By Sanusi Umar, MD

In a consecutive series of 12 men evaluated for suspected or confirmed dissecting cellulitis of the scalp, three met a demanding set of prespecified criteria. Each had clinicopathologically confirmed acne keloidalis nuchae at the posterior hairline and nape, dissecting cellulitis involving at least three scalp zones, and extensive cutis verticis gyrata involving at least three zones.

The repetition was not limited to appearance. It extended to anatomic distribution, patient-reported sequence, and biopsy findings. That convergence led our team to propose the AKN-DCS-CVG constellation as a candidate syndromic triad rather than three unrelated diagnoses occurring in the same patients.

The open-access paper, “A Candidate Syndromic Triad of Acne Keloidalis Nuchae, Dissecting Cellulitis, and Secondary Cutis Verticis Gyrata,” was published August 28, 2026, in Clinical, Cosmetic and Investigational Dermatology. The authors are Sanusi Umar, MD; Ochanya Ogah, MD; Jason Yang, MD; Belinda H Tan, MD, PhD; Nancy Aiead; and Paul K Shitabata, MD.

Three patients, one recurring clinicopathologic pattern

Acne keloidalis nuchae, or AKN, is a folliculocentric inflammatory scarring disorder that usually centers on the posterior hairline and nape. Dissecting cellulitis of the scalp, or DCS, produces boggy inflammatory nodules, drainage, and scarring alopecia. Cutis verticis gyrata, or CVG, describes deep ridges and furrows that give the scalp a folded appearance. In these cases, CVG was interpreted as secondary to severe chronic inflammatory and fibrotic scalp remodeling.

The three patients were 30 to 40 years old. Two identified as Hispanic and one as African American. All had class II or class III tumorous AKN, diffuse DCS, and extensive cerebriform scalp folding. Their nuchal and scalp lesions were not assigned solely from photographs. The diagnoses were supported by examination, trichoscopy, scalp-zone mapping, and biopsies reviewed by two board-certified dermatopathologists.

“These conditions can be diagnosed and treated separately, so their relationship may be missed,” Dr. Umar said. The practical concern is that an examination focused only on the most obvious lesion may fail to identify disease elsewhere on the scalp.

The nape disease was reported first

All three patients reported the same chronology. Disease at the posterior hairline and nape began first. Approximately 1 to 2 years later, diffuse inflammatory scalp disease and scalp furrowing were recognized.

That repeated sequence is important, but it must be interpreted carefully. The study was retrospective, and chronology depended on patient recall. It does not prove that AKN caused DCS or CVG. It does, however, identify a recurring order of clinical events that deserves prospective study.

The sequence also changes what clinicians should ask. A patient presenting with extensive scalp nodules and folds may need a detailed history of earlier papules, pustules, plaques, or masses at the posterior hairline. Conversely, a patient with severe AKN should be asked about new scalp pain, drainage, nodules, hair loss, and progressive folding outside the nuchal area.

CVG may mark a more extensive phenotype

The new report builds on an earlier 108-patient AKN cohort. In that study, CVG was present in three of seven patients with scalp-wide AKN, compared with one of 101 patients without scalp-wide AKN. In the three affected scalp-wide cases, AKN preceded CVG by approximately 1 to 2 years.

The current series adds a further element: all three patients with the complete triad had scalp-wide DCS supported by clinical and histopathologic assessment. This suggests that CVG may be a visible marker of a more extensive inflammatory and fibrotic scalp phenotype.

The finding does not establish a single mechanism. Secondary CVG may represent downstream remodeling produced by severe overlapping AKN and DCS rather than a separate disease process. That distinction is one reason the authors use the terms “candidate” and “syndromic triad” rather than claiming that a distinct inherited syndrome has been proven.

Multisite biopsy connected the clinical findings

The biopsy framework sampled three diagnostic compartments in each triad case: a representative nuchal lesion, an active inflammatory scalp lesion, and clinically normal-appearing scalp located away from visible inflammation.

Nuchal specimens showed a fibrosing scarring alopecia centered on the folliculosebaceous unit, with follicular destruction, lamellar fibroplasia, mixed inflammation, keratinaceous debris, and foreign-body reaction, supporting AKN. Active scalp lesions showed follicular occlusion and rupture, neutrophil-rich suppurative inflammation, foreign-body reaction, and dermal fibrosis, supporting DCS.

The third compartment provided the most unifying observation. Clinically normal-appearing scalp in all three patients showed perifollicular infundibulo-isthmic lymphocytic inflammation and fibrosis, known as PIILIF. This pattern consists of lymphocytic inflammation and early fibrosis around the upper hair follicle, even where the scalp does not look visibly inflamed or scarred.

A companion 12-patient DCS study found PIILIF in all clinically normal-appearing scalp biopsies and in all sampled clinically inactive nodules. Active DCS lesions retained that pattern but added prominent suppurative inflammation and remodeling. Across AKN, DCS, and clinically normal-appearing scalp in the triad cases, immunohistochemistry also showed a similar CD4-predominant T-cell pattern and prominent CD117-positive mast cells.

These findings provide biologic coherence, but they are not disease-specific. The cross-sectional data cannot determine whether PIILIF precedes, follows, or coexists with clinically apparent AKN and DCS. It should therefore be viewed as a hypothesis-generating shared histologic signature, not a proven cause.

A father-son clue, but not proof of inheritance

One patient’s father had severe cystic acne, chronic inflammatory boggy scalp lesions suggestive of DCS, diffuse scalp folding consistent with CVG, and a posterior hairline plaque suggestive of AKN. The visual similarity across two generations is notable.

