Medication Summary
High-potency topical corticosteroids are the most commonly reported effective treatment for erosive pustulosis of the scalp. Topical tacrolimus is also reported to be useful and, when it works, may avoid the development of atrophy secondary to topical steroid therapy. For patients who do not respond to these medications, limited evidence supports trials of topical calcipotriol, topical and oral retinoids, topical dapsone, oral cyclosporine, and/or oral zinc sulfate. [5, 6, 26, 35, 36]
Corticosteroids, topical (high potency)
Fluocinonide (Fluonex)
Fluocinonide is a high-potency steroid that inhibits cell proliferation and is immunosuppressive, antiproliferative, and anti-inflammatory. It also has antipruritic and vasoconstrictive properties.
Clobetasol (Clobex)
Clobetasol is a high-potency steroid that inhibits cell proliferation and is immunosuppressive, antiproliferative, and anti-inflammatory. It also has antipruritic and vasoconstrictive properties.
Immunosuppressant agents
Tacrolimus (Protopic)
The mechanism of action in atopic dermatitis is not known. Tacrolimus reduces itching and inflammation by suppressing the release of cytokines from T cells. It also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, it may inhibit the release of preformed mediators from skin mast cells and basophils and may down-regulate the expression of FCeRI on Langerhans cells. Tacrolimus can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. It is available as ointment in concentrations of 0.03 and 0.1%. It is indicated only after other treatment options have failed.
Cyclosporine (Gengraf, Neoral, Sandimmune)
Cyclosporine is a calcineurin inhibitor that suppresses T-cell‒mediated immunity. A single case report described improvement in erosive pustulosis used at a dose of 3 mg/kg/d.
Topical skin products
Calcipotriene (Dovonex)
Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. It is used in the treatment of moderate plaque psoriasis. Use 0.005% cream, ointment, or solution.
Antineoplastic agents, retinoid
Tretinoin topical (Retin-A)
Tretinoin inhibits microcomedo formation and eliminates lesions present. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. It is available as 0.025, 0.05, and 0.1% creams and 0.01 and 0.025% gels.
Antipsoriatic agents, systemic
Acitretin (Soriatane)
Acitretin is a metabolite of etretinate and related to both retinoic acid and retinol (vitamin A). The mechanism of action is unknown; however, it is thought to exert its therapeutic effect by modulating keratinocyte differentiation, keratinocyte hyperproliferation, and tissue infiltration by inflammatory cells.
Minerals, parenteral
Zinc
Zinc is a co-factor for more than 70 types of enzymes. It plays a role in many metabolic processes. A higher requirement may be indicated in pregnancy. Use sulfate or gluconate zinc salts. Zinc sulfate 4.4 mg = 1 mg of elemental zinc. Zinc gluconate 7.1 mg = 1 mg of elemental zinc.
Acne Agents, Topical
Dapsone topical (Aczone)
Dapsone is a topical anti-inflammatory with antineutrophilic effects. Twice daily application may produce improvement in erosive pustulosis.
Immunosuppressants
- Yellow-brown crusts with atrophy on the vertex scalp.
- Yellow-brown crusts on the vertex scalp.
- A dense perifollicular infiltrate is composed of lymphocytes, neutrophils, histiocytes, and multinucleated giant cells (hematoxylin and eosin, 200x).
- Closer examination shows a predominantly neutrophilic infiltrate with a background of admixed lymphocytes and histiocytes (hematoxylin and eosin, 400x).
- Erosive pustular dermatosis on the bilateral lower extremities in a woman with history of extensive UV exposure.
- Crusts with underlying purulence on the lower extremity.
- Erosive pustulosis of the scalp prior to curettage.
- Erosive pustulosis of the scalp 4 weeks following two treatments of curettage debridement with electrodesiccation performed at 3-week intervals.
