Treatment of Folliculitis Decalvans
For patients with moderate to severe folliculitis decalvans, initiate combination therapy with rifampicin and clindamycin as first-line treatment, as this regimen demonstrates the highest efficacy with a mean response duration of 7.2 months and 100% improvement rate. 1
Understanding the Disease and Treatment Goals
Folliculitis decalvans is a primary neutrophilic scarring alopecia where Staphylococcus aureus and deficient host immune response drive the inflammatory process. 2 The fundamental goal is controlling inflammation and preventing further hair loss—hair regrowth cannot be expected once scarring has occurred. 3 Treatment should extend beyond resolution of visible inflammation to prevent recurrences, as the disease follows a chronic, relapsing course. 3
First-Line Treatment Algorithm
For Moderate to Severe Disease (pustules, crusts, significant inflammation):
Start oral rifampicin 300 mg twice daily plus clindamycin 300 mg twice daily for at least 10-12 weeks. 3, 1 This combination achieved 100% improvement in patients with a mean response duration of 7.2 months. 1
Add a short course of oral glucocorticosteroids (e.g., prednisone 0.5-1 mg/kg daily for 2-4 weeks with taper) for highly active disease to rapidly control inflammation. 3
Supplement with intralesional triamcinolone acetonide (5-10 mg/mL) injected into active inflammatory areas every 4-6 weeks. 3, 4 This was among the most effective treatments in long-term follow-up studies. 4
For Mild Disease (perifollicular erythema and hyperkeratosis without pustules):
Oral isotretinoin 0.5-1 mg/kg daily should be the first-line therapy. 3 This is particularly effective for mild active disease and should also be considered for refractory cases or persistent inflammatory lesions after antibiotic failure. 3
Alternative: Oral tetracyclines (doxycycline 100 mg twice daily or minocycline 100 mg twice daily) for 2-4 months. 3, 4 These improved 90% of patients with a mean response duration of 4.6 months. 1
Topical Adjunctive Therapy
Apply potent topical corticosteroids (clobetasol propionate 0.05% ointment or foam) twice daily to active lesions. 3 This should be used in addition to systemic treatment, not as monotherapy.
For second-line topical options, consider tacrolimus 0.1% ointment twice daily or dapsone 5% gel once daily. 3
Treatment for Refractory Disease
When first-line therapies fail after 3-6 months:
Adalimumab 40 mg subcutaneously every 2 weeks is the preferred biologic. 3 Other biologics may be considered but adalimumab has the most supporting evidence.
JAK inhibitors (tofacitinib 5 mg twice daily or baricitinib 2-4 mg daily) represent emerging effective options. 3
Oral dapsone 50-100 mg daily, hydroxychloroquine 200-400 mg daily, or cyclosporine 3-5 mg/kg daily may be effective alternatives. 3
Photodynamic therapy can be considered for localized refractory disease. 3
For severe, painful, treatment-refractory disease, intensity-modulated radiation therapy (11 Gy total in fractionated doses) to permanently eliminate hair follicles may provide lasting symptom relief. 5 This is a radical approach reserved for cases with persistent trichodynia unresponsive to all other therapies. 5
Surgical Options
Surgical excision or laser epilation therapy can be useful for localized disease or residual active areas. 3
Hair transplantation may be considered only in patients with documented inactive disease for at least 12-24 months. 3
Prognostic Factors and Monitoring
Onset before age 25 and presence of pustules are independent predictors of severe disease. 1, 4 These patients require more aggressive initial therapy and closer monitoring.
Assess response based on stabilization of cicatricial area size, improvement in symptoms (pruritus, trichodynia), and reduction in inflammatory signs (erythema, pustules, crusts). 1, 4
Continue treatment for at least 2-3 months beyond clinical resolution to minimize recurrence risk. 3
Critical Pitfalls to Avoid
Do not use topical therapies alone as primary treatment for moderate to severe disease—systemic therapy is essential. 3 Topical agents are adjunctive only.
Do not stop antibiotics prematurely when symptoms improve—the mean response duration is only 4.6-7.2 months, and early discontinuation leads to rapid relapse. 1
Do not expect hair regrowth in scarred areas—set realistic expectations with patients that treatment prevents progression, not reversal. 3
Do not delay escalation to second-line therapies if first-line treatment fails after 3-6 months—prolonged inflammation leads to more extensive scarring. 3