What is Folliculitis decalvans, its epidemiology and clinical presentation, and what are the recommended management strategies?

Folliculitis Decalvans: Clinical Overview and Management

Definition and Epidemiology

Folliculitis decalvans (FD) is a rare, chronic inflammatory scalp disorder classified as primary neutrophilic cicatricial alopecia that predominantly affects young to middle-aged adults with a slight male predominance. 1, 2

• The condition leads to progressive, irreversible scarring alopecia through chronic suppurative folliculitis 1
• Pathogenesis remains incompletely understood but involves Staphylococcus aureus colonization and deficient host immune response 1, 3
• Some familial cases and occurrence in immunocompromised patients (including HIV-positive individuals) suggest underlying immune dysfunction 4, 1

Clinical Presentation

Primary Features

• Follicular pustules with purulent discharge are the hallmark finding, typically located at the vertex and occipital scalp 4, 1
• Diffuse and perifollicular erythema that heals with centrifugal scarring and permanent hair loss 4
• Follicular tufting (polytrichia) where multiple hair shafts emerge from a single dilated follicular opening 1
• Hemorrhagic crusts and erosions frequently present 1, 2

Associated Symptoms

• Patients commonly report pain, pruritus, or burning sensations at affected sites 4, 2, 5
• The disease causes significant psychological distress due to visible scarring and chronic symptoms 4
• Involvement of body sites other than the scalp is rare 4

Diagnostic Considerations

• Clinical diagnosis based on characteristic pustular lesions with scarring alopecia pattern 1
• Histopathology shows neutrophilic inflammatory infiltrate in early lesions, with lymphocytes and plasma cells in advanced stages 1
• S. aureus can often be cultured from pustules 4, 1
• Must differentiate from dissecting cellulitis, central centrifugal cicatricial alopecia, and lichen planopilaris 2

Management Strategy

First-Line Antibiotic Therapy

Oral antibiotics remain the cornerstone of treatment due to both antimicrobial and anti-inflammatory properties. 4, 1

Preferred Regimens:

• Oral fusidic acid 500 mg three times daily has demonstrated excellent efficacy with minimal adverse effects and low resistance rates despite widespread use 4

  • Treatment duration of 2-3 months typically required 4
  • Highly bioavailable with long plasma half-life 4
  • Consider maintenance therapy with zinc sulfate after initial course to prevent recurrence 4

• Tetracyclines (doxycycline 100 mg twice daily or minocycline 100 mg twice daily) for 2-4 months are commonly used alternatives 6, 1

  • Both are more effective than tetracycline 500 mg but neither is superior to the other 7

• Combination therapy with oral clindamycin 300 mg twice daily plus rifampicin 600 mg once daily for 10 weeks is recommended for refractory cases 7, 1

  • This addresses potential S. aureus involvement and provides enhanced anti-inflammatory effects 7

Topical Adjunctive Therapy

• Topical clindamycin 1% solution/gel applied twice daily for up to 12 weeks 8, 6
• Topical fusidic acid as adjuvant treatment 4
• Betamethasone dipropionate 0.05% with salicylic acid 3% lotion once daily to reduce inflammation and remove crusts 4
• Azelaic acid 5% lotion once daily 4
• Mild to moderate potency topical corticosteroids short-term only, as prolonged use causes skin atrophy 8, 7

Decolonization Protocol for Recurrent Disease

A 5-day decolonization regimen should be implemented for patients with recurrent FD: 8, 6, 7

• Intranasal mupirocin ointment twice daily
• Daily chlorhexidine body washes
• Daily decontamination of personal items (towels, sheets, clothing)
• Maintenance with mupirocin ointment twice daily to anterior nares for the first 5 days of each month reduces recurrences by approximately 50% 7

Advanced and Refractory Cases

• Intralesional corticosteroids for localized lesions at risk of scarring provide rapid improvement in inflammation and pain 7
• Intensity-modulated radiation therapy (IMRT) via tomotherapy can be considered for severe, refractory cases with persistent trichodynia 5
  • Delivered as 11.0 Gy in two series (5.0 Gy in 5 fractions, then 6 Gy boost) 5
  • Achieves lasting symptom relief by irreversibly eliminating hair follicles 5
  • Reserved for cases unresponsive to all medical therapies 5

Supportive Care Measures

• Use gentle pH-neutral soaps with tepid water for cleansing 8, 6
• Pat skin dry after showering; avoid rubbing 8, 6
• Wear loose-fitting cotton clothing to reduce friction 8
• Avoid greasy creams and manipulation of affected areas 8, 6
• Apply warm compresses 3-4 times daily to promote drainage 6

Treatment Algorithm

1. Mild disease: Start topical clindamycin 1% twice daily plus topical corticosteroid short-term 8, 6
2. Moderate disease or inadequate response after 4-6 weeks: Add oral fusidic acid 500 mg three times daily or tetracycline 6, 4
3. Severe or non-responsive after 8-12 weeks: Switch to clindamycin 300 mg twice daily plus rifampicin 600 mg once daily 7, 1
4. Recurrent disease: Obtain bacterial cultures and implement decolonization protocol 8, 7
5. Refractory cases: Consider intralesional corticosteroids or IMRT 7, 5

Common Pitfalls

• Avoid stopping treatment prematurely, as FD typically relapses when therapy is discontinued 4, 1
• Do not use prolonged topical steroids due to risk of skin atrophy 8, 7
• Obtain bacterial cultures in recurrent or treatment-resistant cases to identify MRSA or other resistant organisms 8, 6
• The treatment goal is to halt inflammation and prevent further irreversible follicular destruction, not to restore lost hair 4
• Maintenance therapy is often necessary to prevent recurrence 4