Original Article Effective Treatment of Folliculitis

Decalvans Using Selected Antimicrobial

Agents
Caulloo Sillani, Zhang Bin, Zhao Ying, Cai Zeming, Yang Jian,
Zhang Xingqi
Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University,
Guangzhou, Guangdong, People’s Republic of China

Address for correspondence: Abstract

Prof. Dr. Zhang Xingqi,
58, Zhong Shan, 2nd Road, Folliculitis Decalvans (FD) is a rare neutrophilic infammation of the scalp characterized
by painful, recurrent purulent follicular exudation resulting in primary cicatricial alopecia.
Department of Dermatology,
However, unclear etiology makes FD treatment a difficult task. A wide variety of topical and
The First Affiliated Hospital, systemic agents have been tried previously, with varied results. We present here a case
Sun Yat-sen University, series report of a set of 13 patients with FD on antimicrobial therapy.
Guangzhou - 510 080,
Guangdong, People’s
Republic of China.
Key words: Folliculitis decalvans, antimicrobial, primary cicatricial alopecia
Email: xingqizhang@hotmail.
com DOI: 10.4103/0974-7753.66908

INTRODUCTION antibiotic sensitivity test from six cases. Scalp biopsies were
done on seven patients with signed consents. The protocol

F olliculitis Decalvans (FD) is a rare neutrophilic

inflammation of the scalp characterized by painful,
recurrent purulent follicular exudation resulting in primary
of antimicrobial therapy was based on the severity of the
disease and antimicrobial sensitivity results. Patients with
mild FD were started on Minocycline 100 mg twice daily,
cicatricial alopecia. The superantigens theory,[1] with an orally. Patients with moderate FD were given a combination
abnormal host defense mechanism is widely accepted. of Minocycline 100 mg twice daily and Rifampicin 150 –
However, unclear etiology makes FD treatment a difficult 300 mg twice daily. The adjuvant drugs used were topical
task. A wide variety of topical and systemic agents including fusidic acid or mupirocin, selenium sulfide shampoo, oral
antimicrobials, antifungals, retinoids, corticosteroids, as well compound glycyrrhizin, and zinc gluconate. The patients
as laser depilation treatment have been tried previously, were reassessed after two weeks. Patients with deteriorating
with varied results.[2-7] We present here a case series report clinical symptoms, development of new skin lesions, and
of a set of 13 patients with FD, who presented to our hair expansion of the involved area were given additional
clinic for the past one year. Clarythromycin 250 mg twice daily and/or Acitretin 10 mg
once a day. The patients were assessed weekly or biweekly
until satisfactory disease control, followed by monthly
Materials and Methods
review.
Thirteen Chinese patients presenting to our hair clinic
between December 2008 and December 2009 with signs RESULTS
and symptoms of folliculitis Decalvans, were enrolled. A
detailed clinical history was taken followed by a thorough The results are listed in Table 1. There were 11 males
scalp examination and routine systemic examination. The (85%) and two females (15%) in the patient group, 15
severity of the disease was assessed based on the clinical to 66 years of age, with a mean age of 30.1±13.4 years.
presentation, type of skin lesions, the area involved, and The course of the disease varied from two weeks to
duration of the disease. four years. The chief complaints were mainly painful
scalp lesions accompanied by varying degrees of pruritis
Pus swabs from intact pustules were taken for culture and and hair loss. Androgenetic alopecia, acne, and atopic

