Folliculitis decalvans (FD) is a challenging disease to treat. Recently, I have had two female patients with progressive FD, a teenager and a 69-year-old woman. They are understandably upset by the symptoms and appearance of their condition. Both were placed on doxycycline and clobetasol. I have reviewed the treatment options in the latest edition of our Treatment of Skin Disease text. I was hoping to find something more.
The following are 2 recent abstracts from the literature, the first by Bunagan et al (1) and the second by Tietze et al (2). I have underlined the conclusions of each.
To date, there is no standard treatment of folliculitis decalvans (FD), a rare type of cicatricial alopecia.
The records of 23 patients with FD (1998-2012) were retrospectively analyzed, with added data review on the course and treatment of long-standing cases.
Initial management consisted mostly of intralesional triamcinolone acetonide, clobetasol lotion, and either cephalexin, minocycline, doxycycline, or tetracycline. Alternatives consisted of rifampicin, clindamycin, ciprofloxacin, and isotretinoin. Remission was achieved in weeks to months in more than half of the cases, with low occurrence of relapse. The poor responders had a protracted course of temporary improvement and multiple relapses.
The majority of patients showed improvement and subsequent remission with oral antibiotics. In some patients, it took years of slow taper before the antibiotic could be discontinued. Only a few patients had recalcitrant disease, with minimal response to their initial and alternative medications.
Folliculitis decalvans leads to scarring alopecia through inflammatory destruction of the hair follicle. Currently, antibiotics are most commonly used to treat this disease. However, treatment regimens with antibiotics feature a high relapse rate and encourage the development of resistant bacteria.
To evaluate the outcome of different treatment options for folliculitis decalvans. Retrospective study to compare the efficacy of different treatment regimens in 28 patients with folliculitis decalvans.
The success of treatment with clindamycin and rifampicin, clarithromycin, dapsone and isotretinoin was analysed. The evaluation of the combination of clindamycin and rifampicin showed the lowest success rate in achieving long-term remission, since 80% of the patients relapsed shortly after end of treatment. Clarithromycin and dapsone were more successful with long-term and stable remission rates of 33% and 43% respectively. Treatment with isotretinoin was the most successful oral treatment in our analysis with 90% of the patients experiencing stable remission during and up to two years after cessation of the treatment.
The common use of antibiotics as first-line therapy in folliculitis decalvans needs to be re-evaluated critically and oral isotretinoin should be considered as valid treatment alternative.
Admittedly, treating FD makes me pull my hair out, and it leaves me scarred. But that pales in comparison to the effect on my patients. For whatever reason (and I cannot think of a good reason) I cannot recall the last time I prescribed isotretinoin for FD (or even if I ever have).
What has been your experience?
- Bunagan MJ, et al. Retrospective review of folliculitis decalvans in 23 patients with course and treatment analysis of long-standing cases. J Cutan Med Surg 2015; 19: 45-9.
- Tietze JK, et al. Oral isotretinoin as the most effective treatment in folliculitis decalvans: A retrospective comparison of different treatment regimens in 28 patients. J Eur Acad Dermatol Venereol 2015; 29: 1816-21.