It is not diagnostic proof. The father did not undergo biopsy, so the published report classifies his presentation as a clinically suspected but unconfirmed triad-like phenotype. The observation raises the possibility of shared susceptibility, especially because familial AKN and familial DCS have been reported, but one family cannot establish heritability or identify a genetic mechanism.

Systematic family histories and, where appropriate, clinical and pathologic evaluation of relatives should be considered in future studies. Any genetic conclusion will require a larger, independently ascertained cohort.

What clinicians should look for

The central clinical message is reciprocal examination.

In a patient with AKN, new scalp folds or diffuse boggy, painful, or draining nodules should prompt examination of the entire scalp for DCS. In a patient with DCS, the posterior hairline and nape should be deliberately examined for AKN papules, plaques, or masses. Extensive CVG in either setting may signal a high burden of inflammation and fibrotic remodeling.

Trichoscopy can help map perifollicular erythema, scale, casts, and other abnormalities that may not be obvious on routine inspection. When morphology is atypical, disease appears to overlap, or the diagnosis will affect management, trichoscopy-guided multisite biopsy can improve clinicopathologic adjudication.

The study did not evaluate treatment and does not establish that earlier therapy prevents DCS, CVG, scarring, or relapse. It therefore does not support a specific treatment algorithm. Its immediate value is diagnostic: recognize that disease may extend beyond the most visible region, examine the full scalp and nape, and consider early referral to a hair-disorders specialist.

A candidate syndrome that now needs validation

This was a small, retrospective, single-center case series drawn from a referral-enriched clinic population. The three cases identified among 12 men should not be interpreted as a prevalence estimate. Patient recall may have affected chronology, standardized longitudinal follow-up was unavailable, and the father’s triad-like phenotype was not histologically confirmed.

The next step is prospective, multicenter validation with standardized scalp-zone examination, trichoscopy, multisite biopsy, longitudinal follow-up, and systematic assessment of relatives. Larger studies can determine how often the constellation occurs, whether the reported chronology is reproducible, which patients are most at risk for extensive remodeling, and whether PIILIF has prognostic or therapeutic value.

For now, the evidence supports a careful conclusion: severe AKN, scalp-wide DCS, and extensive secondary CVG can occur as a reproducible clinicopathologic constellation. Recognizing that pattern may help clinicians identify coexisting disease across scalp regions sooner and may create a stronger foundation for future therapeutic research.

We are grateful to the patients who permitted publication of their clinical details and photographs, and to every coauthor whose work made the study possible.

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Further Reading

1. https://dru.com/acne-keloidalis-nuchae-dissecting-cellulitis-john-case/
2. https://dru.com/piilif-in-dissecting-cellulitis-what-paired-biopsies-reveal-across-normal-appearing-scalp-quiet-nodules-and-active-lesionspiilif-in-dissecting-cellulitis/
3. Umar, Sanusi et al. “A Retrospective Cohort Study and Clinical Classification System of Acne Keloidalis Nuchae.” The Journal of clinical and aesthetic dermatology vol. 14,4 (2021): E61-E67.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142833/

The post Acne Keloidalis Nuchae, DissectingCellulitis, and CVG: A Candidate Syndromic Triad appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

If your scalp bumps settle and then return, read this

A painful scalp bump appears. Pressure builds. It may become tender, swell, drain pus and then seem to calm down.

For a while, there is relief.

Then the same area becomes active again, or a new bump appears nearby.

For people living with dissecting cellulitis, this cycle can affect far more than the scalp. Drainage can stain pillowcases, hats or clothing. There may be concern about odor. Haircuts become difficult. Pain interferes with sleep. Visible scarring and hair loss can cause embarrassment and make people withdraw socially.

The most frustrating part is often the recurrence. A bump can look quiet while the disease later returns in that area or extends elsewhere.

Our newly published study asked whether the visible bumps are only part of the story.

The answer may be important: in this small study, a hidden pattern of inflammation and early fibrosis called PIILIF was found not only in active dissecting cellulitis lesions, but also in every normal-looking scalp sample and every clinically quiet nodule examined. 

What is dissecting cellulitis of the scalp?

Dissecting cellulitis of the scalp, also called perifolliculitis capitis abscedens et suffodiens, is a chronic, relapsing form of scarring alopecia.

It can cause:

• Deep, painful scalp bumps 
• Pus-filled lesions 
• Drainage 
• Abscesses 
• Tunnels beneath the skin, also called sinus tracts 
• Thickened scar tissue 
• Permanent hair loss 

As the condition becomes more destructive, hair follicles can rupture and be replaced by scar tissue. Once a follicle has been permanently destroyed by scarring, it may no longer be capable of producing hair. 

Dissecting cellulitis has traditionally been understood mainly through its most visible and destructive phase: inflamed nodules, pus, follicular rupture, tunnels and scarring.

But those features do not fully explain why the disease returns after appearing quiet, why it spreads into nearby scalp or why a firm residual bump can later become inflamed again.

The question our study asked

We asked a straightforward question:

In a patient with dissecting cellulitis, is scalp that looks normal truly normal under the microscope?

The study included 12 consecutive men with dissecting cellulitis confirmed through clinical examination and biopsy.

Using magnified scalp examination, called trichoscopy, we obtained two small scalp samples during the same evaluation:

1. One biopsy from scalp that showed no visible nodule, pustule, tunnel or hair loss 
2. One biopsy from an active lesion or, when no active lesion was present, a firm but clinically quiet nodule 

The specimens were examined in both vertical and horizontal planes and independently reviewed by two board-certified dermatopathologists who were blinded to the clinical details. 

