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Erosive Pustular Dermatosis
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Erosive pustular dermatosis (EPD) is a chronic inflammatory skin disorder of the scalp. It primary affects elderly patients, though patients as young as six months have been reported with the condition. EPD is more common in women than men. The lesions appear as thick yellow crusts, erosions, and sterile pustules on a bed of atrophic skin. EPD will damage hair follicles leading to a scarring alopecia. There may be associated symptoms such as pain or itching. The typical signs of infection including edema, lymphadenopathy, and warmth are not present. The findings of EPD are nonspecific and may be present in other disease processes.

The etiology of EPD is unclear, but it is thought to be caused by sun damage or local mechanical trauma from procedures or topical medicines. Some of the associated therapies include cryotherapy and topical chemotherapy for treatment of actinic keratosis or superficial skin cancers, surgery, skin grafting, and laser therapy. Autoimmune disorders including Hashimoto’s thyroiditis, autoimmune hepatitis, and rheumatoid arthritis have been reported in association with the skin condition. EPD has also been reported on the lower legs of patients with long-standing venous insufficiency who are undergoing compression therapy.

The diagnosis for EPD is made clinically by your physician. The time to diagnosis may be prolonged because it is often mistaken for an infectious or cancerous process. Fungal and bacterial cultures of the lesions are typically negative. It is important to biopsy the lesions to rule out other diseases that present in a similar fashion. Other special tests such as Tzanck smears and immunofluorescence studies may be of use to the medical provider to eliminate an autoimmune bullous (blistering) disorder from the list of possible diagnoses. Imaging is not necessary to diagnose EPD.

Erosive pustular dermatosis is a chronic condition requiring long-term therapy. Initial therapy involves good local skin care including debriding the crusts and daily washing. High-potency topical steroids are first-line treatment; however, the major disadvantage of topical steroids is the potential for additional skin atrophy with prolonged use. Other treatments such as topical tacrolimus, topical and oral retinoids, and topical calcipotriene have been effective in certain cases. Light therapy, though a documented cause of EPD, seems to be effective in a subset of patients. Topical and oral antibiotics have been unsuccessful for treatment. Surgery is not recommended due to potential worsening of the condition.

In summary, EPD is a slowly progressive chronic inflammatory skin condition usually found on the scalp of elderly women that results in hair loss. The diagnosis is often delayed due to the characteristic nonspecific skin findings. During follow-up care, patients with EPD should be monitored for secondary skin cancers including squamous cell carcinoma and basal cell carcinoma. EPD will typically reoccur if treatment is stopped, though it responds well once the initial treatment is resumed.  Sun protection is recommended for all patients.


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