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Case presentation
A 20-year-old male from central India presented to the outpatient department of a tertiary care hospital with multiple painful pustules covering the crown and occipital areas of his scalp (Figure (Figure1). 1 ). The patient had no history of pruritus, hidradenitis suppurativa, acne, or scalp injuries. Multiple nodulocystic lesions and patches of hair loss over the occipital and crown region were noted during the clinical examination.
Figure 1
Multiple nodulocystic lesions are present on the occipital and crown area of the scalp (black arrows).
All laboratory tests, such as the fasting lipid profile, thyroid profile, liver function test, renal function test, total blood count, and other indicators of inflammation, were within normal ranges. No fungal growth was seen in the fungal culture. Methicillin-sensitive S. aureus was found in moderate amounts in the swabs taken from the intact pustules. Methicillin-sensitive S. aureus was also detected in pustule scalp bacterial cultures (Figures (Figures2, 2 , ,3 3 ).
Figure 2
Round (1-3 mm), golden-yellow colonies of Staphylococcus aureus on blood agar.Figure 3
Yellow-colored colonies of Staphylococcus aureus on mannitol salt agar (MSA).A diagnosis of FD was made for the patient based on the clinical presentation, examination, and culture results. The patient was prescribed topical ozenoxacin 2% lotion twice daily for one month and oral doxycycline 100 mg BD. At one-month follow-up, the patient showed a recession of nodulocystic lesions with reticular patches of alopecia and hair regrowth (Figure (Figure4 4 ).
Other possible causes for your hair loss
A dermatologist may rule out other causes of hair loss, such as:
- hormonal conditions related to pregnancy, menopause, and elevated androgen levels
- a recent acute illness, such as the flu or an infection
- underactive thyroid (hypothyroidism)
- radiation exposure
- cancer treatments
- certain medications, such as birth control pills, anabolic steroids, and blood thinners
- ringworm
- chronic stress
- stress from a recent traumatic event
- malnutrition (especially iron and protein deficiencies)
- vitamin A overdose
- weight loss
- eating disorders
- poor haircare
- tight hairstyles
Once other causes for your hair loss are ruled out, a dermatologist might recommend a biopsy and culture. This procedure involves taking a small sample of your scalp or your skin and sending it to a lab for testing. A blood test may also be ordered to help rule out any other underlying issues, such as thyroid disease.
- medical history
- physical exam
- possible biopsy
- blood test
- skin culture
There is currently no cure for FD. The main goals of treatment are to reduce inflammation and prevent the condition from getting worse. Because FD is a rare condition, most treatment studies have been small, with no overwhelming consensus about the most effective option.
Some treatments are more effective for certain people than they are for others. You may need to pursue a variety of treatment options or a combination of two or more approaches to manage your symptoms. Among the more widely used treatments are:
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.
What Causes Folliculitis Decalvans?
For most people, this doesn't cause a problem. The bacterium occurs naturally on your skin.
Folliculitis decalvans may occur due to a hypersensitivity reaction to "superantigens." Superantigens are a class of toxins produced by bacteria and viruses that trigger an intense response in people who have a compromised or defective immune system. This response may be hereditary because folliculitis decalvans is known to occur more frequently among members of the same family.
Despite its appearance, folliculitis decalvans is not skin cancer. Though it is linked with a specific bacterium and often improves with antibiotics, the problem is not considered contagious.
Common Triggers for Folliculitis Decalvans
Folliculitis may be triggered when the hair follicle becomes damaged or blocked. This can occur when the follicle rubs against clothing or shaving, leaving the damaged hair follicle susceptible to infection.
The cause of folliculitis decalvans is not understood. The following circumstances have been identified as possible triggers, though they have not been proved as causes:
- Abnormal immune response to Staphylococcus aureus
- Males, usually in their 40s and 50s
- Family history of the condition
