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Folliculitis decalvans

14 October 2019, by MENDES R.


Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology



Folliculitis decalvans (FD) is a rare and chronic type of “cicatricial alopecia”. Cicatricial alopecia represents a diverse group of disorders that cause the destruction of the hair follicle and replace it with scar tissue causing permanent hair loss. FD is further classified as a primary cicatricial alopecia because the hair follicle is the target of the destructive inflammatory process. Clinically it presents as an expanding patch of alopecia (visible hairlessness) with peripheral pustules on the scalp.

2.2 - WHO GETS IT?

It occurs in otherwise healthy men and women of all ages, although it is more common in young and middle-aged adults. It is not contagious and it is seen worldwide.


A detailed clinical history and thorough examination of the scalp are the first steps in the diagnosis of FD. However, obtaining a biopsy of an active lesion of your scalp is vital for confirmation and assessment. This disease is progressive and often relapses, but early diagnosis and therapeutic intervention can often prevent extensive permanent damage. Once a definitive diagnosis and assessment is made, your doctor can determine the best treatment for you.


FD predominantly involves the crown and posterior area of the scalp. It usually begins as a red bump around the hair follicle. The main characteristic is the development of scarred areas and pustules surrounding the hair follicles. Other common features, which are also more evident around the follicles, include:

  • Redness together with yellow-gray scales
  • Erosions and haemorrhagic crusts
  • Multiple hairs emerging from one single follicle may be seen
  • With disease progression, atrophic flesh-coloured to ivory-white patches of alopecia appear
  • Other sites (besides the scalp) can be involved, including the beard, underarms, pubic hair, legs and arms

 As a patient you will probably complain of:

  • Pain, itching and/or burning sensations
  • Discharge of purulent material
  • Spontaneous bleeding may occasionally occur


The cause of FD is unknown. However, it seems to be related with an excessive inflammatory response to bacteria, particularly Staphylococcus aureus which can be noted with special stains of biopsies and/or cultures of pustules in almost every patient. There may be a genetic predisposition since S. aureus is common in the average population but fewer than 0.05% of the carriers suffer from FD. In addition, familial cases of FD have been reported. Like in other types of primary cicatricial alopecia the inflammation is directed at the hair follicle leading to its permanent destruction. In FD the involved inflammatory cells are primarily neutrophils that can be seen on early skin biopsies.

Other proposed but unclear etiological factor include scalp injury and seborrhoea.

It is important to recall that FD is not contagious and occurs in otherwise healthy individuals.


FD may be highly distressing, especially if you are suffering from extensive scalp involvement or if you have tried treatments before with little or no results. There are important things you should know:

  • The aim of treatment is to prevent scarring and if scarring has already developed it will be permanent. This means that hair regrowth cannot be expected.
  • Treatment is important to prevent further hair loss and to control local symptoms like pain or itching.
  • Keep in mind that treatment is not easy. FD can be very resistant and long-term therapy is often necessary.

Your physician will be glad to explain you any uncertainty you might have and to address all the treatment possibilities and side effects.

Most of the therapeutic approaches are focused on S. aureus eradication. These include prolonged use of oral antibiotics, particularly rifampin and clindamycin combination therapy over 10-12 weeks which has achieved successful long-term remissions. Oral therapy may sometimes be combined with topical antibiotics such as mupirocin, clindamycin, fusidic acid and erythromycin. In very mild cases topical antibiotics may be enough.

Topical corticosteroids and injection of corticosteroids may be useful to reduce inflammation and relief of associated symptoms (itching, burning and pain). Other therapies include oral corticosteroids (for short periods of time and only in highly active and progressive cases), dapsone and oral isotretinoin. Surgical options may be considered only for exceptional cases with no sign of disease activity after several years.


Important tips for patients with FD

  • You may experience emotional side effects from physical hair loss. Remember you are not alone and there are many resources available. Joining a support group may be helpful!
  • There are many different possibilities of camouflage techniques. You may use hair pieces, wigs, hats and scarves.
  • Keep in mind that all kinds of headdresses must be cleaned with antiseptic syndets and you should switch between different kinds of headpieces. This is because they may act as a reservoir for S. aureus. However, if you take the necessary precautions, there will be no problem. Use them freely!
  • Shampoo daily with an antiseptic cleanser. If you feel daily shampooing is drying out your skin significantly tell your physician about it! Topical antibiotics and/or topical steroids may be given in ointment or oil formulation.
  • Talk with your physician about any uncertainty you might feel. Education about your condition will enable you to understand it, cope with it better and taking an active role in decisions regarding your treatment and well-being.

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