UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Folliculitis decalvans

Author
Lynne J Goldberg, MD
Section Editor
Maria Hordinsky, MD
Deputy Editor
Abena O Ofori, MD

INTRODUCTION

Folliculitis decalvans (FD) is a rare, chronic cicatricial (scarring) alopecia that classically presents as an expanding patch of alopecia with peripheral pustules on the scalp (picture 1A-B). The cause of FD is unknown; it is speculated that the disease reflects an abnormal response to bacteria, particularly Staphylococcus aureus.

FD usually occurs in adults. In addition to hair loss and pustular lesions, affected patients may experience associated pruritus or pain. Systemic antibiotic therapy is the mainstay of treatment. The response to treatment is variable and relapse is common.

The clinical features, diagnosis, and management of FD will be reviewed here. Other cicatricial alopecias are reviewed separately. Of note, FD is distinct from keratosis follicularis spinulosa decalvans, a rare genetic disorder characterized by keratotic follicular papules and cicatricial alopecia. (See "Evaluation and diagnosis of hair loss", section on 'Cicatricial alopecia'.)

CLASSIFICATION

Folliculitis decalvans (FD) is classified as a primary cicatricial alopecia, a group of disorders in which an inflammatory process targets the hair follicle, resulting in follicular destruction and permanent hair loss. This is in contrast to secondary cicatricial alopecia, in which scarring processes in the skin incidentally destroy hair follicles. FD was further classified as a primary neutrophilic cicatricial alopecia in a classification scheme created by the participants of a 2001 workshop on cicatricial alopecia sponsored by the North American Hair Research Society [1]. This classification system was based upon the type of inflammatory infiltrate associated with specific subtypes of cicatricial alopecia. The classification of cicatricial and noncicatricial alopecias is reviewed in detail separately. (See "Evaluation and diagnosis of hair loss", section on 'Classification'.)

Although the term "folliculitis decalvans" was coined by Brocq in 1905 [2], earlier reports of what was likely FD date back to the late 1800s [3,4]. For several decades, there was much diagnostic confusion between FD and other cicatricial alopecias [5].