What we found beneath normal-looking scalp

PIILIF was found in all 12 normal-looking scalp biopsies.

PIILIF stands for perifollicular infundibulo-isthmic lymphocytic inflammation and fibrosis. In plain language, it describes immune-cell inflammation and early fibrotic change concentrated around the upper part of the hair follicle.

This means that scalp without visible bumps, pus, tunnels or hair loss still showed a consistent inflammatory and early fibrotic pattern under the microscope.

That finding supports the possibility that dissecting cellulitis may affect a wider field of scalp than the visible lesions suggest. 

The qualification matters: this was a small, specialty-clinic cohort. Finding PIILIF in 12 of 12 normal-looking samples does not establish that it is present in every person with dissecting cellulitis.

A quiet bump may not be biologically quiet

Three patients had no visibly active lesion when their biopsies were taken. Instead, they had firm residual nodules without redness, tenderness, drainage or other signs of active inflammation.

PIILIF was found in all three clinically quiet nodules.

These quiet nodules did not show the destructive, pus-forming changes seen in active disease. Their sebaceous glands, commonly known as oil glands, were also preserved.

This is an important distinction.

A nodule that looks calm may no longer be in an active destructive phase, but the presence of PIILIF suggests that the tissue may not be completely normal at the microscopic level. Because only three quiet nodules were studied, this finding should be viewed as an early clue that requires confirmation in larger studies. 

What changes when dissecting cellulitis becomes actively destructive

The nine active lesions showed two overlapping patterns.

The first was PIILIF, the upper-follicle inflammatory and early fibrotic pattern also found in normal-looking scalp.

The second was the aggressive, pus-forming destruction traditionally associated with active dissecting cellulitis.

Among the nine active lesions:

• All nine contained neutrophils, the white blood cells strongly associated with pus-forming inflammation 
• Five showed granulation tissue, indicating ongoing injury and tissue repair 
• Six showed complete loss of sebaceous glands 
• Six showed follicular rupture or destruction 
• Six contained hair shafts released into the surrounding tissue 

In other words, active disease did not replace PIILIF. The destructive flare appeared on top of a PIILIF background. 

The oil-gland clue

Sebaceous glands are part of the hair-follicle unit and produce the oils associated with the follicular environment.

In the study:

• Sebaceous glands were preserved in the clinically quiet nodules 
• Complete sebaceous gland loss was absent from the matched normal-looking scalp samples 
• Complete sebaceous gland loss was found in six of the nine active lesions 

This difference raises an important possibility: sebaceous gland destruction may help mark a transition toward a more damaging and potentially less reversible phase of disease.

That is a hypothesis, not a proven sequence.

Because the study examined patients at one point in time, it could not determine whether PIILIF develops first, whether it persists after an active lesion improves or whether quiet nodules represent partly treated lesions, spontaneously improved lesions or samples taken outside a destructive focus. 

Why dissecting cellulitis may relapse or spread

The findings support what researchers call a field-effect hypothesis.

Under this model, the painful, draining bumps are the most visible expression of the disease, but a quieter inflammatory field may extend into scalp that appears unaffected.

This could help explain:

• Why a flare returns after appearing to settle 
• Why new lesions develop near previously affected areas 
• Why a quiet nodule later becomes active 
• Why visible treatment of one bump may not address the full scalp environment 
• Why dissecting cellulitis sometimes overlaps with other follicle-centered scarring disorders 

The study shows an association across these scalp states. It does not yet prove that PIILIF causes relapse, predicts spread or inevitably progresses into a destructive lesion. 

Why “dandruff” can be misleading

Three of the 12 patients had previously been treated for presumed seborrheic dermatitis, commonly called dandruff.

None of the biopsies taken for this study showed the microscopic features needed to support seborrheic dermatitis.

This does not mean that ordinary dandruff is dissecting cellulitis. Seborrheic dermatitis is common, and most people with dandruff do not have PIILIF or dissecting cellulitis.

The practical message is narrower:

When redness, scale or flaking persists alongside painful bumps, drainage, progressive scarring or unexplained hair loss, the diagnosis may deserve another look.

The study authors also acknowledged that prior antifungal shampoos or topical corticosteroids could have reduced signs of seborrheic dermatitis before biopsy. The absence of seborrheic dermatitis in these samples therefore cannot prove that every earlier diagnosis was wrong. 

How this connects with acne keloidalis nuchae and the wider PIILIF research

Three of the 12 patients, or 25%, also had biopsy-confirmed acne keloidalis nuchae (AKN) on the back of the scalp. PIILIF was also identified in a sideburn biopsy from one patient. 

These findings connect with two earlier studies from our group.

In our AKN study, PIILIF was found in normal-looking scalp in all 41 patients examined. That work proposed that a broader, clinically subtle follicle-centered process may coexist with visible AKN lesions. 

In our androgenetic alopecia study, PIILIF was found in normal-looking scalp in 81% of a 129-patient referral-center cohort and was more common in advanced or treatment-resistant pattern hair loss. 

Taken together, these studies identify a recurring upper-follicle inflammatory and early fibrotic pattern across clinically different forms of hair loss.

They do not yet prove that PIILIF is the universal cause of AKN, pattern baldness, dissecting cellulitis or every scarring alopecia. They do, however, establish a focused research direction that deserves further study.

