What is the treatment for pustules on the scalp?

Treatment of Scalp Pustules

The most important first step is to obtain fungal and bacterial cultures from the scalp pustules before initiating treatment, as the most common cause is inflammatory tinea capitis (fungal infection), which requires systemic antifungal therapy, not just topical or antibiotic treatment. 1

Immediate Diagnostic Approach

• Collect specimens by plucking hairs, scraping scale with a blunt scalpel, or using scalp brushings before starting any treatment, as laboratory confirmation is essential to identify the causative organism and guide systemic therapy 1
• Look specifically for these clinical patterns that indicate fungal infection:
  • Diffuse pustular pattern: scattered pustules with patchy alopecia and painful regional lymphadenopathy 1
  • Kerion: painful, boggy inflammatory mass studded with pustules and thick crust (commonly misdiagnosed as bacterial abscess) 1
  • Associated findings: broken hair stubs ("black dot"), fine scaling, or areas of hair loss 1

Primary Treatment Algorithm

If Tinea Capitis (Fungal Infection) is Suspected or Confirmed:

Systemic antifungal therapy is mandatory - topical treatments alone are insufficient for scalp fungal infections 1

• The specific antifungal agent and duration depend on the identified organism (Trichophyton vs Microsporum species) 1
• For inflammatory variants with kerion, add oral corticosteroids (topical or occasionally oral if severe) to reduce the host inflammatory response - this does NOT require stopping antifungal therapy 1
• A common pitfall: Do not mistake kerion for bacterial abscess - while secondary bacterial infection can occur and should be cultured, the primary pathology is fungal and requires antifungal treatment 1

If Secondary Bacterial Infection is Present:

• Obtain bacterial cultures before starting antibiotics to guide therapy based on sensitivities 1
• Administer antibiotics for at least 14 days based on culture results 1
• Signs suggesting bacterial superinfection include: failure to respond to initial treatment, painful lesions, pustules extending to arms/legs/trunk, yellow crusts, or discharge 1

If Erosive Pustular Dermatosis (Rare, Elderly Patients):

• This presents as sterile pustules, erosions, and crusted lesions in elderly patients, often after trauma or cryotherapy 2
• Treat with potent topical corticosteroids twice daily, with improvement typically seen within 10 days 2
• Maintenance therapy with topical tacrolimus prevents relapse 2

Symptomatic Management During Treatment

• Topical low-to-moderate potency corticosteroids (hydrocortisone 2.5% or alclometasone 0.05%) can be applied for symptomatic relief of inflammation 1
• Oral antihistamines may help with pruritus that persists after treatment initiation 1
• Avoid frequent washing with hot water, which worsens inflammation 1

Critical Pitfalls to Avoid

• Never treat presumptively without cultures - the causative organism determines whether systemic antifungals, antibiotics, or both are needed 1
• Do not stop antifungal therapy if a "dermatophytid" reaction develops - this pruritic papular eruption (especially around the ear) represents a cell-mediated response to effective treatment and should be managed with topical corticosteroids while continuing antifungals 1
• Do not use topical antifungals alone for scalp infections - they cannot penetrate hair follicles adequately 1
• Send post-treatment samples to confirm clearance before discontinuing therapy 1

When Bacterial Infection is the Primary Concern

If pustular acne or folliculitis (not fungal) is confirmed:

• Oral antibiotics for 6 weeks (doxycycline 100 mg twice daily, minocycline 50 mg twice daily, or oxytetracycline 500 mg twice daily) combined with topical low/moderate potency steroids 1
• For resistant cases, consider co-trimoxazole with topical gentamicin 3
• Reassess after 2 weeks; if no improvement, obtain cultures and adjust antibiotics based on sensitivities 1