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Discussion
Our case studies show that PDT sessions resulted in stabilization of FD and a decrease in symptoms in all 4 patients, with excellent tolerance (VAS, 0-2/10). All patients indicated that the reduction of symptoms resulted in a significant improvement of their quality of life (not assessed with a standardized score). The PDT sessions of the first patient were performed at 37 J/cm 2 , and the PDT sessions of the next 3 patients were performed at 12 J/cm 2 , according to the device available at the time. There was no difference between light irradiation of 12 and 37 J/cm 2 in the effectiveness of treating actinic keratosis. 7 One patient was prescribed adalimumab during PDT sessions, which may have had a synergistic effect against FD.
The reported clinical results of treatment of FD with PDT are variable. 8 , 9 Miguel-Gomez et al 3 reported a prospective series of 10 patients treated by conventional PDT. Nine patients (90%) showed clinical improvement, and 6 patients (60%) had a persistent remission. The main side effect was pain. In contrast, in a study by Burillo-Martinez et al, 10 PDT resulted in no improvement in all 3 patients and an overall worsening of the disease in 1 patient. All patients experienced discomfort that lasted from 1 to 3 days.
Despite encouraging results in the treatment of FD, conventional PDT has 2 main disadvantages compared with textile PDT: variability of light delivery and pain. These 2 parameters are improved by using new light-emitting devices. 7 , 11 , 12 On the basis of our clinical experience, we believe that monthly to weekly sessions are required until the symptoms are controlled. The disease often recurs a few months after the sessions are stopped. 1 To avoid recurrence, regular sessions of PDT could be performed. Furthermore, a well-tolerated illumination device, such as textile PDT, facilitates multiple sessions.
Systemic antibiotic therapy is currently the first-line treatment for FD, but it can increase bacterial resistance. Higher resistance rates of S aureus were shown in a cohort of patients with FD. 13 Photodynamic therapy has antibacterial effects, with no resistance, and provides local immunomodulation, 4 , 14 which could help reduce the use of repeated antibiotic therapies and the risk of bacterial resistance. The bactericidal effect of PDT on S aureus biofilm has been shown in vitro, with more than 99% of bacteria killed after the treatment. 15
Successful Management of Folliculitis Decalvans
This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Folliculitis decalvans (FD) is a rare disease that causes inflammation on the scalp, leading to scarring alopecia. It commonly affects young and middle-aged men and is characterized by pustules, papules, scarring, hemorrhagic crusts, and erosions. The exact cause of FD is not fully understood, but it is believed that Staphylococcus aureus may play a role in its development. The condition is thought to be influenced by a combination of genetic, allergic, infectious, and immunological factors. This report describes a 20-year-old male patient who experienced painful pustules on his scalp for six months. The pustules first appeared on the occipital region and then spread to the crown. The patient was diagnosed with FD after a thorough clinical and pus culture examination. Treatment involved a month-long prescription of doxycycline (100 mg BD) and topical ozenoxacin (2%), which led to successful remission of the lesions.
Keywords: staphylococcus aureus, antibiotics therapy, oral doxycycline, scalp nodule, cicatricial alopecia
Case series
Patient 1 was a 24-year-old man with a 5-year history of FD that had been treated unsuccessfully with multiple antibiotics, dapsone, and systemic retinoids. The physical examination revealed a large area of cicatricial alopecia with numerous erosive lesions and some pustules ( Fig 2 , A). The symptoms (exudate and pain) caused severe functional impairment. Three sessions of textile PDT at 37 J/cm 2 were performed at 1-week intervals. Systemic retinoids were stopped on the day of the first PDT session. Tolerance was excellent during the illumination (VAS, 0/10). A few crusts and light erythema spontaneously resolved within 2 days after the treatment. Favorable treatment outcomes were noticeable at 3-month follow-up. There were clear reductions in pain, burning, and oozing, and the pustules had resolved ( Fig 2 , B). The alopecia was relatively stable, with a slight progression at the center of the alopecic area. Control of the disease lasted for 4 months. Adalimumab 40 mg every 2 weeks was then prescribed, allowing stabilization of the disease.