                              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Oct 03 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Olsen EA, Bergfeld WF, Cotsarelis G, et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 2003; 48:103.
  2. Brocq L, Lenglet E, Ayrignac J. Recherches sur l’alopécie atrophicante, variété psuedopelade. Ann Dermatol Syph 1905; 6:1.
  3. Quinquaid E. Folliculite épilante et destructive des regions values. Bull Mem Soc Hop Paris 1888; 5:395.
  4. LAYMON CW. The cicatricial alopecias; an historical and clinical review and an histologic investigation. J Invest Dermatol 1947; 8:99.
  5. Little EG. Folliculitis Decalvans. Proc R Soc Med 1930; 23:809.
  6. Whiting DA. Cicatricial alopecia: clinico-pathological findings and treatment. Clin Dermatol 2001; 19:211.
  7. Tan E, Martinka M, Ball N, Shapiro J. Primary cicatricial alopecias: clinicopathology of 112 cases. J Am Acad Dermatol 2004; 50:25.
  8. Chiarini C, Torchia D, Bianchi B, et al. Immunopathogenesis of folliculitis decalvans: clues in early lesions. Am J Clin Pathol 2008; 130:526.
  9. Annessi G. Tufted folliculitis of the scalp: a distinctive clinicohistological variant of folliculitis decalvans. Br J Dermatol 1998; 138:799.
  10. Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol 1999; 140:328.
  11. Chandrawansa PH, Giam YC. Folliculitis decalvans--a retrospective study in a tertiary referred centre, over five years. Singapore Med J 2003; 44:84.
  12. Sillani C, Bin Z, Ying Z, et al. Effective treatment of folliculitis decalvans using selected antimicrobial agents. Int J Trichology 2010; 2:20.
  13. Brooke RC, Griffiths CE. Folliculitis decalvans. Clin Exp Dermatol 2001; 26:120.
  14. Grabczynska SA, Holden CA. Tufted folliculitis in a 10-year-old child. Br J Dermatol 1999; 140:975.
  15. Marrack P, Kappler J. The staphylococcal enterotoxins and their relatives. Science 1990; 248:705.
  16. Ross EK, Tan E, Shapiro J. Update on primary cicatricial alopecias. J Am Acad Dermatol 2005; 53:1.
  17. Matard B, Meylheuc T, Briandet R, et al. First evidence of bacterial biofilms in the anaerobe part of scalp hair follicles: a pilot comparative study in folliculitis decalvans. J Eur Acad Dermatol Venereol 2013; 27:853.
  18. Tong AK, Baden HP. Tufted hair folliculitis. J Am Acad Dermatol 1989; 21:1096.
  19. Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis decalvans. Dermatol Ther 2008; 21:238.
  20. Jaiswal AK, Vaishampayan S, Walia NS, Verma R. Folliculitis decalvans in a family. Indian J Dermatol Venereol Leprol 2000; 66:216.
  21. Douwes KE, Landthaler M, Szeimies RM. Simultaneous occurrence of folliculitis decalvans capillitii in identical twins. Br J Dermatol 2000; 143:195.
  22. Scribner MD. Folliculitis decalvans. Arch Dermatol 1971; 104:451.
  23. Karakuzu A, Erdem T, Aktas A, et al. A case of folliculitis decalvans involving the beard, face and nape. J Dermatol 2001; 28:329.
  24. Sperling LC, Solomon AR, Whiting DA. A new look at scarring alopecia. Arch Dermatol 2000; 136:235.
  25. Powell J, Dawber RP. Folliculitis decalvans and tufted folliculitis are specific infective diseases that may lead to scarring, but are not a subset of central centrifugal scarring alopecia. Arch Dermatol 2001; 137:373.
  26. Smith NP. Tufted folliculitis of the scalp. J R Soc Med 1978; 71:606.
  27. Weedon D. Diseases of cutaneous appendages. In: Weedon's Skin Pathology, 3rd ed, Elsevier Limited, Edinburgh 2010. p.397.
  28. Stefanato CM. Histopathology of alopecia: a clinicopathological approach to diagnosis. Histopathology 2010; 56:24.
  29. Rakowska A, Slowinska M, Kowalska-Oledzka E, et al. Trichoscopy of cicatricial alopecia. J Drugs Dermatol 2012; 11:753.
  30. Tailor A, Asher RG, Craig PJ, et al. The current state of play in the histopathologic assessment of alopecia: two for one or one for two? J Cutan Pathol 2013; 40:298.
  31. Rubin AI, Seykora JT. Is more hair always better? A single biopsy specimen is preferred for the evaluation of alopecia. J Cutan Pathol 2014; 41:66.
  32. Baroni A, Ruocco E, Aiello FS, et al. Tinea capitis mimicking tufted hair folliculitis. Clin Exp Dermatol 2009; 34:e699.
  33. Tangjaturonrusamee C, Piraccini BM, Vincenzi C, et al. Tinea capitis mimicking folliculitis decalvans. Mycoses 2011; 54:87.
  34. Yang BH, Bang CY, Byun JW, et al. A case of cicatricial alopecia associated with erlotinib. Ann Dermatol 2011; 23:S350.
  35. Hepper DM, Wu P, Anadkat MJ. Scarring alopecia associated with the epidermal growth factor receptor inhibitor erlotinib. J Am Acad Dermatol 2011; 64:996.
  36. Bunagan MJ, Banka N, Shapiro J. Retrospective Review of Folliculitis Decalvans in 23 Patients with Course and Treatment Analysis of Long-standing Cases. J Cutan Med Surg 2015; 19:45.
  37. Suter L. [Folliculitis decalvans]. Hautarzt 1981; 32:429.
  38. Abeck D, Korting HC, Braun-Falco O. Folliculitis decalvans. Long-lasting response to combined therapy with fusidic acid and zinc. Acta Derm Venereol 1992; 72:143.
  39. Paquet P, Piérard GE. [Dapsone treatment of folliculitis decalvans]. Ann Dermatol Venereol 2004; 131:195.
  40. Tietze JK, Heppt MV, von Preußen A, et al. Oral isotretinoin as the most effective treatment in folliculitis decalvans: a retrospective comparison of different treatment regimens in 28 patients. J Eur Acad Dermatol Venereol 2015; 29:1816.
  41. Gemmeke A, Wollina U. Folliculitis decalvans of the scalp: response to triple therapy with isotretinoin, clindamycin, and prednisolone. Acta Dermatovenerol Alp Pannonica Adriat 2006; 15:184.
  42. Mihaljević N, von den Driesch P. Successful use of infliximab in a patient with recalcitrant folliculitis decalvans. J Dtsch Dermatol Ges 2012; 10:589.
  43. Castaño-Suárez E, Romero-Maté A, Arias-Palomo D, Borbujo J. Photodynamic therapy for the treatment of folliculitis decalvans. Photodermatol Photoimmunol Photomed 2012; 28:102.
  44. Walker SL, Smith HR, Lun K, Griffiths WA. Improvement of folliculitis decalvans following shaving of the scalp. Br J Dermatol 2000; 142:1245.
  45. Bastida J, Valerón-Almazán P, Santana-Molina N, et al. Treatment of folliculitis decalvans with tacrolimus ointment. Int J Dermatol 2012; 51:216.
  46. Kreutzer K, Effendy I. Therapy-resistant folliculitis decalvans and lichen planopilaris successfully treated with adalimumab. J Dtsch Dermatol Ges 2014; 12:74.
  47. Ismail N, Ralph N, Murphy G. Intravenous human immunoglobulin for treatment of folliculitis decalvans. J Dermatolog Treat 2015; 26:471.
  48. Parlette EC, Kroeger N, Ross EV. Nd:YAG laser treatment of recalcitrant folliculitis decalvans. Dermatol Surg 2004; 30:1152.
  49. Meesters AA, Van der Veen JP, Wolkerstorfer A. Long-term remission of folliculitis decalvans after treatment with the long-pulsed Nd:YAG laser. J Dermatolog Treat 2014; 25:167.
  50. Smith EP, Hardaway CA, Graham BS, Johnstone PA. Folliculitis decalvans treated with radiation therapy. Cutis 2006; 78:162.
  51. Miguel-Gomez L, Vano-Galvan S, Perez-Garcia B, et al. Treatment of folliculitis decalvans with photodynamic therapy: Results in 10 patients. J Am Acad Dermatol 2015; 72:1085.
  52. Burillo-Martinez S, Maroñas-Jimenez L, Palencia-Pérez SI, et al. Failure of photodynamic therapy (PDT) in 3 patients with folliculitis decalvans. J Am Acad Dermatol 2016; 74:e69.
  53. Miguel-Gómez L, Vañó-Galván S, Pérez-García B. Reply: Treatment of folliculitis decalvans with photodynamic therapy. J Am Acad Dermatol 2016; 74:e71.
  54. Donovan JC, Shapiro RL, Shapiro P, et al. A review of scalp camouflaging agents and prostheses for individuals with hair loss. Dermatol Online J 2012; 18:1.
  55. Otberg N, Wu WY, Kang H, et al. Folliculitis decalvans developing 20 years after hair restoration surgery in punch grafts: case report. Dermatol Surg 2009; 35:1852.
  56. Yip L, Ryan A, Sinclair R. Squamous cell carcinoma arising within folliculitis decalvans. Br J Dermatol 2008; 159:481.