A 36-Year-Old Man with Inflammatory Lesions and Crusts on the Scalp

Abstract

Folliculitis decalvans is a rare type of neutrophilic cicatricial alopecia. The etiopathogenesis of the disease remains unclear. It may result from a complex combination of a bacterial infection (particularly Staphylococcus aureus), a hypersensitivity reaction to “superantigens,” and a defect in host cell-mediated immunity regulation. Folliculitis decalvans the most commonly occurs in young to middle-aged men of African descent. The disease is initially characterized by the follicular papules and pustules. With progression, tufted hairs, erosions, hemorrhagic crusts, and nodules are detected. In late stages of the disease, irregularly shaped patches of cicatricial alopecia occur. The lesions are the most commonly localized in the vertex, the parietal, and the occipital areas. Moreover, folliculitis decalvans has been noted in other locations, including the face, neck, axillae, and pubic region. The diagnosis of folliculitis decalvans is established based on clinical manifestation and a histopathological examination. Trichoscopy may be useful to avoid scalp biopsy. The first-line treatment for folliculitis decalvans usually consists of oral tetracyclines. In severe cases or ineffectiveness of tetracyclines, combination of rifampicin and clindamycin is recommended. Isotretinoin can be also useful. Additionally to systemic treatment, topical antiseptic agents and antibiotics or topical and intralesional corticosteroids can be used. Other treatment option include dapsone, first-generation cephalosporin, systemic steroids, topical calcineurin inhibitors, photodynamic therapy and surgical treatment.