A, Before photodynamic therapy: numerous erosive lesions, oozing, and inflammation. B, Evolution at 3 months after 3 sessions of textile photodynamic therapy: decrease in erosive lesions, oozing, and inflammation and stability of alopecia.
Patient 2 was a 37-year-old man who received a diagnosis of FD 10 years previously. He had been treated with systemic retinoids and topical and systemic antibiotics without any improvement. He had had no treatment in the past year. The physical examination showed a cicatricial alopecic area, with pustules and crusts on the periphery ( Fig 3 , A). Three sessions of textile PDT at 12 J/cm 2 were performed at 1-month intervals. Tolerance was excellent (VAS, 0/10). Light erythema and edema were noted after each illumination. The evolution was favorable at 3 months, with a decrease of symptoms such as pain and burning and stability of the alopecic area ( Fig 3 , B). Systemic retinoids were then prescribed for a period of 6 months, allowing stabilization of the disease. At 2 years of follow-up, the disease was stable and the patient only applied topical moisturizers.
Treatment for Folliculitis Decalvans
Treatment for folliculitis decalvans varies by individual in its effectiveness. The goal of treatment is to encourage disease remission (no symptoms). Most therapies can be administered at home, though some may require outpatient visits to a healthcare provider.
For most people, treatment involves a combination of topical solutions and/or oral antibiotics. It is a lengthy process because this condition can return after a course of successful therapy and trigger a recurrence of symptoms.
There is no specific treatment approved for folliculitis decalvans, so there is a wide range of approaches. The following therapies are the most common:
Antibiotics
Systemic antibiotics are regarded as the first-line treatment for folliculitis decalvans because they can eradicate Staphylococcus aureus. Though these treatments can be effective, symptoms often relapse after the interruption of therapy. Antibiotic resistance is also a concern with long-term use.
The following antibiotics are the most common:
- Oral tetracyclines :
- Minocin, Solodyn, others ( minocycline )
- Vibramycin -D, Efracea ( doxycycline )
- Adoxa, Declomycin , others (tetracycline)
- Tetralysal ( lymecycline )
- Rifadin, Rimactane ( rifampicin ) with or without Cleocin ( clindamycin ) (oral)
- First-generation cephalosporins:
- cephalexin oral
- Velosef ( cephradine oral)
- Duricef ( cefadroxil oral)
- Ancef ( cefazolin ) (intravenous and intramuscular)
Corticosteroids
Corticosteroids can help manage symptoms of itching, pain, and inflammation. They are also effective in treating the scar tissue common with folliculitis decalvans.
- Topical products (creams, gels, and ointments applied over the surface of the affected area)
- Intralesional injection (injection into a lesion)
- Systemic treatments (administered orally or intravenously for treatment throughout your body)
Introduction
Folliculitis decalvans (FD), often known as scarring alopecia, is one kind of primary cicatricial alopecia. This uncommon skin disorder is the root cause of about 10% of primary cicatrizing alopecia cases. Inflammatory neutrophilic infiltrates and scarring that results in papules and pustules around hair follicles indicate it [1]. It primarily affects males in their middle years and is more prevalent in those with darker skin tones [2,3]. Although the actual etiology of the illness remains uncertain, Staphylococcus (S.) aureus has been proposed as a possible culprit. There are other factors, such as the genetic link, since the illness is caused by cytotoxins or superantigens that bind to major histocompatibility complex (MHC) II molecules and has been seen in several families [4].
According to a recent systematic review overviewing 20 studies, including 282 patients ,the authors observed lack of high quality of evidence regarding the efficacy of FD-specific treatments. Antibiotics like clindamycin, rifampicin, doxycycline and azithromycin, tacrolimus, external beam radiation, isotretinoin, human immunoglobulin, adalimumab, infliximab, long-pulse ND:Yag, and red light photodynamic therapy have been tested, but the studies lack quality of evidence. However, a combination of clindamycin and rifampicin was found to be the most commonly used treatment in reviewed studies [5]. The present report consisted management of FD using a combination of two drugs with early response and no remission for a longer duration.