A 32-year-old man complained of persistent, painful, draining scalp lesions that had been present for the past five years. These lesions caused progressively worsening alopecia accompanied by drainage that often was purulent. The lesions had been incised and drained in the past, and a recent culture grew only rare gram-positive cocci. Treatments over the preceding years involved various oral and topical medications, including antibiotics, antifungals, isotretinoin (Accutane), dapsone, and intralesional steroids. Oral steroids controlled the lesions, but symptomatic flares occurred when these were weaned.
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