What this study does not prove

The findings are important, but they must be interpreted within the study’s limits:

• The cohort included only 12 men from one specialty clinic 
• There was no healthy control group 
• Only three clinically quiet nodules were studied 
• The study was retrospective and cross-sectional 
• It cannot establish whether PIILIF comes before, follows or persists after active disease 
• Prior treatments were not standardized and may have changed some biopsy findings 
• The study did not compare treatments 
• It did not prove that treating PIILIF prevents relapse, spread or permanent hair loss 

Larger controlled studies following patients over time are needed to determine whether PIILIF predicts new lesions, extension, relapse or treatment response. 

What patients should do

Consider evaluation by a dermatologist experienced in scarring alopecia when you have:

• Recurrent painful scalp bumps 
• Pus or repeated drainage 
• Firm nodules that repeatedly become inflamed 
• Tunnels beneath the scalp 
• Progressive scarring or permanent hair loss 
• Disease extending beyond the original lesion 
• Persistent redness or scale that does not behave like routine dandruff 
• A history of dissecting cellulitis together with AKN, severe acne or hidradenitis suppurativa 

Not every patient needs multiple biopsies. The decision should be based on the history, clinical examination, palpation, trichoscopy, prior pathology and the question that needs to be answered.

The central lesson from this research is simple:

Do not assume that the edge of the visible bump is necessarily the edge of the disease.

Request a Complex Dissecting Cellulitis and Scarring Alopecia Evaluation

For patients with recurrent, extensive, treatment-resistant or diagnostically unclear scalp disease, a focused evaluation can help define the diagnosis, disease extent and next clinical steps.

Frequently Asked Questions

Is PIILIF the same as dissecting cellulitis?

No. Dissecting cellulitis is the clinical disease that produces painful nodules, pus, tunnels, scarring and permanent hair loss. PIILIF is a microscopic pattern of upper-follicle inflammation and early fibrosis that may represent a quieter component of the disease.

Does this study mean the entire scalp is diseased?

No. The study found PIILIF in all 12 selected normal-looking biopsy sites, but the cohort was small and the sites were chosen with trichoscopy. The findings support a possible wider inflammatory field, not a conclusion that every follicle or every area of scalp is equally affected.

Does a quiet nodule mean the disease is cured?

Not necessarily. In this small study, all three clinically quiet nodules still contained PIILIF, although they lacked the destructive pus-forming features of active lesions. More research is needed to understand what quiet nodules represent over time.

Does dandruff mean I have PIILIF or dissecting cellulitis?

No. Dandruff is common and usually unrelated to dissecting cellulitis. Further evaluation becomes more relevant when scale or redness occurs with recurrent painful bumps, drainage, scarring, tunnels or progressive hair loss.

Did this study identify the best treatment for dissecting cellulitis?

No. The study evaluated biopsy findings, not treatment effectiveness. It provides a framework for future studies testing whether care should address both visible destructive flares and the quieter PIILIF component.

Do I need a biopsy?

Not everyone does. A biopsy may be useful when the diagnosis is uncertain, disease continues to recur, the visible findings do not explain the symptoms or a clinician needs to determine what is happening beyond the active lesion.

Publication

Perifollicular Lymphocytic Inflammation and Fibrosis in Dissecting Cellulitis: Evidence of a Consistent Histopathologic Pattern

Published in Clinical, Cosmetic and Investigational Dermatology on July 17, 2026. 

Medical note: This article is for educational purposes and does not provide medical advice. Diagnosis and treatment must be individualized by a qualified clinician. The study discussed here did not compare treatments.

The post Video: Why Dissecting Cellulitis Keeps Coming Back: Hidden Inflammation Beyond the Visible Scalp Bumps appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Clinical premise

Dissecting cellulitis of the scalp is conventionally classified as a neutrophilic primary cicatricial alopecia characterized by follicular occlusion, rupture, abscess formation, sinus tracts, granulation tissue and scarring.

Those features define active destructive disease. They do not fully account for:

• Relapse after apparent clinical quiescence 
• Extension into adjacent scalp 
• Reactivation of clinically quiet nodules 
• Overlap with other folliculocentric scarring disorders 

The study tested whether PIILIF, an upper-follicle lymphocytic-fibrotic pattern previously described in clinically normal-appearing scalp in other cicatricial alopecias, was also present in DCS outside actively suppurative lesions. 

Study rationale and cohort

This was a retrospective, exploratory, single-center clinicopathologic study of consecutive patients with clinicopathologically concordant DCS evaluated from December 2022 through November 2024.

The cohort included:

• 12 men 
• Mean age of 30 years 
• Age range of 21 to 46 years 
• Nine patients with an active lesion at lesional biopsy 
• Three patients with no active lesions but a clinically inactive residual nodule 
• Three patients with concurrent histologic AKN 
• One patient with PIILIF identified in a sideburn biopsy 

Each patient underwent a protocolized paired-biopsy evaluation during routine care. 

Biopsy-site definitions

Clinically normal-appearing scalp, or cNAS

Scalp without visible:

• Nodules 
• Pustules 
• Sinus tracts 
• Alopecia 

The area was normal on inspection and palpation at the time of biopsy.

Trichoscopy was used to identify subtle perifollicular abnormalities, including mild erythema, hyperpigmentation or scale, to guide site selection. The cNAS biopsy was typically obtained from parietal scalp approximately 2 to 3 cm from the nearest clinically evident lesion. 

