What is Folliculitis Decalvans?

What is folliculitis decalvans?

Folliculitis decalvans is a chronic, neutrophilic inflammation that results in scarring hair loss. Tufted hair folliculitis is probably a subset of folliculitis decalvans although tufting can be seen in other forms of cicatricial alopecia as well.

Folliculitis decalvans

Who gets folliculitis decalvans?

Folliculitis decalvans usually presents in the 4th and 5th decades, with a male predominance. Children are not affected.

There are probably no racial differences in prevalence, although it has been claimed to be more common in African-American women.

Familial cases have been rarely reported.

What causes folliculitis decalvans?

Folliculitis decalvans is considered to be the result of an abnormal immune response to Staphylococcus aureus, although this is not yet proven.

What are the clinical features of folliculitis decalvans? 

Folliculitis decalvans typically affects the scalp, often around the crown, but may affect the beard area, axillae, limbs, and pubic hair. The characteristic clinical features include:

• Irregular, atrophic white patches of scarring and hair loss — solitary or multiple

• Induration of the scalp

• Follicular pustules and perifollicular crusts at the patch periphery

• Follicular hyperkeratosis, scale, and erosions

• Tufting — multiple hair shafts emerge from a single hair follicle, resulting in a ‘doll’s hair’ appearance

• Mild itch, discomfort, or pain.

Folliculitis decalvans

Perifollicular crusting and scale

Tufted hairs and perifollicular crusting

Tufted hairs and perifollicular erythema

Dermoscopy of folliculitis decalvans

• Tufted hairs

• White dots

• Perifollicular erythema and scale

• Scattered follicular pustules

What are the complications of folliculitis decalvans?

• Permanent progressive hair loss

• Psychological effects of hair loss

• Squamous cell carcinoma

How is folliculitis decalvans diagnosed?

Folliculitis decalvans is a clinical diagnosis confirmed on bacteriology/mycology and histology if required.

Skin biopsy of an early lesion shows a neutrophilic infiltrate dilating the infundibulum of the hair follicle. The follicle in later lesions has ruptured resulting in perifollicular scarring and mixed inflammatory infiltrate including foreign body giant cells.

What is the differential diagnosis for folliculitis decalvans?

• Tinea capitis

• Perifolliculitis capitis abscedens et suffodiens

• Other causes of cicatricial alopecia including discoid lupus erythematosus and lichen planopilaris

What is the treatment for folliculitis decalvans?

General measures

• Topical antiseptics and shampoos — although little evidence for efficacy

Specific measures

• Antibiotics

  • Topical such as fusidic acid

  • Oral tetracyclines, azithromycin, rifampicin in combination with clindamycin

• Other systemic agents (off-label)

  • Oral isotretinoin, dapsone, tacrolimus, apremilast

  • Intravenous immunoglobulin, tumour necrosis factor inhibitors

• Physical therapies

  • Photodynamic therapy

  • Surgery for permanent hair loss if in remission

What is the outcome for folliculitis decalvans?

Folliculitis decalvans usually follows a chronic fluctuating course of exacerbations and remissions over many years. It is not clear that treatment influences the long-term prognosis despite successfully reducing inflammation in the short-term. Early diagnosis and treatment are important but permanent hair loss is to be expected.