What is the management of folliculitis decalvans?

Management of Folliculitis Decalvans

Oral isotretinoin should be considered as first-line therapy for folliculitis decalvans due to its superior efficacy in achieving long-term remission compared to antibiotic regimens. 1, 2

Initial Assessment and Diagnosis

• Folliculitis decalvans presents with follicular pustules, perifollicular erythema, follicular tufting, and often hemorrhagic crusts and erosions, primarily affecting the vertex and occipital scalp 3
• Diagnosis is based on clinical presentation and confirmed by histopathology showing neutrophilic inflammatory infiltrate in early lesions with lymphocytes and plasma cells in advanced lesions 3
• Staphylococcus aureus and deficient host immune response play important roles in pathogenesis 3

Treatment Algorithm

First-Line Therapies

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

  • Oral isotretinoin is recommended as first-line therapy with 90% of patients experiencing stable remission during and up to two years after treatment 1, 2

• For moderate to severe inflammation (with pustules, crusts, or extensive involvement):

  • Oral antibiotics should be initiated 1
  • For highly active disease, consider a short course of oral glucocorticosteroids 1
  • Topical therapy should include gentle pH-neutral soaps and tepid water for cleansing 4

Specific Antibiotic Regimens

• Combination of clindamycin and rifampicin has shown limited success with 80% relapse rate after treatment discontinuation 2
• Clarithromycin and dapsone have demonstrated better outcomes with long-term remission rates of 33% and 43% respectively 2
• Fusidic acid (500 mg three times daily) has shown promising results in case reports 5

Second-Line Therapies

• For refractory cases or persistent inflammation despite antibiotics:
  • Oral isotretinoin if not used as first-line 1, 2
  • Photodynamic therapy 1
  • Biologics (preferably adalimumab) for therapy-recalcitrant cases 1, 6
  • JAK inhibitors, oral dapsone, hydroxychloroquine, or cyclosporine 1

Topical Treatments (as adjuncts to systemic therapy)

• Topical or intralesional corticosteroids to reduce inflammation 1
• Topical tacrolimus 0.1% or dapsone 5% as second-line topical options 1
• Avoid greasy creams and manipulation of skin in the affected area to reduce risk of secondary infection 4, 7

For Recurrent Disease

• Consider a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and decontamination of personal items 7
• For nasal colonization with S. aureus, applying mupirocin ointment twice daily in the anterior nares for the first 5 days each month can reduce recurrences by approximately 50% 7

Surgical Interventions

• Surgical excision or laser therapy can be useful in selected cases 1
• Hair transplantation may be considered only in patients with inactive disease 1

Important Considerations and Pitfalls

• As folliculitis decalvans is a form of scarring alopecia, the goal of therapy is to control inflammation and prevent further hair loss; hair regrowth cannot be expected 1
• Treatment should extend beyond resolution of manifestations to avoid recurrences 1
• Avoid topical acne medications without dermatologist supervision as they may irritate and worsen the condition 4, 7
• Avoid prolonged use of topical steroids as they may cause skin atrophy 4, 7
• Regular follow-up is essential to monitor disease activity and adjust treatment accordingly 1