Active DCS lesion

A lesion showing one or more of the following:

• Erythema 
• Tenderness 
• Drainage 
• Fluctuance 

Clinically inactive, or quiet, nodule

A residual indurated nodule without signs of active inflammation.

Paired-biopsy method

Each patient underwent:

1. A 6 mm punch biopsy from cNAS 
2. A second 6 mm punch biopsy from an active DCS lesion or, when no active lesion was present, a clinically inactive nodule 

Both specimens were obtained from the same scalp during the same clinical evaluation.

The paired design allowed comparison of the clinically visible disease state with scalp that appeared unaffected in the same patient. 

Sectioning and histopathologic assessment

Each specimen was processed with both:

• Vertical sections 
• Transverse sections 

Vertical sections were used to assess upper-follicle inflammation, while transverse sections improved visualization of concentric perifollicular fibrosis and adnexal loss.

PIILIF was defined as:

• A perifollicular lymphocytic infiltrate centered on the infundibulum and/or isthmus 
• Associated perifollicular lamellar fibroplasia or early concentric fibrosis 
• No alternative dominant diagnostic pattern involving the interfollicular epidermis 

Two board-certified dermatopathologists independently reviewed the slides while blinded to clinical information, sampling site, lesion activity and treatment history. Differences were resolved by consensus. 

Immunohistochemistry

The study used:

• CD4 and CD8 to characterize the relative T-cell population 
• CD117 to support mast-cell identification 
• Alpha-smooth muscle actin, or alpha-SMA, when fibrosis was equivocal on hematoxylin and eosin staining 

Immunohistochemistry was evaluable in eight active-lesion and cNAS pairs.

Across disease states:

• Infiltrates were consistently CD4-predominant 
• CD117-positive mast cells were prominent 

The findings support an immunologically active upper-follicle process rather than nonspecific end-stage scar alone. 

Findings across the three sampled states

Active lesions therefore showed classic neutrophilic destruction and tissue remodeling superimposed on an upper-follicle PIILIF background. 

Interpretation

A possible field effect

The presence of PIILIF in cNAS, quiet nodules and active lesions supports a field-effect hypothesis in which low-grade upper-follicle inflammation and early fibrosis extend beyond clinically obvious DCS margins.

This model could help explain relapse, extension and overlap with other folliculocentric disorders.

It remains associative. The study cannot establish whether PIILIF precedes, follows or persists after active DCS lesions. 

A possible two-layer inflammatory model

The findings support a working model in which:

1. A chronic lymphocytic-fibrotic upper-follicle pattern is present across a wider scalp field 
2. Episodic neutrophil-dominant activation produces follicular rupture, pus, granulation tissue, gland loss and scarring 

This model is hypothesis-generating and was not directly tested mechanistically.

The sebaceous-gland distinction

Sebaceous glands were preserved in cNAS and quiet nodules but completely absent in six of nine active lesions.

This separation raises the hypothesis that sebaceous gland loss may mark a transition toward less reversible disease.

The cross-sectional design cannot prove that sequence. A quiet nodule may represent:

• A treated or spontaneously improved lesion 
• An earlier component of a larger lesion 
• A biopsy taken outside a destructive focus 

Dandruff-related diagnostic discordance

Three patients had previously been managed as having seborrheic dermatitis, but none of the study biopsies supported that diagnosis.

This supports a low threshold for reconsidering the diagnosis when persistent perifollicular erythema or scale does not fit the clinical course.

Prior antifungal or corticosteroid exposure may have attenuated seborrheic dermatitis findings, so the study does not establish that every previous dandruff diagnosis was incorrect. 

Overlap with AKN and disease beyond the scalp

Concurrent histologic AKN was present in three of 12 patients. PIILIF was also found in a sideburn specimen from one patient.

These observations support investigation of broader folliculocentric susceptibility in selected patients, but they are too limited to establish prevalence or a universal overlap phenotype. 

One-Page Paired-Biopsy Request Guide

Research-informed protocol based on the published study. This is not a formal consensus guideline and should be adapted to the clinical question.

Clinical indication

Consider a paired-biopsy approach when evaluating:

• Recurrent or extending DCS 
• Persistent disease despite conventional therapy 
• Clinically quiet nodules with a history of reactivation 
• Discordance between symptoms and visible findings 
• Suspected DCS and AKN overlap 
• Persistent perifollicular scale or erythema previously attributed to seborrheic dermatitis 
• Suspected extension beyond the visibly affected scalp 

Specimen A: Clinically normal-appearing scalp

Select a site that has:

• No visible nodule 
• No pustule 
• No sinus tract 
• No clinically evident alopecia 
• No palpable active lesion 

Preferred study location:

• Parietal scalp 
• Approximately 2 to 3 cm from the nearest visible lesion 
• Guided by subtle trichoscopic perifollicular erythema, hyperpigmentation and/or scale 

Specimen B: Lesional scalp

When active disease is present, target a lesion showing:

• Erythema 
• Tenderness 
• Drainage 
• Fluctuance 

When no active lesion is present, target:

• A residual, firm, clinically inactive nodule 

Collection

• Obtain separate 6 mm punch biopsies 
• Place specimens in separately labeled containers 
• Record exact scalp location 
• Label each as cNAS, active lesion or inactive nodule 
• Document whether specimens were obtained during the same evaluation 
• Include recent and prior treatment exposure 

Processing request

Request:

• Vertical sections 
• Transverse sections 
• Adequate sampling of the upper follicle and surrounding dermis 

Histopathologic features to assess

For both specimens:

