Erosive pustular dermatosis of the scalp: treatment with topical tacrolimus.

A 65-year-old man had an 8-year history of erosive, pustular, and atrophic lesions on his alopecic scalp (Figure1). The lesions developed since 1992, after treatment of actinic keratoses by topical fluorouracil and local trauma. Histologic examination of a skin biopsy specimen revealed an ulcerated atrophic epidermis with parakeratosis; a chronic inflammatory dermal infiltrate composed of lymphocytes, macrophages, and neutrophils; and a complete absence of hair follicles. Results of direct immunofluorescence microscopy and microbiologic examination were negative. Blood zinc level was within normal limits, and serum immunoelectrophoresis did not show a monoclonal gammopathy. No evidence for an underlying systemic disease was found to suggest superficial pyoderma gangrenosum. The diagnosis of erosive pustular dermatosis of the scalp (EPDS) was then made. The patient had been treated in 1993 with a 1-year course of topical 0.05% retinoic acid, and thereafter with a 5-month course of 30-mg/d oral isotretinoin, which resulted in worsening of the lesions. Furthermore, a 2-month trial with 100 mg/d of oral sulfapyridine was ineffective. From 1995 to 1999, repeated applications of potent topical corticosteroids (clobetasol propionate and mometasone furoate) improved the skin disease, but also increased the skin atrophy (Figure 2), with erythema and telangiectasias.