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  • Folliculitis decalvans (FD) is more common in middle-aged men.

  • FD usually presents on the vertex of the scalp and has a typical centrifugal progression.

  • FD presents with scalp erythema, follicular pustules, tufted hair, and crusts.


  • Scarred areas are often thicker and indurated compared to the atrophic cicatricial patches of other inflammatory primary scarring scalp disorders.

  • Tufted folliculitis, perifollicular hyperplasia arranged in a starburst pattern, thick peripilar casts, and twisted and elongated capillary loops can be seen on trichoscopy.

  • Trichoscopy can itself confirm diagnosis, but a biopsy is always recommended.


  • The combination of oral rifampicin and clindamycin, although effective, should be avoided due to antibiotic resistance that might prevent use of these drugs in serious infections.

  • Oral tetracyclines are the first line of treatment.

  • Intralesional triamcinolone, injected into the hair-covered areas surrounding scarring alopecia lesions, can halt spread of the condition and reduce symptoms of itch and burning.

  • Patients should use an antimicrobial shampoo daily.


  • Follicular tufting that includes more than six hairs is very suggestive for this diagnosis.

  • A sketch and measurements of the scarred areas are helpful to monitor disease progression: baseline scalp photography should be carried out, ideally with a ruler on the first visit.

  • A nasal swab should be performed to identify an occult S. aureus reservoir.


  • All kinds of head covers (bandanas, caps, hats, hair weaves, hairpieces, wigs) have to be cleaned with antiseptic syndets diligently as they can be a reservoir for S. aureus.


  • When members of the same household have similar scalp symptoms or other skin lesions and/or pets have fur problems think of deep fungal infections with zoophilic dermatophytes.

  • Presence of pustules indicates a clinical relapse.

  • Patients younger than 25 years often have severe form of FD.


  • Before starting treatment, patients must be informed that hair already lost will not regrow and that treatment aims to stop inflammation and disease progression.

  • Patients should know that 57%–80% of FD relapse after oral antimicrobial treatment, and that, long-term antibiotic treatment (more than 6 months up to 12 years) is often required with flare-ups when treatment is discontinued.

  • FD is life-changing but is not life-threatening. The earlier one gets treatment the better the prognosis; it affects otherwise healthy men and women, is not contagious, and not hereditary.


Folliculitis decalvans (FD) is a rare neutrophilic scarring alopecia that represents a therapeutic challenge.1–5 The aetiology of FD is still uncertain, but it may represent an interaction between the infection by S. aureus and the host.6 However, the mere presence of S. aureus in nasal cultures or pustules is insufficient evidence for a major role in the pathogenesis of FD and further research is required to determine the exact association between the bacterial infection ...

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