What is the best approach to treating a case of folliculitis decalvans?

Treatment Approach for Folliculitis Decalvans

The most effective first-line treatment for folliculitis decalvans is oral isotretinoin, which has shown a 90% success rate in achieving stable remission during and up to two years after treatment cessation. 1

Initial Assessment and Classification

• Determine disease severity based on the maximum diameter of the largest alopecic patch:

  • Slight: <2 cm
  • Moderate: 2-4.99 cm
  • Severe: ≥5 cm 2

• Risk factors for severe disease include:

  • Onset before 25 years of age
  • Presence of pustules within the alopecic patch 2

Treatment Algorithm

First-Line Therapy

• For mild active disease (perifollicular erythema and hyperkeratosis, without pustules or crusts):

  • Oral isotretinoin should be considered as first-line therapy 3

• For moderate to severe inflammation (with pustules and crusts):

  • Oral antibiotics are recommended 3
  • Options include:
    • Tetracycline 500 mg twice daily for 4 months (90% improvement rate) 4, 2
    • Combination of clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks (100% improvement rate, mean duration of response 7.2 months) 4, 2

• For highly active disease:

  • A short course of oral glucocorticosteroids may be beneficial as adjunctive therapy 3

Topical Adjunctive Therapies

• Topical or intralesional corticosteroids should be added to systemic treatment 3

  • Intralesional triamcinolone acetonide for localized lesions at risk of scarring 5
  • Clobetasol lotion for more diffuse involvement 5

• Other topical options:

  • Topical clindamycin 1% solution/gel applied twice daily 4
  • Topical tacrolimus 0.1% or dapsone 5% as second-line options 3

For Refractory Cases

• If inadequate response to first-line therapy, consider:
  • Oral dapsone (43% long-term remission rate) 1
  • Oral clarithromycin (33% long-term remission rate) 1
  • Oral fusidic acid 500 mg three times daily 6
  • Photodynamic therapy, biologics (preferably adalimumab), JAK inhibitors, hydroxychloroquine, or cyclosporine 3

Supportive Measures

• Use gentle pH-neutral soaps with tepid water for cleansing 7, 4
• Pat the skin dry after showering 7, 4
• Wear loose-fitting cotton clothing to reduce friction 7, 4
• Avoid greasy creams in affected areas 7, 4
• Avoid manipulation of the skin to reduce risk of secondary infection 7, 4

Monitoring and Follow-up

• Bacterial cultures should be obtained for recurrent or treatment-resistant cases to guide antibiotic selection 4
• For patients on isotretinoin, monitoring of liver function tests and lipid levels is recommended 4
• Treatment should be extended beyond resolution of manifestations to prevent recurrences 3

Surgical Options

• For stable, inactive disease:
  • Surgical excision or laser therapy can be useful 3
  • Hair transplantation can be considered in patients with inactive disease 3

Common Pitfalls to Avoid

• Discontinuing antibiotics too early - some patients require years of slow taper before antibiotics can be discontinued 5
• Relying solely on the combination of clindamycin and rifampicin, which has a high relapse rate (80%) shortly after treatment cessation 1
• Using topical acne medications without dermatologist supervision, as they may irritate and worsen the condition 4
• Prolonged use of topical steroids, which may cause skin atrophy 4

Important Considerations

• Folliculitis decalvans is a form of scarring alopecia - the aim of therapy is to control inflammation and prevent further hair loss, but hair regrowth cannot be expected 3
• The course of the disease is typically chronic and relapsing, requiring long-term management strategies 3, 2
• While antibiotics have traditionally been first-line therapy, recent evidence suggests oral isotretinoin may be more effective for achieving long-term remission 1