• Infundibulo-isthmic lymphocytic infiltrate 
• Perifollicular lamellar fibroplasia or early concentric fibrosis 
• Sebaceous gland preservation or loss 
• Epithelial atrophy 
• Bulbar inflammation or fibrosis 
• Interfollicular epidermal involvement 
• Alternative diagnostic patterns 

For active lesions:

• Neutrophilic infiltrates 
• Follicular rupture 
• Extravasated hair shafts 
• Granulation tissue 
• Avascular scarring 
• Sinus tracts 
• Adnexal loss 

Suggested ancillary stains

When tissue is sufficient and clinically appropriate:

• CD4 
• CD8 
• CD117 
• Alpha-SMA when early fibrosis is equivocal on routine staining 

Suggested requisition wording

Clinical history of recurrent or suspected dissecting cellulitis. Paired specimens submitted from clinically normal-appearing scalp and an active lesion or clinically inactive nodule. Please evaluate for perifollicular infundibulo-isthmic lymphocytic inflammation and fibrosis, sebaceous gland status, follicular rupture, neutrophilic inflammation, granulation tissue and scarring. Please process with vertical and transverse sections. Consider alpha-SMA, CD4, CD8 and CD117 if tissue and findings permit.

Limitations

The study’s main limitations include:

• Small sample size 
• Single specialty-clinic cohort 
• Referral and spectrum bias 
• Retrospective design 
• Cross-sectional sampling 
• No healthy or disease control group 
• Heterogeneous treatment exposure before biopsy 
• No standardized treatment timing 
• Only three inactive nodules 
• No treatment-stratified analysis 
• Categorical rather than quantitative histologic scoring 
• No prespecified interobserver agreement analysis 
• No proof of temporal sequence 
• No treatment comparison 

The 100% cNAS finding should therefore not be interpreted as proof that PIILIF is universal or specific to all DCS cases. 

Unanswered research questions

The publication creates several testable questions:

1. Does PIILIF in cNAS precede the development of visible DCS lesions? 
2. Does the burden or distribution of PIILIF predict extension or relapse? 
3. Does sebaceous gland loss mark a transition toward less reversible disease? 
4. Are quiet nodules early lesions, partially controlled lesions or post-destructive remnants? 
5. What molecular event converts a lymphocytic-fibrotic field into a neutrophil-dominant flare? 
6. How do DHT signaling, cytokine activity, mast cells, microbiome changes and follicular rupture interact? 
7. Is PIILIF specific to DCS or shared across a broader group of cicatricial alopecias? 
8. Does addressing PIILIF in addition to suppressing active neutrophilic inflammation improve long-term outcomes? 

Prospective longitudinal studies with standardized clinical scores, serial paired biopsies, healthy or disease controls, quantitative pathology and spatial immune analysis are needed. Interventional studies will be required before any treatment-specific conclusions can be made. 

Refer a DCS Case

The clinician referral form should request:

• Patient age and sex 
• Disease duration 
• Current activity status 
• Distribution of lesions 
• History of drainage, pain, tunnels and scarring 
• Prior biopsy reports 
• Prior and current treatments 
• Scalp photographs 
• Trichoscopy images 
• History or examination findings of AKN 
• History of acne, hidradenitis suppurativa or pilonidal disease 
• Suspected facial or beard-area extension 
• Reason for referral 
• Co-management preference 

Request the Paired-Biopsy Protocol

Provide a downloadable one-page PDF version of the protocol above, with:

• Site definitions 
• Sampling map 
• Specimen labels 
• Processing instructions 
• Suggested requisition wording 
• Dermatopathology checklist 

Express Interest in a Multicenter PIILIF Study

The collaboration form should request:

• Clinician name and credentials 
• Institution or practice 
• City and country 
• Estimated annual DCS case volume 
• Access to trichoscopy 
• Ability to perform paired scalp biopsies 
• Dermatopathology support 
• Institutional review board capability 
• Interest in prospective registry participation 
• Interest in serial biopsy studies 
• Interest in treatment trials 
• Preferred contact information 

Publication

Perifollicular Lymphocytic Inflammation and Fibrosis in Dissecting Cellulitis: Evidence of a Consistent Histopathologic Pattern

Published in Clinical, Cosmetic and Investigational Dermatology on July 17, 2026. 

Publication-Link Implementation

Perifollicular Lymphocytic Inflammation and Fibrosis in Dissecting Cellulitis: Evidence of a Consistent Histopathologic Pattern https://doi.org/10.2147/CCID.S614816

The post PIILIF in Dissecting Cellulitis: What Paired Biopsies Reveal Across Normal-Appearing Scalp, Quiet Nodules and Active Lesions appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

The Baldcast serves as an avenue for showcasing the experiences of actual patients with complex scalp and hair issues. Additionally, it demonstrates the value of providing patients with educating them on their condition and giving them hope through advanced treatments available at the clinic.

The Journey of Care and Commitment

Seven years of care from Dr. Umar for Robert Peeters represents the type of long term physician-patient relationships that lead to positive and transformative changes in a person’s health and self-confidence. 

Dr. Umar also introduces Robert’s mother, who has provided continuous emotional support during all seven years of the treatment process, further highlighting the importance of involving family members in the overall treatment plan for successful patient care.

How Specialized Hair Restoration Can Evolve into Friendship

The relationship between Dr. Umar and Robert illustrate how a long term doctor-patient relationship built on trust and personalized treatment for conditions like hairline bumps can evolve into a long-lasting and meaningful friendship. 

