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Chapter 82: Folliculitis Decalvans

Rebecca H. Goldberg; Lynne J. Goldberg

FOLLICULITIS DECALVANS

Therapeutic Approach

Folliculitis decalvans, also known as “tufted folliculitis” due to the clinical feature of several hairs arising from a single follicle, is the most common neutrophilic scarring alopecia. It is characterized by perifollicular pustules and inflammation that destroys the follicle leading to round or oval patches of permanent hair loss. Treatment may reduce symptoms and control progression, but there is no curative therapy to date. First-line therapy includes topical and/or oral antibiotics depending on disease extent, often in combination with topical or intralesional steroids. More severe or extensive disease requires oral antibiotics or other systemic therapies, such as isotretinoin or dapsone. Maintenance therapy may be necessary. See Table 82-1.

Table 82-1Folliculitis Decalvans Treatment Table
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Table 82-1 Folliculitis Decalvans Treatment Table
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MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING (PO UNLESS SPECIFIED) ADVERSE EFFECTS (COMMON)1 SUGGESTED MONITORING1 LEVEL OF EVIDENCE
Topical Therapy
High-potency corticosteroid First-line Anti-inflammatory QD/BID × 2-4 wk, then taper Atrophy, dyspigmentation None IV2
Clindamycin Mild Anti-inflammatory, antimicrobial (bacteriostatic) BID Irritation None IV2
Dapsone gel 5% Recalcitrant Anti-inflammatory, antimicrobial (bacteriostatic) 3×/wk Sinusitis None III3
Tacrolimus ointment 0.1% Recalcitrant Calcineurin inhibitor BID Burning, pruritus, erythema, headache None III4
Mupirocin ointment 2% Recalcitrant Antimicrobial (bacteriostatic/bactericidal) 2-3×/d Irritation, pruritus, nausea None III5
Manuka honey Adjuvant Antimicrobial QD × 1 m None None III6
Systemic Therapy
Tetracycline First-line Anti-inflammatory, antimicrobial (bacteriostatic) 500 mg BID Photosensitivity, esophagitis, contraindicated in pregnancy and children <8 y CBC, CMP, prolonged use or preexisting disease only III7
Cephalexin First-line Anti-inflammatory, antimicrobial (bactericidal) 250-500 mg BID-QID Genital candidiasis CBC, CMP, prolonged use or preexisting disease only IV2
Minocycline First-line Anti-inflammatory, antimicrobial (bacteriostatic) 50-100 mg BID Dizziness, fatigue, pseudotumor cerebri, hyperpigmentation, lupus-like syndrome CBC, CMP, prolonged use or preexisting disease only III7,8
Doxycycline First-line Anti-inflammatory, antimicrobial (bacteriostatic) 50-100 mg BID Photosensitivity, hyperpigmentation, esophageal injury, contraindicated in children <8 y CBC, CMP, prolonged use or preexisting disease only III7,9
Rifampin + clindamycin Recalcitrant Anti-inflammatory, antimicrobial (bacteriostatic, rifampin also bactericidal) 300 mg of each BID × 10 wk

R: anemia, C. difficile-associated diarrhea (ad), hepatotoxicity

C: C. diff-ad

 Baseline and periodic CBC, CMP III10,11, IV2
Isotretinoin Recalcitrant Inhibition of neutrophil migration and toll-like receptor 2 Variable; from 0.1 to 1.0 mg/kg/d, 2.5 to >7 m, may need maintenance Elevated triglycerides/CPK/LFTs, pediatric back pain, arthralgia Baseline and periodic CBC, CMP, lipids, bHCG, monitor for behavioral sx III12,13
Prednisone Recalcitrant Anti-inflammatory 1 mg/kg, then taper Adrenal suppression, cardiovascular/CNS/behavioral/GI/neuromuscular/ocular effects, Cushingoid features, hyperglycemia, immunosuppression, acne Baseline and periodic BP, CBC, CMP, prolonged or high dose use, consider periodic bone density, screen for occult infection IV2
Adalimumab Recalcitrant TNFα-blocker SQ; 40 mg/wk to QOwk +/− loading doses Antibody development, positive ANA, rash, injection site reaction, URI, headache, elevated CPK in children

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