What is the treatment for abscesses on the scalp with associated hair loss?

Treatment of Scalp Abscesses with Associated Hair Loss

Incision and drainage is the definitive treatment for scalp abscesses, with antibiotics added only when systemic signs of infection are present or in high-risk patients; the underlying cause of hair loss must be identified separately, as it may represent alopecia areata, folliculitis decalvans, or other scarring alopecias requiring distinct management. 1, 2

Immediate Management of the Abscess

Primary Treatment: Incision and Drainage

• Perform incision and drainage promptly for all scalp abscesses - this is the definitive treatment regardless of size 1, 2
• Simply cover the surgical site with dry sterile gauze after drainage; wound packing causes more pain without improving healing 1, 2
• Needle aspiration should not be attempted, as it has only 25% success rate overall and <10% success with MRSA infections 1

Culture and Microbiological Testing

• Obtain Gram stain and culture of pus from the abscess to identify the causative organism, though treatment can proceed without waiting for results in typical cases 1
• Consider atypical organisms if there is history of scalp injections (corticosteroids for hair loss treatment), as Mycobacterium abscessus has been reported in this context 3
• Culture is particularly important for recurrent abscesses to guide targeted antibiotic therapy 1

When to Add Antibiotics to Incision and Drainage

Indications for Antibiotic Therapy

Antibiotics are not needed for simple abscesses treated with adequate incision and drainage alone 1, 2. Add antibiotics when:

• Systemic inflammatory response syndrome (SIRS) is present: temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or WBC >12,000 or <4,000 cells/µL 1, 2
• Multiple infection sites or rapid progression with surrounding cellulitis 2
• Immunocompromised patients (including HIV-positive patients) 2, 4
• Abscess in difficult-to-drain areas 2
• Lack of response to incision and drainage alone 2

Antibiotic Selection

• First-line oral options for outpatient MRSA coverage: clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, or minocycline 2
• Duration: 5-10 days when antibiotics are indicated 1, 2
• Do not use rifampin as single agent or adjunctive therapy for skin abscesses 2
• Do not use fluoroquinolones for MRSA coverage, as they are inadequate 2

Identifying the Underlying Cause of Hair Loss

The presence of abscesses with hair loss requires distinguishing between several distinct entities:

Folliculitis Decalvans (Scarring Alopecia with Pustules)

• Presents with follicular pustules, perifollicular erythema, and progressive scarring alopecia, typically at vertex and occipital scalp 4, 5
• Treatment approach: Oral fusidic acid 500 mg three times daily for 2-3 months has shown success 4
• Alternative: Combination of clindamycin with rifampicin (most commonly used for this condition) 4
• Tetracyclines are also frequently used 4
• Topical betamethasone dipropionate 0.05% with salicylic acid 3% can be added as adjunctive therapy 4

Dissecting Cellulitis (Perifolliculitis Capitis Abscedens et Suffodiens)

• Severe suppurative process with fluctuating painful fistule-forming abscesses, typically occipital scalp, resulting in extensive scarring 6
• Treatment requires combination therapy: systemic antibiotics (metronidazole plus clindamycin), surgical drainage of nodular formations, and high-dose isotretinoin 1 mg/kg for 3-5 months 6

Recurrent Furunculosis

• Deep follicular infections with S. aureus, often recurrent and may spread among family members 7
• Management strategy: Incision and drainage for fluctuant lesions, plus consideration of decolonization 7
• For recurrent S. aureus infections: 5-day decolonization regimen with intranasal mupirocin twice daily, daily chlorhexidine washes, and daily decontamination of personal items 1
• Culture patient, family members, and close contacts to identify chain of infection 7

Alopecia Areata (Non-Scarring, No True Abscesses)

• If the "abscesses" are actually inflamed patches without true suppuration, consider alopecia areata 1
• Diagnosis: look for exclamation mark hairs, yellow dots on dermoscopy, and absence of scarring 1
• Treatment for patchy alopecia areata: intralesional triamcinolone acetonide 5-10 mg/mL injected into affected areas 1
• Spontaneous remission occurs in 80% with limited patches of <1 year duration 1

Critical Diagnostic Considerations

Essential Investigations When Diagnosis is Unclear

• Fungal culture to rule out tinea capitis (scalp inflamed with scaling) 1
• Skin biopsy for suspected scarring alopecia 1
• Consider serology for lupus erythematosus and syphilis if clinical features suggest 1
• Acid-fast bacilli staining and culture if history of scalp injections or minimal symptoms despite large lesions 3

Common Pitfalls to Avoid

• Do not routinely prescribe antibiotics for simple abscesses after adequate incision and drainage - this contributes to resistance without improving outcomes 2
• Do not confuse alopecia areata (autoimmune, non-scarring) with infectious scarring alopecias - the former has preserved follicles and potential for complete recovery 1
• Do not delay treatment of scarring alopecias, as hair follicle destruction is irreversible once scarring occurs 5
• In recurrent cases, failure to culture and identify carriers among close contacts perpetuates the cycle of reinfection 1, 7