Extensive, non-healing scalp ulcer associated with trauma-induced chronic osteomyelitis

A 77-year-old woman presented with a trauma to the scalp caused from the blade of a windmill. The condition was persistent from the past 50 years. At the initial examination, a deep, foul-smelling and well-circumscribed ulcer was apparent on the head region, involving the majority of the cranium. Skin biopsy specimens of the lesion were nonspecific. The bone biopsy showed extensive necrotic areas of bone and soft tissues, with lymphocytic exudate foci. A computed tomography scan of the head revealed bone destruction principally involving both the parietal bones, and parts of the frontal and occipital bones. Streptococcus parasanguis was isolated from the skin culture, and Proteus mirabilis and Peptostreptococcus sp. were identified in the cultures from the bone. A long-term treatment with amoxicillin-clavulanic acid (1 g/12 h) and levofloxacin (500 mg/day) was prescribed, but even after 6 months, the lesion remained unchanged. The frequency of occurrence of scalp ulcers in dermatological patients is less, principally because of the rich blood supply to this area. We have not found any similar case report of a scalp ulcer secondary to chronic osteomyelitis discovered more than 50 years after the causal trauma. We want to highlight the importance of complete cutaneous evaluation including skin and bone biopsies, when scalp osteomyelitis is suspected.