Through Robert’s story, the podcast continues to emphasize the commitment of the clinic to provide each patient with personalized and comprehensive care, utilizing the expertise of its doctors; and providing each patient with the long term support necessary to achieve optimal results from treatment.

For medical details of this case, visit dru.com.

Watch Robert’s Story

Watch the first chapter of Robert’s transformation here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD) or Acne Keloidalis Nuchae (AKN), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Robert’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

Disclaimer:
This story reflects one patient’s personal experience and treatment by Dr. Sanusi Umar. Individual results vary. Always consult a qualified physician for personalized advice.

The post Video: 7 Years of Care: Robert Peeters’ Scalp Treatment Journey for Acne Keloidalis Nuchae (Part 1) appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Diseases such as AKN are very often misunderstood. They may appear as hairline bumps or Barber’s Bumps. However, the underlying problem is chronic inflammation which will ultimately create scarring and long-lasting changes to the skin.

For Anwar, the painful bumps that have consistently returned were only half of his battle. He had to fight emotionally to build walls, avoid attention, and hide his true self.

However, when the disease was finally understood and treated, Anwar was able to heal. Healing came through a focus on the biology of the condition versus its surface appearance. This acne kelo, what seemed permanent started to change.

More Than Scars: Understanding The Journey

For years, Anwar relied on hats and other ways to hide the visible effects of his condition. Like many patients living with acne keloidalis nuchae, he became increasingly aware of how his appearance affected his confidence and interactions with others.

Over time, those feelings led him to build emotional walls as well. Hiding became more than a physical habit. It became a way of protecting himself from unwanted attention, questions, and assumptions.

Looking back, Anwar recognizes how much energy was spent trying to conceal a condition that had become a major part of his daily life.

Today, that chapter is behind him.

Rewriting The Story: An Acne Keloidalis Patient Story of Success

Now, Anwar views the world differently than before.

His scars are no longer the only chapter in his story; they are now only one chapter. That change in perspective is almost as great of a change as the physical change that occurred.

If you are looking for a long-term solution to hairline bumps, or if you are seeking information about treatment options for Acne Keloidalis, Anwar’s message is simple: healing is possible. There may be time involved. There may be challenges and there may be setbacks. But progress is possible with the right direction and support.

“Scars may shape us, but they do not define us.”

Anwar’s experience reminds each of us that we all deserve the chance to move forward — not only with clear skin, but also with new confidence and a rewritten version of ourselves.

Alt text: Anwars is a testimony that even after years of battling with AKN, there is still a chance to rewrite the whole story of your life, and it begins when you believe that long-term healing is attainable.

For medical details of this case, visit dru.com.

Watch Anwar’s Story

Watch Anwar’s transformation update here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Anwar’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

The post Video: Scars Do Not Define: An Acne Keloidalis Nuchae Patient Success Story appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

With confidence, and yet some degree of hesitation, Anwar enters the room. He was energized from traveling, and the air around him is calming; however, this moment has greater importance than ever before.

How He Has Shown Up To the World for Years

For many years, what appeared to others as razor bumps on the head or ingrown hair bumps have significantly influenced how Anwar shows himself to the world. That is changing.

The changes in Anwar’s body are evident during the consultation. When comparing the pre-consultation photographs to those taken after the consultation with Dr. Sanusi Umar, the change is much deeper than simply what we see on the surface. 

Acne keloidalis nuchae has a common misdiagnosis in the beginning stages of the disease. Many people believe that the bumps appearing on their scalp represent barber bumps or minor irritations.

A Moment to Show the World

Then comes the question: “Are you prepared to show the world?”

That is a very significant moment. Individuals who previously experienced recurring hairline bumps or bumps that continue to come back may find it difficult to be seen. However, Anwar states he is somewhat nervous but ready.

As the moment becomes more intense, Anwar removes the hat, but the final reveal is left until Part 2.

To patients looking for a long-term solution for hairline bumps, or to those who are seeking treatment options for acne keloidalis, this moment represents more than a physical change. This moment is about regaining confidence, and the option to decide when and how to be seen.

For medical details of this case, visit dru.com.

Watch Anwar’s Story

Watch Anwar’s transformation update here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Anwar’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

The post Video: Anwar’s Journey Continues – A New Path Without Razor Bumps appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

This was more than just a physical transformation for Anwar; it was a mental one. What was once a source of Anwar’s feelings of being exposed or embarrassed has now turned into a story about how resilient he is and how well he managed his medical condition.

Managing Folliculitis Keloidalis Nuchae

Anwar’s experience illustrates the reality of acne keloidalis nuchae – an ongoing inflammatory process, which may look like bumps caused by razors, bumps at the hair line, or ingrown hair bumps. For many of these patients, they have tried every remedy imaginable to manage their bumps – home remedies, barbershop fixes, over-the-counter products, etc., without much success.

To effectively treat AKN, professional assistance is required. As Anwar states, “seeing a medical professional is crucial.” Traveling, cost, scheduling issues, etc. should not deter individuals from seeing a doctor. The consistency of seeking treatment, the direction from a medical professional and the determination to seek help will be what will allow you to manage your constant painful bumps and achieve a long term solution.

Emotional Impact of Treatment and Recovery

While Anwar’s experience has brought about significant improvements physically, emotionally, Anwar shares that the psychological benefit is equally impressive. To those who have experienced a condition such as Anwar, Anwar recommends that you continually search for answers and solutions. Trust that qualified professionals can assist you. And do not let small barriers hinder you from moving forward.

