A-Z OF SKIN

Folliculitis Decalvans is an uncommon inflammatory scalp condition which can result in destruction of hair follicles and permanent loss of hair. The condition predominantly affects young and middle-aged adults and is more common in males. It can be hereditary in some families.

This is not well understood and the exact cause is unknown.  In many cases bacteria called Staphylococcus aureus (S. aureus) can be isolated from the pustules. It is thought that S.aureus triggers an immune reaction which results in the changes that are seen.

Affected areas develop recurrent crops of pustules as well as redness, scaling, crusting and loss of hair.  This causes scarring which eventually results in pale, smooth, bald patches.  In some people, multiple hairs can be seen exiting from a single hair follicle. This is known as “tufting”.  Folliculitis decalvans more commonly affects the top and back sections of the scalp.  Other hair bearing areas such as the armpits, beard or pubic region may rarely also be affected.

There may be itching, pain and tenderness in the affected areas.  However, some people do not experience any symptoms at all.

The diagnosis is made by a dermatologist from clinical history and examination findings.  A swab may be taken from an intact pustule from the scalp or inside the nose to check for the presence of S. aureus.  A skin scraping may be required to exclude a fungal infection. Sometimes, one or two biopsies from the scalp may be needed to establish the diagnosis and exclude other scarring forms of hair loss.

Treatment can be difficult and is aimed at controlling rather than “curing” the condition.  Topical antibiotics such as 1% clindamycin can be tried in the first instance in mild cases. However, more severe disease will require oral antibiotics such as doxycycline, minocycline, erythromycin or dicloxacillin. Rifampicin is an antibiotic that is said to have stronger action against S. aureus and is usually prescribed together with another antibiotic (clindamycin) to prevent emergence of bacteria resistance.

Some affected individuals will require long-term treatment to prevent relapse.  S. aureus, if present, will need to be eradicated by using intranasal antibiotics such as 2% mupiricin ointment.  In addition, an antiseptic or tar shampoo may be recommended.

The addition of topical and intralesional (injections) corticosteroids helps reduce inflammation and symptoms of itching and burning.  Oral corticosteroids are occasionally prescribed to control aggressive disease.

Many other treatments such as oral isotretinoin, dapsone and zinc sulphate have been used with variable success.  Laser treatment or surgical procedures are not commonly used and flare-ups of the condition can occur following treatment.