What is tufted folliculitis and how should it be diagnosed and managed?

Tufted Folliculitis: Diagnosis and Management

Tufted folliculitis is a rare, chronic scarring folliculitis of the scalp characterized by multiple hair tufts (typically 10-30 hairs) emerging from single dilated follicular openings within patches of scarring alopecia, and should be treated with prolonged courses of oral antibiotics targeting Staphylococcus aureus. 1, 2

Clinical Presentation and Diagnosis

The hallmark diagnostic feature is the presence of multiple hair tufts scattered within patches of scarring alopecia, with each tuft consisting of 20-30 hair shafts emerging from a single dilated follicular orifice. 3, 2

Key Clinical Features to Identify:

• Circumscribed inflammatory lesions on the scalp with exudation and crusting that evolve into scarring alopecia 3
• Multiple hair tufts emerging from dilated follicular openings within the scarred areas 2
• Pustular discharge may be present from the dilated follicular ostia 3
• The condition typically affects the scalp exclusively 1, 2

Differentiation from Similar Conditions:

• Folliculitis decalvans: Can only be differentiated by the presence of multiple scattered hair tufts within scarring patches; otherwise clinically and histologically identical 2
• Hidradenitis suppurativa: Presents with larger, tender, draining lesions in flexural areas (axillae, groin, perineal regions) rather than the scalp 4
• Acne keloidalis nuchae: Distinguished by keloidal plaques 2
• Dissecting cellulitis: Shows coalescing nodules with purulent discharge 2

Diagnostic Workup:

• Obtain bacterial cultures from pustules or exudate to identify causative organisms, as Staphylococcus aureus is the most frequently detected pathogen 5, 3
• Histopathology shows clustering of adjacent follicular units opening at the bottom of an epidermal depression, with polymorphous inflammatory infiltrate and fibrosing process 3, 2
• Evaluate for predisposing factors including recent scalp trauma, as the condition can develop after scalp injury 3, 6

Treatment Algorithm

First-Line Therapy: Oral Antibiotics

Oral tetracyclines are the recommended first-line systemic treatment, with doxycycline 100mg twice daily or minocycline 100mg twice daily for extended courses of 2-4 months. 5, 7

• The infectious nature of the disease has been verified through effective treatment with antibacterial medications 1
• Alternative oral antibiotics include flucloxacillin, erythromycin, ciprofloxacin, or amoxicillin-clavulanic acid if tetracyclines are contraindicated 3
• For MRSA-suspected or confirmed cases, use trimethoprim-sulfamethoxazole 7

Adjunctive Topical Therapy:

• Apply topical clindamycin 1% solution/gel twice daily for up to 12 weeks as adjunctive treatment 5, 7
• Topical erythromycin, povidone-iodine, or ketoconazole can be considered, though evidence is limited 3
• Apply warm compresses 3-4 times daily to promote drainage and reduce inflammation 5

Surgical Management:

• Perform incision and drainage for larger lesions or abscesses 5, 8
• Avoid manipulation or squeezing of lesions to prevent secondary bacterial spread 8

Management of Recurrent Disease

Implement a comprehensive decolonization protocol, as recurrence is common and the condition often proves recalcitrant to treatment. 3

Decolonization Regimen:

• Apply intranasal mupirocin ointment twice daily for 5 days 5, 8
• Perform daily chlorhexidine body washes 5, 8
• Decontaminate personal items including towels, sheets, and clothes daily 5, 7

Long-Term Suppression:

• Apply mupirocin ointment twice daily in the anterior nares for the first 5 days of each month to reduce recurrences by approximately 50% 5, 8
• Consider clindamycin 150mg orally once daily for 3 months for recurrent cases caused by susceptible S. aureus 5

Preventive and Supportive Measures

• Use gentle pH-neutral soaps with tepid water for cleansing the scalp 5, 7
• Pat skin dry after showering rather than rubbing 5, 7
• Wear loose-fitting cotton clothing to reduce friction and moisture 5, 7
• Avoid greasy creams or pomades on the affected scalp area 5, 7

Critical Pitfalls to Avoid

• Do not rely on topical treatments alone, as the condition typically requires systemic antibiotics given its infectious etiology and tendency for recurrence 1, 3
• Do not use topical corticosteroids on infected areas, as they may worsen the infection despite reducing inflammation 5
• Do not neglect to culture recurrent or persistent lesions, as this identifies resistant organisms and guides appropriate antibiotic selection 5, 8
• Recognize that transient improvement followed by recurrence is common, requiring prolonged treatment courses rather than short-term therapy 3
• Understand that the fibrosing process causing hair tufting represents irreversible scarring alopecia, so early aggressive treatment is essential to prevent progression 2, 9