Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Folliculitis decalvans
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Folliculitis decalvans (FD) is a rare, neutrophilic, inflammatory scalp condition presenting as single or multiple areas of alopecia, characterized by pustule formation, erythema, and increased scale with ‘tufted’ hair follicles evident at the edge of the scarring hair loss patch. FD can involve any areas of the scalp, although the vertex and occiput are most affected; non-scalp involvement is uncommon. FD tends to run a chronic, progressive course. Multivariate analysis from one large retrospective case series suggests that onset at <25 years of age and presence of pustules are independently associated with severe disease.
The condition can occur in either sex but has a predilection for adult men. Frequent isolation of Staphylococcus aureus from lesional skin and observed improvement with antistaphylococcal therapy has implicated this bacterium in disease development. An abnormal host response in genetically susceptible individuals may also be contributory. However, recent identification of a persistent, abnormal subepidermal microbiota and non-staphylococcal bacterial biofilms deeper in lesional hair follicles may suggest alternative microbial factors contributing to disease activity.
Management Strategy
The goal of therapy in FD is to arrest the inflammatory process and prevent extension of irreversible alopecia. Initial investigations should exclude other conditions known to mimic FD (e.g., tinea capitis) and the rare complication of squamous cell carcinoma. A confirmatory scalp biopsy is often performed, and a bacteriology swab should be taken from lesional skin to determine culture and sensitivity (as bacterial resistance is common). Nasal staphylococcal eradication should also be considered in confirmed carriers.
To date, there are no reported randomized controlled trials for treatment in FD. Efficacy data are available from case reports, case series, and small studies only. Systemic antibiotics ( tetracyclines, flucloxacillin, macrolides, and third generation cephalosporins ) remain the mainstay of initial therapy, although relapses are common on stopping treatment. The combination of oral rifampicin and clindamycin administered as a 10-week course has been shown to reduce activity and induce sustained remission, and thus is considered the most effective treatment for FD. Occasionally, repeat courses may be required. Rifampicin monotherapy is not advised due to the risk of developing drug resistance.
Second-line treatment options include isotretinoin , corticosteroids , dapsone , and oral zinc sulfate . Isotretinoin is reported to have lower relapse rates than antibiotics with treatment cessation, while corticosteroids (topical, intralesional, and oral) are recognized adjunctive therapies. Dapsone (75–100 mg) may also produce a satisfactory outcome but often requires low-dose maintenance therapy to sustain remission. Oral zinc sulfate , as monotherapy or combined with fusidic acid , may also be efficacious.
Third-line treatment options include a range of topical, physical, biological, and cellular therapy. Topical tacrolimus ointment , medical ( manuka ) honey, photodynamic therapy , and human immunoglobulin therapy may be effective. More recently, biological therapy ( adalimumab/biosimilar, infliximab , and secukinumab) have been successful in treating severe recalcitrant disease.
In those unresponsive to medical therapy surgical interventions, such as scalp excision , laser epilation or superficial radiotherapy may be considered to permanently epilate the scalp, thereby removing the inflammatory focus of the condition.
Specific Investigations
How not to get scar(r)ed: a guide to diagnosis in primary cicatricial alopecias
Harries MJ, Trueb R, Messenger A, et al. Br J Dermatol 2009; 160: 482–501.
A systematic approach is presented to accurately diagnose scarring alopecias, including FD.
Tinea capitis mimicking folliculitis decalvans
Tangjaturonrusamee C, Piraccini BM, Vincenzi C, et al. Mycoses 2011; 54: 87–8.
A case of tinea capitis caused by Microsporum canis mimicking FD.
Folliculitis decalvans and cellular immunity – 2 brothers with oral candidiasis
Shitara A, Igareshi R, Morohashi M. Jpn J Dermatol 1974; 28: 133.
Severe FD in two siblings who also had chronic oral candidiasis; defective cell-mediated immunity was demonstrated.
Updates in therapeutics for folliculitis decalvans: a systematic review with evidence-based analysis
Rambhia PH, Conic RR, Murad A, et al. J Am Acad Dermatol 2019; 80: 794–801 .
A systematic review of current treatments for FD and treatment outcomes.
Folliculitis decalvans: a multicenter review of 82 patients
Vañó-Galván S, Molina-Ruiz AM, Fernández-Crehuet P, et al. J Eur Acad Dermatol Venereol 2015; 29: 1750–7.
A retrospective review of 82 patients with FD. Between 90% and 100% of patients on either oral doxycycline 100 mg daily, azithromycin 500 mg three times a week, or combination of clindamycin and rifampicin demonstrated improvement.
Effective treatment of folliculitis decalvans using selected antimicrobial agents
Sillani C, Bin Z, Ying Z, et al. Int J Trichology 2010; 2: 20–3.
Thirteen patients with mild-to-moderate FD. Minocycline 100 mg twice daily as monotherapy was effective in six patients, with a further three patients responding to minocycline and rifampicin in combination.
Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings
Powell JJ, Dawber RPR, Gatter K. Br J Dermatol 1999; 140: 328–33.
Eighteen patients with folliculitis decalvans were treated with oral rifampicin 300 mg twice daily and oral clindamycin 300 mg twice daily combination for 10 weeks. All patients reported improvement during treatment, with 10 patients achieving a lasting remission.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here
