Background
Erosive pustulosis of the scalp was first described by Pye, Peachey, and Burton in 1979 as a rare disorder of uncertain etiology seen in elderly individuals.[1] Erosive pustulosis of the scalp is characterized by sterile pustules, erosions, and crusted lesions, as shown in the images below. These lesions result in scarring alopecia of the involved areas.[2] Although its etiology remains unknown, erosive pustulosis of the scalp is seen in atrophied skin secondary to actinic damage or exposure to local trauma. Cases of erosive pustulosis of the scalp have been reported following skin grafting, radiation, cryotherapy, or topical chemotherapy, among others.[3]
Yellow-brown crusts with atrophy on the vertex scalp. 
Yellow-brown crusts on the vertex scalp. Cases affecting the extremities have been reported but are less common, often found in non–sun-damaged skin of patients with chronic venous insufficiency.[3]
Pathophysiology
The etiology of erosive pustulosis of the scalp is poorly understood; however, several factors that may be related to the pathogenesis of the disease are known, as follows:
- Cutaneous atrophy from any cause, but most commonly actinic damage, is a predisposing condition to erosive pustulosis of the scalp and seems to be present in almost all reported cases.[3]
- Trauma and tissue damage appear to play roles in the development of erosive pustulosis of the scalp. Causes include herpes zoster and iatrogenic insults of cryotherapy, topical chemotherapy, excisional surgery, grafting,[2, 3] topical methylaminolevulinate photodynamic therapy,[4] and carbon dioxide laser therapy.[5] A localized form of erosive pustulosis of the scalp has been reported after implantation of a cochlear implant.[6] Unfortunately, cessation of trauma does not result in clearing of erosive pustulosis of the scalp.[2, 3]
- Chronic inflammation is noted in histology studies, and it clearly plays a role in the persistence of erosive pustulosis of the scalp.[3]
- Erosive pustulosis of the scalp has been associated with autoimmune disorders, including rheumatoid arthritis, autoimmune hepatitis, Hashimoto thyroiditis, and Takayasu aortitis. Cutaneous autoimmunity, however, has not been described.[2]
- An association of erosive pustular dermatosis involving the lower leg has been reported with ankylosing spondylitis. The authors proposed that neutrophilic dysfunction may play a role. Patients positive for HLA-B27 have increased neutrophil motility and chemotaxis compared with their negative counterparts. In addition, chronic venous insufficiency may have predisposed this patient to immunoglobulin M and complement deposition into the basement membrane, possibly triggering neutrophil chemotaxis and margination.[7]
Epidemiology
Frequency
United States
Erosive pustulosis of the scalp has been considered a rare entity. However, a 2007 publication reported 11 cases diagnosed in a single clinic over 3 years.[3] This suggests that erosive pustulosis of the scalp is more common than previously thought.
Mortality/Morbidity
Erosive pustulosis of the scalp causes mild-to-moderate pruritus and pain. The appearance of the erosions and crusts are embarrassing to the patient, and the end result is scarring alopecia. Erosive pustulosis of the scalp is not a fatal condition.
Race
Erosive pustulosis of the scalp is found more commonly in white persons.[8]
Sex
Erosive pustulosis of the scalp has a female predominance, with a female-to-male ratio of approximately 2:1.[3]
Age
Erosive pustulosis of the scalp primarily affects elderly persons, although cases have been reported in young patients following surgical excisions on the scalp.[3]
Pye RJ, Peachey RD, Burton JL. Erosive pustular dermatosis of the scalp. Br J Dermatol. May 1979;100(5):559-66. [Medline].
Van Exel CE, English JC 3rd. Erosive pustular dermatosis of the scalp and nonscalp. J Am Acad Dermatol. Aug 2007;57(2 Suppl):S11-4. [Medline].
Patton D, Lynch PJ, Fung MA, Fazel N. Chronic atrophic erosive dermatosis of the scalp and extremities: A recharacterization of erosive pustular dermatosis. J Am Acad Dermatol. Sep 2007;57(3):421-7. [Medline].
Guarneri C, Vaccaro M. Erosive pustular dermatosis of the scalp following topical methylaminolaevulinate photodynamic therapy. J Am Acad Dermatol. Mar 2009;60(3):521-2. [Medline].
Tavares-Bello R. Erosive pustular dermatosis of the scalp. A chronic recalcitrant dermatosis developed upon CO2 laser treatment. Dermatology. 2009;219(1):71-2. [Medline].
Marzano AV, Ghislanzoni M, Zaghis A, Spinelli D, Crosti C. Localized erosive pustular dermatosis of the scalp at the site of a cochlear implant: successful treatment with topical tacrolimus. Clin Exp Dermatol. Jul 2009;34(5):e157-9. [Medline].
Erdmann M, Kiesewetter F, Schuler G, Schultz E. Erosive pustular dermatosis of the leg in a patient with ankylosing spondylitis: neutrophilic dysfunction as a common etiological factor?. Int J Dermatol. May 2009;48(5):513-5. [Medline].
Mehmi M, Abdullah A. Erosive pustular dermatosis of the scalp occurring after partial thickness skin graft for squamous cell carcinoma. Br J Plast Surg. Dec 2004;57(8):806-7. [Medline].
Laffitte E, Kaya G, Piguet V, Saurat JH. Erosive pustular dermatosis of the scalp: treatment with topical tacrolimus. Arch Dermatol. Jun 2003;139(6):712-4. [Medline].
Seez M, Rodriguez-Martín M, Sidro M, Carnerero A, Garcia-Bustínduy M, Noda A. Successful treatment of erosive pustular dermatosis of the scalp with topical tacrolimus. Clin Exp Dermatol. Sep 2005;30(5):599-600. [Medline].
Meyer T, Lopez-Navarro N, Herrera-Acosta E, Jose A, Herrera E. Erosive pustular dermatosis of the scalp: a successful treatment with photodynamic therapy. Photodermatol Photoimmunol Photomed. Feb 2010;26(1):44-5. [Medline].
Allevato M, Clerc C, del Sel JM, Donatti L, Cabrera H, Juarez M. Erosive pustular dermatosis of the scalp. Int J Dermatol. Nov 2009;48(11):1213-6. [Medline].
Ikeda M, Arata J, Isaka H. Erosive pustular dermatosis of the scalp successfully treated with oral zinc sulphate. Br J Dermatol. Jun 1982;106(6):742-3. [Medline].
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