Dr. Umar also concurs with Anwar stating the changes Anwar has undergone both visually and psychologically, and the positive effects of his increased confidence. What was once a cause for Anwar’s discomfort, embarrassment and anxiety, is now a testament to the effectiveness of the treatment for Anwar’s acne keloidalis nuchae and Anwar’s ability to persevere.

For medical details of this case, visit dru.com.

Watch Anwar’s Story

Watch Anwar’s transformation update here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Anwar’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

The post Video: Anwar’s Transformation: The Reveal appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Prior to treatment, the bumps were not only physical; they also drew attention. Whether viewed as ingrown hair bumps, or even as keloids on the scalp, Anwar felt like he was always being watched. Today, Anwar tells us about a very different reality – far fewer eyes upon him, much less attention, and the freedom to live his life as he chooses without having to define himself by his appearance. 

Understanding the Condition Behind the Change

What Anwar experienced is common in patients dealing with acne keloidalis nuchae, often misdiagnosed early on. Many people initially believe they are dealing with simple barber’s bumps or irritation from haircuts. However, the underlying issue is deeper rooted in chronic inflammation and follicular injury.

Over time, this inflammation can lead to painful bumps, scarring changes, and areas that feel like they won’t heal. For patients like Anwar, the condition becomes more than cosmetic. It affects confidence, daily interactions, and how they show up in the world.

A Shift in Confidence and Daily Life

Anwar’s words highlight a key outcome that goes beyond medical treatment: anonymity. The ability to not “stand out” anymore is something many patients deeply value. When visible symptoms like hairline bumps or bumps that keep coming back are reduced, the mental burden often lifts as well.

For those searching for a long term solution for hairline bumps or exploring treatment for acne keloidalis, Anwar’s story reinforces an important point, which is that real change is possible when the condition is properly understood and managed.

This chapter isn’t just an update. It’s a reminder that treating chronic scalp conditions isn’t only about the skin—it’s about restoring how someone feels in their own presence every day.

For medical details of this case, visit dru.com.

Watch Anwar’s Story

Watch Anwar’s transformation update here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Anwar’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

The post Video: Why Anwar No Longer “Stands Out” Due To Acne Keloidalis Nuchae appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

When there is chronic inflammation from this condition, it will lead to the release of various signaling molecules including cytokines and growth factors into the tissues around the affected follicle. Cytokines and growth factors are important parts of the body’s immune response and can affect nearby tissue.

A Single Disease Process for Other Scalp Disorders

According to Dr. Umar, the same biological processes that produce chronic folliculitis of the nape are likely to create the same biological processes that produce dissecting cellulitis, a chronic disease of the scalp that creates deep nodules, swelling and potentially drainage under the skin.

Additionally, Dr. Umar states that the same biological processes that produce chronic folliculitis of the nape are also responsible for cutis verticis gyrata (CVG), a disease process where the scalp develops folds similar to the ridges of a mountain range

Once the inflammatory cascade begins, the environment of the scalp is much more likely to generate additional diseases.

Turning Off the Source of Inflammation

Dr. Umar states that the focus of the treatment plan is to eliminate the initial source of inflammation that is creating the growth factors and cytokines. Once the original source of inflammation has been eliminated, the number of biologic signals that promote the development of other diseases such as dissecting cellulitis and CVG should be decreased.

Once the diseased follicles that are producing the factors and cytokines are removed, the engine that continues to fuel the inflammatory cycle will also be eliminated.

By removing the source of growth factors and cytokines Dr. Umar was able to reduce the likelihood of additional diseases developing.

Watch John’s Story

Watch the thirteenth chapter of John’s transformation here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch John’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

The post Video: Chronic Folliculitis of the Nape: The First Trigger appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

CVG causes the scalp to develop deep grooves and ridges. It was determined by specialists that the long-term inflammation of AKN caused the onset of CVG.

It shows that if left untreated or advanced, scalp disorders can develop into more serious structural disorders with time.

The Psychological And Emotional Toll Of Having Chronic Scalp Disease

Robert has described years of physical pain and emotional distress before receiving the care from a specialist. Not just the outward signs, he also experienced depression, anxiety, fear, and frustration, which made him feel alone when doctors would tell him that they were unable to assist him.

Notably, many people who suffer from severe AKN and CVG experience an overwhelming sense of loss of self-worth; in addition to their mental health, it negatively impacts their overall quality of life.

From Hopelessness To Fighting For Healing

Robert admitted that he has given up many times during his search for answers, but he never stopped looking. At age 43, he looks back at his experiences with realism and fortitude, and knows that every day has both its good and bad aspects.

He is a great example of what can be achieved through finding the correct medical professionals and the latest treatments available for the bumps on his head. Even though his experiences were extremely challenging, he was able to transition from hopelessness to hope for healing.

For medical details of this case, visit dru.com.

Watch Robert’s Story

Watch the second chapter of Robert’s transformation here:

• Instagram
• TikTok

Take the Next Step

If you or someone you love is facing Folliculitis Decalvans (FD), don’t lose heart.
Early, expert attention can change the trajectory of your journey. Watch Robert’s story, learn more at dru.com, and explore your own next steps toward healing.

At The Bumpinator and The BaldCast, every patient is a hero.

Disclaimer:
This story reflects one patient’s personal experience and treatment by Dr. Sanusi Umar. Individual results vary. Always consult a qualified physician for personalized advice.

The post Video: Severe Folliculitis Keloidalis Nuchae and CVG: Robert’s Life Before and After Treatment appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.