Folliculitis decalvans: Causes, Symptoms & treatment

Folliculitis decalvans is a chronic inflammatory disorder of the scalp. It is a type of alopecia (hair loss) that results in scarring of the scalp and it is a relatively a rare condition. This condition mainly affects the scalp but any hair bearing region on the body like the beard, armpit region or the pubic area   can be affected as well. It is not a contagious disease though there is a recent evidence of familial cases indicating a hereditary predisposition

What is Folliculitis decalvans?

Folliculitis decalvans is a progressive disorder of the scalp characterised by inflammation and scarring. It causes inflammation of the hair follicles which makes the follicles purulent accompanied by redness and swelling. This ultimately destroys the follicles and results in permanent hair loss. The chronic inflammation leads to scarring and Folliculitis decalvans progresses to cicatricial alopecia (baldness with scarring). This condition affects both men and women and can occur at any time from adolescent to adult life. However it has been observed that men are likely to have an early onset from adolescence whereas women tend to develop it much later in their life after 40 years of age.

What are the signs and symptoms of Folliculitis decalvans?

The Hallmark feature of Folliculitis decalvans is follicular scarring and pustules, which may be purulent. Patients also report itching, pain and a burning sensation.  In many cases crusting around the pustules and spontaneous bleeding is also observed. Folliculitis decalvans predominantly starts at the occipital and vertex region and is confined to a few patches or advances to cicatricial alopecia with many oval patches of scars. Another common feature of Folliculitis decalvans is tufted folliculitis. When many hairs sprout out of a single follicle, it is called tufting. These tufts of hair are shed and the follicles are eventually destroyed thus leaving a scar. However, many people do not encounter and specific symptoms at all.

What is the treatment of Folliculitis decalvans?

The primary cause of Folliculitis decalvans is unknown. This makes it difficult to find the right treatment. However, the bacteria Staphylococcus aureus along with poor immunity and an inflammatory response leads to the development of this condition. The treatment primarily aims at eliminating Staphylococcus aureus. There is no specific cure to Folliculitis decalvans but the disease can be restrained to smaller patches by antibiotic therapy.  It includes topical antiseptics, topical and oral antibiotics, for example rifampicin along with clindamycin has shown to be effective. Topical antibiotics accompanied by intranasal therapy have shown positive results. Corticosteroids provide symptomatic relief and subside inflammation. Oral therapy including dapsone and zinc sulphate has also shown positive effects to an extent.

What causes Folliculitis decalvans?

The exact cause of Folliculitis decalvans is not known. But the organism Staphylococcus aureus seems to play a role in the pathogenesis of the disease as it is found in the pustular lesions. Staphylococcus aureus constitutes the normal flora of the skin. It is debatable if the bacteria is simply colonising the infection or it is primarily responsible for inducing an immune response. Another causative possibility suspected is a strong abnormal inflammatory response to the pathogen. Also, familial investigations have led to the conclusion that there is a certain genetic predisposition linked to this disorder.

What does Folliculitis decalvans look like?

Folliculitis decalvans presents as round bald patches that can be surrounded by pustules, crusting and even erosions. The bald patches of Folliculitis decalvans generally develop at the vertex and occipital regions of the head. Nonetheless other hair bearing regions may also get affected. The affected region initially gets red and swollen, and a follicular lesion is formed which turns into a pus filled pustule. This pustule typically has hair at the centre. Soon a crust forms around this pustule, which later detaches along with the hair. Sometimes there is spontaneous bleeding observed from these crusts. These pustules start occurring frequently and they ultimately kill the hair follicle.  This causes scarring and hair loss that eventually develops into pinkish or whitish bald patches. Another characteristic feature of Folliculitis decalvans is presence of tufting hair, wherein many hairs grow out from a single follicle analogous to toothbrush bristles. Folliculitis decalvans possesses a distinct appearance and progresses in a chronic manner.

How is Folliculitis decalvans diagnosed?

Folliculitis decalvans can be diagnosed on the basis of dermatoscopic examination of the scalp. A comprehensive clinical history and examination findings help in diagnosing the disorder. Initially the scalp is examined for scarring and further investigation is done for presence of crusts, pustules and tufted hair. Usually swabs from intact pustules are microscopically examined for the presence of Staphylococcus aureus. Skin scrapings are taken to investigate and rule out fungal infections. Eliminating these other infections is important because often fungal infections like ringworm appear similar to Folliculitis decalvans. Many a times, the dermatologists may carry out more than one biopsy to for diagnosis of Folliculitis decalvans and rule out other types of Alopecia.

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