Case and Research Letter
Response to Photodynamic Therapy for Pustular Dermatosis of the Scalp and Hypertrophic Actinic Keratosis
Respuesta a terapia fotodinámica en paciente con dermatosis pustulosa del cuero cabelludo y queratosis actínicas hipertróficas
A.F. Monteagudo
, I. Belinchón, N. Latorre, J.F. Silvestre
Corresponding author
Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain
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Monteagudo, I. Belinchón, N. Latorre, J.F. Silvestre" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A.F." "apellidos" => "Monteagudo" "email" => array:1 [ 0 => "almudenamonteagudo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Belinchón" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Latorre" ] 3 => array:2 [ "nombre" => "J.F." "apellidos" => "Silvestre" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a terapia fotodinámica en paciente con dermatosis pustulosa del cuero cabelludo y queratosis actínicas hipertróficas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1110 "Ancho" => 1667 "Tamanyo" => 165210 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intense uptake by actinic keratoses as well as by the lesions of erosive pustular dermatosis of the scalp.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Erosive pustular dermatosis of the scalp is a rare inflammatory skin disease that mainly affects older patients and is characterized by the presence of sterile pustules and scabs. Recently, several authors have reported the usefulness of photodynamic therapy in the treatment of this condition.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 79-year-old man with skin phototype III and actinic keratosis of the face and scalp, occasionally treated with cryotherapy, after which the patient would complain of painful erosions in the treated area. On one of his check-up visits he had an outbreak of pustules and scabs that mainly affected the posterior part of the parietal region. The pustules had an erythematous base, and painful erosions and scabs were also visible. Biopsy revealed areas of fibrosis, a predominantly perifollicular neutrophil infiltrate, and areas of scarring. The diagnosis was erosive pustular dermatosis of the scalp, which responded favorably to topical treatment with fusidic acid plus betamethasone cream and healed with scarring alopecia. Thereafter, actinic keratoses in this patient were successfully treated with topical imiquimod to prevent outbreaks of pustulosis. During follow-up, however, he presented with hypertrophic actinic keratoses in the occipital region and numerous pustules that coalesced into lakes of pus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These actinic keratoses did not respond to imiquimod and the erosive pustular dermatosis of the scalp worsened with the use of this agent. It was then decided to try treatment with photodynamic therapy (PDT). At the first session, curettage of the most hypertrophic actinic keratoses was performed and this was followed by an application of Metvix<span class="elsevierStyleSup">®</span> (160<span class="elsevierStyleHsp" style=""></span>mg/g methyl aminolevulinate hydrochloride cream; manufactured by Penn Pharmaceutical Services Ltd, distributed by Galderma) under occlusion for 3<span class="elsevierStyleHsp" style=""></span>hours. Wood light showed intense uptake in the area (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), which was then infiltrated with local anesthetic. Irradiation was by red light (Aktilite CL128, Photocure ASA, Oslo, Norway) at a wavelength of 630 nm, with a fluence of 37<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>. A good response was observed after a week but several actinic keratoses and pustules still remained. A second session 3 weeks later cleared the actinic keratoses and the erosive pustular dermatosis of the scalp was rendered inactive (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Six months later, the improvement in the treated area was maintained and the patient is currently awaiting a further session on the occipital region to treat new actinic keratoses.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Erosive pustular dermatoses are rare inflammatory skin diseases of unknown origin that typically arise either on the legs or on the scalp. Erosive pustular dermatosis of the scalp mainly affects older patients. It is characterized by confluent sterile pustules, erosions, and scabs on the scalp that heal with scarring alopecia. Factors such as local trauma, cryotherapy, and radiotherapy<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> can trigger or worsen this condition. The differential diagnosis includes bacterial folliculitis, inflammatory tinea, blistering diseases such as cicatricial pemphigoid, dissecting cellulitis, and pyoderma gangrenosum.