A 52 Year Old Man with Cerebriform Vegetating Masses on the Scalp

Abstract

In November 2013, a 52 year old man presented with two large nodular cerebriform vegetating masses in the temporal regions of the scalp extending to the occipital regions. These lesions had appeared and worsened during the preceding years. They resembled the folded pattern of cutis verticis gyrata and were studded with pustules in the follicular ostia. Hair was sparse to absent on the gyri and tufted folliculitis-like pattern was seen wherever clusters of hair emerged from sulci between folds (Fig. 7.1). Lesions were foul-smelling. The uninvolved occipital area showed mild skin folding of cutis verticis gyrata. Discrete erosions were also seen in the oral mucosa, as well as a few blisters on his trunk and left knee. He was receiving prednisolone 20 mg/day and methotrexate 10 mg/week. A deep biopsy was performed from his scalp. Suprabasal clefts, acantholysis and tombstone pattern were seen histopathologically. In addition, verrucous acanthosis, papillomatosis, epidermal hyperplasia and heavy dermal inflammatory infiltrate were prominent. Direct immunofluorescence was positive for intercellular epidermal IgG and C3 deposits. KOH smear was negative for fungi. In a culture from the scalp pustules Staphylococcus aureus was retrieved.