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A 73 year old woman was referred with two weeks' history of temporal headaches, jaw claudication, and painful rash on both temples (fig 1). The jaw claudication was so intense that she could take fluids only and could not chew solid food. She had no visual symptoms. The erythrocyte sedimentation rate was 50 mm/1st h and C reactive protein 70 mg/l.
Diagnosis of scalp necrosis in giant cell arteritis (GCA) was made on clinical grounds. Biopsy was not undertaken as she had already been receiving oral corticosteroids and because of the risk (perhaps theoretical) of worsening the scalp necrosis. Treatment with corticosteroids led to a resolution of symptoms and complete healing of the scalp.
Scalp necrosis in GCA is a rare but recognised complication. It may represent a subset of severe disease. Of the 24 cases reported in English, 16 had visual loss, four gangrene of the tongue, and one nasal septal necrosis.1
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