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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
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 ).
Treatment of folliculitis decalvans by photodynamic therapy using a new light-emitting device: A case series of 4 patients
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Folliculitis decalvans (FD) is a rare condition that affects young people, with a slight predominance in males. The lesions start with follicular erythema that progresses to pustules. The pustules evolve into a crust, leading to hair loss and scarring alopecia. The etiology of FD is unknown but could involve an inadequate immune response to Staphylococcus aureus, resulting in a chronic inflammatory reaction of the affected area. Treatment of FD can be challenging. The aim of the treatment is to stop the development of pustules and the extension of irreversible alopecia. However, because the disease is rare, we lack sufficient evidence on the efficacy of therapy. In clinical practice, systemic and topical antibiotics, retinoids, dapsone, zinc, and/or topical tacrolimus are generally used. 1 Some reports of treatment of FD with photodynamic therapy (PDT) have been published, with encouraging results. 2 , 3 These positive results may be due to the antibacterial and immunomodulation effects of PDT. 4 However, the use of this treatment is limited due to the variability of the illumination as well as the pain it causes, which is considered its main side effect. Moseley et al 5 showed that 2 commercial light-emitting devices did not provide uniform light and demonstrated that the fluence rate could be 30% lower than that delivered to the central zone at a distance of only 2 cm from the central zone. To overcome this disadvantage, the development of a flexible light source appears to be an interesting solution for nonplanar surfaces such as the scalp. Recently, a textile PDT device incorporating light-emitting fabric was developed ( Fig 1 , A and B). 6 The treatment of actinic keratosis with textile PDT showed promising results in terms of efficiency and tolerance (visual analog scale [VAS], 0.3/10). 7 Moreover, the flexible nature of this device appears to be well suited for use on curved surfaces such as the scalp, resulting in uniform illumination. 6
Introduction
Acne keloidalis nuchae (AKN) also known as folliculitis keloidalis nuchae (FKN) is one of the chronic forms of scarring folliculitis seen mostly in men of African descent. 1 Although the term “folliculitis keloidalis nuchae” captures the follicular nature of the disorder and is preferred by some, the lesions develop past the nuchal area suggested by the terminology. The term AKN is commonly used although it is generally agreed that the condition is not a keloid, and affected individuals do not have a tendency to develop keloids in other areas of the body. Acne keloidalis (AK) lesions do not have histological features suggestive of a keloids. 2
Hebra in 1860 first used the terminology sycosis framboesiformis although it had been described as a distinct entity in the late 1800s. 3 In 1869, Kaposi referred it to as dermatitis papillaris capillitii, and in 1872, Bazin coined the term AKN. 4 The exact cause of AKN remains unknown. The inciting agents appear to be multifactorial with various factors such as androgens, inflammation, infection, trauma, genetics, and ingrowing hairs being implicated. It shares some similar features with other forms of cicatricial alopecia and may occur together in the same individual. It has been classified as a mixed form of the primary cicatricial alopecia by the North American Hair Research Society. 5 It is characterized by papules, pustules, and sometimes tumorous masses in the nuchal or occipital regions of the scalp hence the name “bumps” evolved in the environment. 6 Despite its common occurrence, treatment may be challenging. This review highlights the epidemiology, clinical features, impact, and treatment challenges.
Epidemiology
AKN occurs majorly in those of African descent. It has been reported in a few Caucasians and other ethnic groups. 7 It is predominantly a disorder of males although there are a few reports in females with a male to female ratio of 20:1. 8 , 9 Reports from Nigeria give a prevalence ranging from 0.7% to 9.4%, 10 – 12 while in Benin in West Africa the prevalence is 0.7%. 13 In South Africa, a prevalence of 4.7% was seen in boys in their last year of school and 10.5% in older men. 14 In African-Americans, the reported prevalence ranges from 0.5% to 13.6%. 5 , 16 The latter was in American footballers who wore headgears for protection. Their Caucasian counterparts wearing the same headgears did not develop AKN.
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