Dissecting Cellulitis of the Scalp: Linking Pathogenesis to Therapy

Dissecting cellulitis of the scalp (DCS) is a chronic, inflammatory follicular occlusion disorder characterized by painful nodules, abscesses, and sinus tracts that lead to scarring alopecia. The therapeutic goal is to limit disease progression and the extent of scarring. Although DCS is traditionally managed with systemic retinoids, antibiotics, and surgical interventions, therapeutic responses are variable and long-term remission remains challenging. Recent insights into the immunological overlap between DCS, hidradenitis suppurativa (HS), and other autoinflammatory follicular disorders have expanded therapeutic options, particularly with biologic agents targeting tumor necrosis factor alpha (TNF-α), interleukin (IL)-17, and IL-23 pathways, as well as Janus kinase (JAK) inhibitors. This review synthesizes the current evidence on medical, procedural, and emerging targeted therapies for DCS, incorporating data from case reports, case series, retrospective cohorts, and recent systematic reviews up to 2025. Special emphasis is placed on the evolving role of biologics and small-molecule inhibitors, which show growing promise for refractory or syndromic presentations. Current evidence supports a stepwise, phenotype-driven approach in which systemic retinoids remain first-line systemic therapy, while biologics represent a rational and increasingly evidence-supported option for moderate-to-severe, treatment-resistant, or syndromic disease. Further controlled studies are needed to define optimal sequencing, duration, and combination strategies for long-term management.