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Treatment is complex and the disease tends to recur. Medium- to high-potency topical corticosteroids have been used successfully, sometimes in conjunction with a topical antibiotic. Topical tacrolimus can also be effective<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and prevents the adverse effects of long-term topical corticosteroid therapy. Other treatments include oral corticosteroids, dapsone, oral retinoids (isotretinoin), and topical calcipotriol. In our patient, treatment of actinic keratoses with cryotherapy probably worsened the erosive pustular dermatosis of the scalp, and cryotherapy was therefore avoided after this second diagnosis was made.</p><p id="par0020" class="elsevierStylePara elsevierViewall">PDT is a well-established treatment for actinic keratoses and other premalignant or malignant conditions.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is particularly useful for the treatment of actinic keratoses in patients with multiple lesions or frequent recurrences. There is evidence of the value of PDT in erosive pustular dermatosis of the scalp,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> attributed to its immunomodulatory effect on inflammatory cells.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Meyer et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reported the case of a 75-year-old woman with erosive pustular dermatosis of the scalp successfully treated with PDT. Recently, Eleftheriou et al<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> published a case similar to ours of a 72-year-old man with actinic keratoses and underlying erosive pustular dermatosis of the scalp. Two sessions of PDT separated by 12 weeks led to resolution of the lesions. However, Guarneri et al<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> described the case of a 93-year-old woman who had an outbreak of erosive pustular dermatosis of the scalp after 2 sessions of PDT for actinic keratoses in the same area. Their patient received a higher fluence than ours (75<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span> compared to 37<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, respectively), and this may have resulted in the appearance of erosive pustular dermatosis of the scalp.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We report a patient with erosive pustular dermatosis of the scalp and multiple hypertrophic actinic keratoses on the scalp; both conditions responded to treatment with PDT. Two sessions of PDT led to considerable improvement, which was maintained at the 6-month follow-up. Experience of using PDT in inflammatory dermatoses like erosive pustular dermatosis of the scalp is limited, but our case provides more evidence that it can be a good therapeutic option for a disorder that is difficult to manage.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Monteagudo AF, et al. Respuesta a terapia fotodinámica en paciente con der-matosis pustulosa del cuero cabelludo y queratosis actínicas hipertróficas. Actas Dermosifiliogr. 2013;104:351–2.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 1667 "Tamanyo" => 251832 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Active lesions of erosive pustular dermatosis of the scalp together with actinic keratoses.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1110 "Ancho" => 1667 "Tamanyo" => 165210 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intense uptake by actinic keratoses as well as by the lesions of erosive pustular dermatosis of the scalp.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1155 "Ancho" => 1667 "Tamanyo" => 219767 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Note the improvement after 2 sessions of PDT.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erosive pustular dermatosis of the scalp: a successful treatment with photodynamic therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. 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Cuesta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/09546634.2010.509640" "Revista" => array:6 [ "tituloSerie" => "J Dermatolog Treat" "fecha" => "2012" "volumen" => "23" "paginaInicial" => "156" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21254852" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Molecular effects of photodynamic therapy for photoaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.S. Orringer" 1 => "C. Hammerberg" 2 => "T. Hamilton" 3 => "T.M. Johnson" 4 => "S. Kang" 5 => "D.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 14 | 24 |