20 International Journal of Trichology / Jan-Jun 2010 / Vol-2 / Issue-1

 Sillani, et al.: Treatment of folliculitis decalvans

Table 1: Results
Patient Age Duration Severity of Culture report Rx (wk-week/s; mo-month/s) Duration of Rx Follow-up
no. of disease / condition (ND-Not Done)
month
1 66 6 Mild ND Minocycline 100 mg bid × 2 wk 1 month Relapse after 8 months
2 40 3 Mild Coagulase Minocycline 100 mg bid × 4 wk 1 month Good hair regrowth,
negative no relapse
Staphylococcus
3 15 0.5 Moderate ND Minocycline 100 mg bid × 4 wk 1 month Good hair regrowth,
no relapse
4 23 1 Mild ND Minocycline 100mg bid × 2 wk 1 month Good hair regrowth,
no relapse
5 34 2 Mild ND Minocycline 100 mg bid × 8 wk 8 weeks Good hair regrowth,
no relapse
6 27 2 Mild ND Minocycline 100 mg bid × 8 wk 3 months Good hair regrowth,
no relapse
7 32 3 Mild ND Minocycline 100 mg bid × 3 mo 3 months Good hair regrowth,
Acitretin 10 mg OD × 2 wk no relapse
8 16 2 Mild ND Minocycline 100 mg bid × 2 wk 1 month Good hair regrowth,
Rifampicin 150 mg bid × 1 wk no relapse
9 25 2 Moderate Citrobacter koseri Minocycline 100 mg bid × 4 mo 4 months Good hair regrowth,
Rifampicin 300 mg bid × 3 mo no relapse
10 24 9 Moderate Nil (twice) Minocycline 100 mg bid × 4 mo 4 months Good hair regrowth,
Rifampicin 300 mg qd × 1 mo no relapse, on topical
drugs
11 39 48 Moderate Staphylococcus Minocycline 100 mg bid × 2 mo > 1 year Still under treatment,
aureus Clarythromycin 250 mg bid × 3 marked improvement,
mo Acitretin 10 mg bid / qd × 1 scalp skin scarring,loss
mo Rifampicin 300 mg bid × 1 mo of follicular ostia
12 30 1 Mild Nil Clarythromycin 250 mg bid × 2 1 month Good hair regrowth,
wk Rifampicin 150 mg bid × 2 wk no relapse
13 20 36 Moderate Nil Clarythromycin 250 mg bid × 4 months Partial hair growth,
4mo Acitretin 10 mg qd-bid × 4 no relapse, on topical
mo Rifampicin 300 mg qd × 3 mo drugs

dermatitis were found in three, three, and one patient, Staphylococcus aureus, Citrobacter koseri, and coagulase-
respectively. No similar family history was found in any negative staphylococcus were grown in three cases, but
of the patients. 84.6% (11 cases) had vertex involvement. no microorganisms were found in the other three cases.
61.5% (8 cases) had occipital involvement, among seven The duration of treatment varied from one month to
cases which overlapped with vertex involvement. The more than one year. Minocycline 100 mg bid, given as
affected scalp area ranged from less than 5% to 20%. monotherapy for an average of 5.7 weeks was able to
The skin lesions varied in morphology, they ranged from clear the scalp lesions in seven patients; only one of them
papular lesions with no exudation to pustular, boggy needed two weeks of oral Acitretin, and one of them had
nodular masses with mild serous exudation on areas of the disease relapse after eight months. A combination
hair loss ranging from 0.5 cm to < 2 cm in diameter. of Minocycline and Rifampicin for an average of 11.7
Tufted hairs were present in two patients. Eight cases weeks was effective in treating three patients, in which
were considered as mild and the rest were considered Minocycline failed as a monotherapy. Combination
as moderate FD cases. Full blood count of the patients of Clarythromycin and Rifampicin for an average of
did not show any significant abnormal deviations. IgE 10 weeks was also effective in clearing scalp lesions
was elevated in two patients (one of whom had a history in two patients. Patient 11 [Figures 1–3] needed
of atopic dermatitis). Autoimmune antibody titers, HIV, combinations of different antimicrobials with aggressive
and RPR / TPPA titers were negative in all the patients. adjuvant therapy, as he neglected treatment in the
Erythrocyte sedimentation rate (ESR) was not elevated beginning and his condition worsened significantly with
in any of the patients. Seven cases who underwent scalp scarring. Only patient 11 had mild side effects from
histopathological examination were all confirmed as FD Rifampicin (nausea and vertigo); it was substituted by
with typical folliculitis and features of scarring alopecia. Clarythromycin after one month of therapy.

