Medline].

  16. McMullan FH, Zeligman I. Perifolliculitis capitis abscedens et suffodiens; its successful treatment with x-ray epilation. AMA Arch Derm. Mar 1956;73(3):256-63. [Medline].

  17. Chinnaiyan P, Tena LB, Brenner MJ, Welsh JS. Modern external beam radiation therapy for refractory dissecting cellulitis of the scalp. Br J Dermatol. Apr 2005;152(4):777-9. [Medline].

  18. Glass LF, Berman B, Laub D. Treatment of perifolliculitis capitis abscedens et suffodiens with the carbon dioxide laser. J Dermatol Surg Oncol. Jun 1989;15(6):673-6. [Medline].

  19. Boyd AS, Binhlam JQ. Use of an 800-nm pulsed-diode laser in the treatment of recalcitrant dissecting cellulitis of the scalp. Arch Dermatol. Oct 2002;138(10):1291-3. [Medline].

  20. Chui CT, Berger TG, Price VH, Zachary CB. Recalcitrant scarring follicular disorders treated by laser-assisted hair removal: a preliminary report. Dermatol Surg. Jan 1999;25(1):34-7. [Medline].

  21. Krasner BD, Hamzavi FH, Murakawa GJ, Hamzavi IH. Dissecting cellulitis treated with the long-pulsed Nd:YAG laser. Dermatol Surg. Aug 2006;32(8):1039-44. [Medline].

  22. Bellew SG, Nemerofsky R, Schwartz RA, Granick MS. Successful treatment of recalcitrant dissecting cellulitis of the scalp with complete scalp excision and split-thickness skin graft. Dermatol Surg. Oct 2003;29(10):1068-70. [Medline].

  23. Moschella SL, Klein MH, Miller RJ. Perifolliculitis capitis abscedens et suffodiens. Report of a successful therapeutic scalping. Arch Dermatol. Aug 1967;96(2):195-7. [Medline].

  24. Shaffer N, Billick RC, Srolovitz H. Perifolliculitis capitis abscedens et suffodiens. Resolution with combination therapy. Arch Dermatol. Oct 1992;128(10):1329-31. [Medline].

  25. Berne B, Venge P, Ohman S. Perifolliculitis capitis abscedens et suffodiens (Hoffman). Complete healing associated with oral zinc therapy. Arch Dermatol. Aug 1985;121(8):1028-30. [Medline].

  26. Kobayashi H, Aiba S, Tagami H. Successful treatment of dissecting cellulitis and acne conglobata with oral zinc. Br J Dermatol. Dec 1999;141(6):1137-8. [Medline].

  27. Karpouzis A, Giatromanolaki A, Sivridis E, Kouskoukis C. Perifolliculitis capitis abscedens et suffodiens successfully controlled with topical isotretinoin. Eur J Dermatol. Mar-Apr 2003;13(2):192-5. [Medline].

  28. Georgala S, Korfitis C, Ioannidou D, Alestas T, Kylafis G, Georgala C. Dissecting cellulitis of the scalp treated with rifampicin and isotretinoin: case reports. Cutis. Sep 2008;82(3):195-8. [Medline].

  29. Bolz S, Jappe U, Hartschuh W. Successful treatment of perifolliculitis capitis abscedens et suffodiens with combined isotretinoin and dapsone. J Dtsch Dermatol Ges. Jan 2008;6(1):44-7. [Medline].

  30. Brandt HR, Malheiros AP, Teixeira MG, Machado MC. Perifolliculitis capitis abscedens et suffodiens successfully controlled with infliximab. Br J Dermatol. Aug 2008;159(2):506-7. [Medline].

  31. Bjellerup M, Wallengren J. Familial perifolliculitis capitis abscedens et suffodiens in two brothers successfully treated with isotretinoin. J Am Acad Dermatol. Oct 1990;23(4 Pt 1):752-3. [Medline].

  32. Dubost-Brama A, Delaporte E, Alfandari S, Piette F, Bergoend H. [Perifolliculitis capitis abscedens and suffidiens. Efficacy of isotretinoin]. Ann Dermatol Venereol. 1994;121(4):328-30. [Medline].

  33. Koca R, Altinyazar HC, Ozen OI, Tekin NS. Dissecting cellulitis in a white male: response to isotretinoin. Int J Dermatol. Aug 2002;41(8):509-13. [Medline].

  34. Omulecki A, Dabkowski J, Zak-Prelich M. Perifolliculitis capitis abscedens et suffodiens--a case report. Med Sci Monit. May-Jun 2000;6(3):602-4. [Medline].

  35. Schewach-Millet M, Ziv R, Shapira D. Perifolliculitis capitis abscedens et suffodiens treated with isotretinoin (13-cis-retinoic acid). J Am Acad Dermatol. Dec 1986;15(6):1291-2. [Medline].

  36. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolliculitis of the scalp. A case report and review of secondary squamous cell carcinomas. J Am Acad Dermatol. Jun 1981;4(6):673-8. [Medline].

  37. Sivakumaran S, Meyer P, Burrows NP. Dissecting folliculitis of the scalp with marginal keratitis. Clin Exp Dermatol. Sep 2001;26(6):490-2. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

perifolliculitis capitis abscedens et suffodiens, dissecting cellulitis of the scalp, PCAS, Hoffman disease, Hoffman's disease, dissecting cellulitis, scalp cellulitis, acne conglobata, hidradenitis suppurativa, pilonidal cysts

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Malgorzata D Skibinska, MD, PhD, Locum Consultant Dermatologist, Department of Dermatology, Basildon University Hospital, UK
Malgorzata D Skibinska, MD, PhD is a member of the following medical societies: British Association of Dermatologists, British Medical Association, European Society for Dermatological Research, Royal College of Physicians of the United Kingdom, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.