What is the treatment for folliculitis decalvans?

From the Guidelines

Folliculitis decalvans is typically treated with a combination of antibiotics and anti-inflammatory medications, with oral antibiotics such as tetracyclines or the combination of clindamycin with rifampin being the first-line treatment. The treatment approach should prioritize reducing bacterial load and inflammation to prevent permanent hair follicle destruction.

Key Treatment Considerations

• Oral antibiotics: doxycycline 100mg twice daily or minocycline 100mg twice daily, or the combination of clindamycin 300mg twice daily with rifampin 300mg twice daily for 10-12 weeks 1.
• Topical treatments: clindamycin lotion, mupirocin ointment, or antiseptic washes containing chlorhexidine or povidone-iodine to reduce bacterial load on the scalp.
• Anti-inflammatory treatments: intralesional corticosteroid injections may help manage inflammation in particularly painful or inflamed areas.
• Maintenance therapy: intermittent use of antibiotics or regular antiseptic shampoos, such as ketoconazole, to prevent recurrence 1.

Additional Recommendations

• Good scalp hygiene is essential, and patients should use aqueous emollients and soap substitutes that are less dehydrating for the skin than normal soaps.
• Shampoos that reduce the risk of scalp folliculitis, such as ketoconazole, betadine, and ceanel, should be recommended.
• Patients should follow up regularly with a dermatologist to adjust treatment as needed, as folliculitis decalvans is a chronic condition with frequent relapses.

From the Research

Treatment Options for Folliculitis Decalvans

The treatment for folliculitis decalvans aims to control inflammation and prevent further hair loss, as hair regrowth cannot be expected due to the scarring nature of the condition 2.

• Oral Antibiotics: In patients with moderate or severe inflammation, oral antibiotics are recommended 2. A retrospective review of 23 patients with folliculitis decalvans found that initial management with oral antibiotics, such as cephalexin, minocycline, doxycycline, or tetracycline, led to remission in more than half of the cases 3.
• Oral Isotretinoin: Oral isotretinoin is considered a first-line therapy in patients with mild active disease and is also recommended in cases of refractory disease or persistent inflammatory lesions 2. A retrospective study of 28 patients found that treatment with isotretinoin was the most successful oral treatment, with 90% of patients experiencing stable remission during and up to two years after cessation of treatment 4.
• Other Systemic Treatments: Other systemic treatments that may be effective include photodynamic therapy, biologics (preferably adalimumab), JAK inhibitors, oral dapsone, hydroxychloroquine, or cyclosporine 2.
• Topical Treatments: Topical or intralesional corticosteroids can be used as an addition to systemic treatment 2. Topical tacrolimus 0.1% or dapsone 5% may be considered as second-line topical therapeutic options 2.
• Surgical Excision or Laser Therapy: In some cases, surgical excision or laser therapy can be useful, and hair transplantation can be considered in patients with inactive disease 2.

Treatment Goals and Considerations

The goal of treatment is to control inflammation and prevent further hair loss, rather than promoting hair regrowth 2. Treatment extended beyond the resolution of manifestations may be considered to avoid recurrences 2. The choice of treatment should be based on the severity of the disease and the patient's response to therapy 2, 3, 4.