Progressive Scalp and Neck Dermatitis with Hair Loss in Young Adult

Case at a Glance

A 36-year-old female presents with a progressive scaling and inflammatory rash affecting the scalp, ears, and neck over several months, associated with hair thinning and significant patient distress.

Patient's Story

The patient reported the onset of a rash on her scalp, ears, and neck that began several months prior to presentation. She described progressive worsening of symptoms despite self-treatment measures. The patient noted associated hair thinning and scalp flaking. She reported similar but milder episodes in the past that had resolved spontaneously. The patient expressed significant concern about her condition but indicated financial constraints preventing formal medical evaluation. She had been self-treating with topical emollients (petroleum-based ointment and coconut oil) applied daily, along with rotating between three different over-the-counter medicated shampoos.

Initial Assessment

Physical examination revealed a well-demarcated erythematous, scaling rash with sharp borders affecting the scalp, postauricular areas, and neck. The lesions showed characteristic scaling and inflammation. Hair thinning was noted in affected areas. The sharp cutoff pattern of the rash raised suspicion for contact dermatitis versus seborrheic dermatitis.

The Diagnostic Journey

Given the distinct border pattern and distribution, differential diagnosis included allergic contact dermatitis, seborrheic dermatitis, and psoriasis. The sharp demarcation suggested possible contact sensitivity to topical products. Patient history revealed no recent changes in personal care products, medications, or environmental exposures. She had been stable on opioid replacement therapy (suboxone) for four years without previous skin reactions.

Final Diagnosis

Suspected allergic contact dermatitis, likely secondary to topical product sensitivity, with possible concurrent seborrheic dermatitis component.

Treatment Plan

Immediate discontinuation of all topical treatments, particularly petroleum-based products. Patient was advised to use gentle, fragrance-free cleansers and avoid potential allergens. Recommendation for patch testing to identify specific contact allergens when resources permit. Short-term topical corticosteroid therapy was considered if accessible.

Outcome and Follow-up

Patient was counseled on allergen avoidance and the potential for delayed-onset sensitivity reactions to previously tolerated products. Follow-up was recommended to monitor response to product discontinuation and assess need for formal dermatological evaluation and patch testing.