Folliculitis decalvans Management

Folliculitis decalvans is a chronic inflammatory scarring alopecia characterized by recurrent inflammation of hair follicles that leads to permanent destruction of hair follicles and irreversible hair loss. The condition most commonly affects the scalp, particularly the vertex and occipital (nape) regions, and is characterized by recurrent pustules, crusting, follicular inflammation, and progressive scarring.

The exact cause is not fully understood, but the disease is thought to result from an abnormal immune response to Staphylococcus aureus colonization in genetically susceptible individuals. Early diagnosis and treatment are important to suppress inflammation, prevent disease progression, and preserve remaining hair follicles.

Pathophysiology (Brief)

The exact etiology remains uncertain. The disease is believed to result from a combination of:

• Chronic bacterial colonization, particularly Staphylococcus aureus

• Abnormal host immune response

• Persistent neutrophilic inflammation

• Progressive destruction of hair follicles

• Replacement of follicles by fibrous scar tissue, leading to permanent alopecia

Signs & Symptoms

Typical lesions include:

• Follicular pustules

• Erythematous papules

• Crusting around hair follicles

• Tender scalp

• Pain or burning sensation

• Pruritus (itching)

Characteristic findings:

• Scarring alopecia

• Tufted hair follicles (multiple hairs emerging from a single follicular opening)

• Progressive permanent hair loss

• Keloid-like plaques in some patients

Common sites:

• Vertex of the scalp

• Occipital scalp (nape of the neck)

• Less commonly, other scalp regions

Diagnostic Criteria

Diagnosis is primarily clinical and based on:

• Recurrent follicular pustules on the scalp

• Progressive scarring alopecia

• Tufted folliculitis

• Characteristic clinical distribution

• Exclusion of other causes of cicatricial alopecia

Investigations

Recommended investigations

• Bacterial swab for culture and sensitivity from pustules

• Full blood picture (FBP) if systemic infection is suspected

Special investigations

• Scalp biopsy to confirm diagnosis and exclude other causes of cicatricial alopecia

• Dermoscopy (trichoscopy), which may demonstrate tufted hairs, perifollicular scaling, and follicular inflammation

Monitoring

During prolonged therapy monitor:

• Clinical response

• Medication adverse effects

• Liver function tests and full blood count when prolonged systemic therapy is used, where indicated

Treatment

Treatment aims to suppress inflammation, eradicate bacterial colonization, relieve symptoms, and prevent further permanent hair loss. Hair already lost due to scarring cannot be restored.

Non-pharmacological Treatment

• Maintain good scalp hygiene.

• Avoid scratching or picking affected lesions.

• Avoid sharing hair clippers, combs, and towels.

• Treat secondary bacterial infection promptly.

• Avoid trauma to the affected scalp.

• Regular follow-up is recommended to monitor disease progression and treatment response.

Pharmacological Treatment

• Doxycycline (PO) 100 mg every 12 hours for 2–4 weeks.

OR

• Clindamycin (PO) 300 mg every 12 hours for 3 months.

AND

• Clobetasol propionate cream/gel (topical) 0.05% — apply every 12 hours for not less than 16 weeks.

AND (for recalcitrant cases)

• Dapsone (PO) 100 mg once daily for 6 months.

• OR S: triamcinolone (intralesional) 10 mg/ml monthly for 6–9 months (with or instead of topical clobetasol).

• Recalcitrant cases: OR S: isotretinoin (PO) 20–40 mg once daily for 3–6 months.

Complications

• Permanent scarring alopecia

• Progressive hair loss

• Recurrent scalp infections

• Cosmetic disfigurement

• Psychological distress

• Keloid-like scarring

• Disease relapse

Prevention

There is no known method of preventing folliculitis decalvans. However, disease progression may be reduced by:

• Early diagnosis and treatment

• Prompt treatment of bacterial infections

• Maintaining good scalp hygiene

• Avoiding repeated trauma to the scalp

• Adhering to prescribed treatment and follow-up

Patient counselling (Important)

• Folliculitis decalvans is a chronic inflammatory disease and is not contagious.

• Hair loss caused by scarring is permanent, making early treatment essential.

• Treatment helps control inflammation and slow disease progression but may not completely prevent recurrence.

• Take antibiotics exactly as prescribed, even if symptoms improve.

• Avoid scratching the scalp or manipulating pustules.

• Attend regular follow-up appointments to monitor disease activity and adjust treatment if necessary.