International Journal of Trichology / Jan-Jun 2010 / Vol-2 / Issue-1 21

 Sillani, et al.: Treatment of folliculitis decalvans

Figure 1a: Patient 11 on presentation Figure 1b: Patient 11 on presentation (close-up)

Figure 2a: Patient 11 after five months of treatment Figure 2b: Patient 11 after five months of systemic antimicrobials
(close-up) with scarring of scalp skin

Figure 3a: Patient 11 dermatoscopic changes – loss of follicular ostia

DISCUSSION

In our group of patients, 85% were males, which concurred

with the male predominance in other studies as well Figure 3b: Patient 11 dermatoscopic changes – tufted hairs

22 International Journal of Trichology / Jan-Jun 2010 / Vol-2 / Issue-1

 Sillani, et al.: Treatment of folliculitis decalvans

(83%).[4] Among patients in whom bacterial and fungal safe and their side-effects when used in separate short
cultures were carried out, only half of them yielded a courses are mild. Most of our patients (9/13) are still
positive result, and Staphylococcus aureus was not always disease-free with good hair regrowth, while the others
the only pathogen found. However, these results could are being controlled either by topical (2/13) or systemic
have been affected by contamination during the sampling antibiotics (1/13). Thus, early and effective treatment
procedures. Tufted hair was not a common finding in our of FD is needed to prevent progression of the disease
patients, with an occurrence of 15% among all patients. and scarring of the scalp skin.
Therefore, it could be a sign of severity of the disease and
not an element for diagnosis.
CONCLUSION
Although non-antibacterials have also been used in the
treatment of FD, the main aim has mainly been focused Minocycline is a very effective antimicrobial agent in mild
on the eradication of S. aureus. Rifampicin, which acts cases, but administration of Rifampicin or Clarythromycin
by inhibiting DNA-dependent RNA polymerase activity in combination with Minocycline is helpful in moderate
in susceptible cells, is very effective against S. aureus. or resistant cases. An early treatment of FD, with proper
Minocycline hydrochloride, which is a semi-synthetic antimicrobials, is important for preventing total destruction
derivative of tetracycline, has a bacteriostatic effect, as of hair follicles leading to scarring alopecia.
it inhibits protein synthesis of Gram negative and Gram
positive microorganisms, including S. aureus. Some studies REFERENCES
have already proved the effectiveness of Rifampicin,[4,8,9]
however, due to rapid emergence of antibiotic resistance, 1. Powell JJ, Dawber RPR, Gatter K. Folliculitis decalvans including tufted
folliculitis: Clinical, histological and therapeutic findings. Br J Dermatol
it has been used in combination with other antimicrobials. 1999;140:328-33.
The use of Clarythromycin, a macrolide antimicrobial, 2. Whiting DA. Cicatricial alopecia: Clinico-pathological findings and
which binds to the 50S ribosomal subunit of susceptible treatment. Clin Dermatol 2001;19:211-5.
microorganisms and inhibits protein synthesis, has 3. Annessi G. Tufted folliculitis of the scalp: A distinctive clinicohistological
variant of folliculitis decalvans. Br J Dermatol 1998;138:799-805.
also been suggested earlier.[1] We thus preferred to use 4. Chandrawansa PH, Giam Y. Folliculitis decalvans - a retrospective study in
Minocycline as the drug of first choice, while Rifampicin a tertiary referred center, over five years. Singapore Med J 2003;44:84-7.
was used additionally when Minocycline monotherapy 5. Abeck D, Korting HC, Braun-Falco O. Folliculitis decalvans: Long-lasting
response to combined therapy with fusidic acid and zinc. Acta Derm
was ineffective. In one of our patients, Rifampicin was Venereol 1992;72:143-5.
substituted by Clarythromycin due to mild side-effects; 6. Gemmeke A, Wollina U. Folliculitis decalvans of the scalp: Response
Clarythromycin proved to be as effective. to triple therapy with isotretinoin, clindamycin,and prednisolone. Acta
Dermatovenerol Alp Panonica Adriat 2006;15:184-6.
7. Parlette EC, Kroeger N, Ross EV. Nd:YAG laser treatment of recalcitrant
The antimicrobials used in this study are only a few of folliculitis decalvans. Dermatol Surg 2004;30:1152-4.
the large variety available for successful FD treatment, 8. Kaur S, Kanwar AJ. Folliculitis decalvans: Successful treatment with a
however, each drug needs proper tailoring according to combination of rifampicin and topical mupirocin. J Dermatol 2002;29:180-1.
the patient’s condition, along with clinical assessment 9. Brozena SJ, Cohen LE, Fenske NA. Folliculitis decalvans--response to
rifampin. Cutis 1988;42:512-5.
and laboratory investigations. Cosmetically acceptable
results have been attained in most of the patients in a
Source of Support: Nil, Conflict of Interest: None declared.
relatively short time. The antimicrobials used are also

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