| 2024 October | 95 | 57 | 152 |
| 2024 September | 110 | 38 | 148 |
| 2024 August | 160 | 65 | 225 |
| 2024 July | 141 | 51 | 192 |
| 2024 June | 115 | 45 | 160 |
| 2024 May | 101 | 42 | 143 |
| 2024 April | 90 | 29 | 119 |
| 2024 March | 92 | 36 | 128 |
| 2024 February | 94 | 42 | 136 |
| 2024 January | 76 | 43 | 119 |
| 2023 December | 85 | 28 | 113 |
| 2023 November | 89 | 32 | 121 |
| 2023 October | 85 | 36 | 121 |
| 2023 September | 76 | 36 | 112 |
| 2023 August | 76 | 28 | 104 |
| 2023 July | 113 | 47 | 160 |
| 2023 June | 97 | 28 | 125 |
| 2023 May | 95 | 52 | 147 |
| 2023 April | 92 | 43 | 135 |
| 2023 March | 76 | 40 | 116 |
| 2023 February | 86 | 28 | 114 |
| 2023 January | 58 | 31 | 89 |
| 2022 December | 56 | 44 | 100 |
| 2022 November | 45 | 29 | 74 |
| 2022 October | 45 | 33 | 78 |
| 2022 September | 58 | 58 | 116 |
| 2022 August | 42 | 40 | 82 |
| 2022 July | 43 | 51 | 94 |
| 2022 June | 48 | 45 | 93 |
| 2022 May | 85 | 55 | 140 |
| 2022 April | 127 | 51 | 178 |
| 2022 March | 72 | 56 | 128 |
| 2022 February | 77 | 34 | 111 |
| 2022 January | 71 | 40 | 111 |
| 2021 December | 49 | 41 | 90 |
| 2021 November | 68 | 46 | 114 |
| 2021 October | 76 | 57 | 133 |
| 2021 September | 56 | 40 | 96 |
| 2021 August | 55 | 45 | 100 |
| 2021 July | 36 | 45 | 81 |
| 2021 June | 57 | 35 | 92 |
| 2021 May | 43 | 66 | 109 |
| 2021 April | 91 | 50 | 141 |
| 2021 March | 67 | 41 | 108 |
| 2021 February | 49 | 41 | 90 |
| 2021 January | 42 | 20 | 62 |
| 2020 December | 41 | 11 | 52 |
| 2020 November | 20 | 15 | 35 |
| 2020 October | 22 | 11 | 33 |
| 2020 September | 43 | 18 | 61 |
| 2020 August | 23 | 21 | 44 |
| 2020 July | 24 | 15 | 39 |
| 2020 June | 25 | 21 | 46 |
| 2020 May | 30 | 20 | 50 |
| 2020 April | 40 | 20 | 60 |
| 2020 March | 22 | 17 | 39 |
| 2020 February | 5 | 2 | 7 |
| 2020 January | 0 | 8 | 8 |
| 2019 December | 4 | 5 | 9 |
| 2019 November | 0 | 3 | 3 |
| 2019 October | 0 | 4 | 4 |
| 2019 September | 4 | 12 | 16 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 0 | 4 | 4 |
| 2019 June | 2 | 12 | 14 |
| 2019 May | 1 | 23 | 24 |
| 2019 April | 0 | 1 | 1 |
| 2019 March | 4 | 8 | 12 |
| 2019 January | 3 | 0 | 3 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 2 | 0 | 2 |
| 2018 May | 0 | 7 | 7 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 1 | 1 | 2 |
| 2018 February | 74 | 6 | 80 |
| 2018 January | 94 | 3 | 97 |
| 2017 December | 101 | 7 | 108 |
| 2017 November | 65 | 5 | 70 |
| 2017 October | 77 | 7 | 84 |
| 2017 September | 72 | 8 | 80 |
| 2017 August | 65 | 17 | 82 |
| 2017 July | 79 | 3 | 82 |
| 2017 June | 61 | 27 | 88 |
| 2017 May | 54 | 4 | 58 |
| 2017 April | 52 | 13 | 65 |
| 2017 March | 40 | 39 | 79 |
| 2017 February | 134 | 4 | 138 |
| 2017 January | 84 | 6 | 90 |
| 2016 December | 68 | 5 | 73 |
| 2016 November | 139 | 5 | 144 |
| 2016 October | 144 | 18 | 162 |
| 2016 September | 210 | 11 | 221 |
| 2016 August | 163 | 7 | 170 |
| 2016 July | 63 | 5 | 68 |
| 2016 June | 5 | 3 | 8 |
| 2016 May | 5 | 11 | 16 |
| 2016 April | 4 | 6 | 10 |
| 2016 March | 8 | 2 | 10 |
| 2016 February | 10 | 9 | 19 |
| 2016 January | 6 | 12 | 18 |
| 2015 December | 13 | 8 | 21 |
| 2015 November | 11 | 12 | 23 |
| 2015 October | 10 | 15 | 25 |
| 2015 September | 16 | 5 | 21 |
| 2015 August | 12 | 1 | 13 |
| 2015 July | 117 | 131 | 248 |
| 2015 June | 89 | 8 | 97 |
| 2015 May | 111 | 16 | 127 |
| 2015 April | 51 | 7 | 58 |
| 2015 March | 56 | 5 | 61 |
| 2015 February | 57 | 4 | 61 |
| 2015 January | 59 | 2 | 61 |
| 2014 December | 63 | 5 | 68 |
| 2014 November | 49 | 2 | 51 |
| 2014 October | 60 | 1 | 61 |
| 2014 September | 40 | 2 | 42 |
| 2014 August | 48 | 6 | 54 |
| 2014 July | 40 | 3 | 43 |
| 2014 June | 52 | 6 | 58 |
| 2014 May | 52 | 6 | 58 |
| 2014 April | 43 | 3 | 46 |
| 2014 March | 43 | 9 | 52 |
| 2014 February | 40 | 4 | 44 |
| 2014 January | 33 | 9 | 42 |
| 2013 December | 37 | 6 | 43 |
| 2013 November | 31 | 7 | 38 |
| 2013 October | 21 | 3 | 24 |
| 2013 September | 21 | 2 | 23 |
| 2013 August | 24 | 5 | 29 |
| 2013 July | 11 | 5 | 16 |
| 2013 June | 2 | 0 | 2 |
| 2013 May | 4 | 3 | 7 |
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