Diseases on Hair Follicles Leading to Hair Loss Part II: Scarring Alopecias

Katharina Wiedemeyer; Wolf-Berhard Schill, MD; Christoph Löser, MD


Skinmed. 2004;3(5) 

In This Article

Neutrophil-Associated Scarring Alopecias

Neutrophil-associated scarring alopecias include folliculitis decalvans, perifolliculitis capitis abscendens et suffodiens (of Hoffman), and acne keloidalis nuchae. Although the exact etiology is still unknown, abnormal inflammatory reactions mostly to Staphylococcus antigens are believed to account for all of the granulocyte-associated alopecias. They most commonly affect the scalp and rarely the beard. The primary differential diagnosis of any bacterial folliculitis is deep trichomycosis, which clinically may look exactly alike.

Folliculitis decalvans starts with perifollicular erythema, follicular papules, and pustules that spread peripherally. Typical are so-called hair tufts, where multiple hair shafts emerge from one dilated follicle opening. This is caused by fibrosis of adjacent follicular units and retention of telogen hairs within the infundibulum.[2] In early lesions, the follicle orifice is expanded and many granulocytes are found inside and outside the follicle. Perifollicular abscesses are formed and further inflammation can lead to rupture of the follicle. The presence of follicular debris causes foreign body reactions and leads to fibrotic scar tissue.

Treatment may be very difficult. In most cases, staphylococci are found within the lesions. The first choice is oral antibiotics. Before antibiotic therapy, a bacterial culture facilitates detection of possible resistant strains, multiresistant staphylococcus aureus in particular. Resistant strains of staphylococci are an increasing problem, which makes antibiotic treatment a matter of responsibility. Interestingly, in folliculitis decalvans staphylococci are also found in phagocytes where they are apparently not destroyed and perpetuate the process when released byz decay of the phagocytes. This might be one of many mechanisms by which bacteria escape the effect of antibiotics. In fact, folliculitis decalvans has been shown to be very resistant to antibiotic treatment. Powell and Dawber.[3] introduced a new treatment regimen consisting of rifampicin (300 mg) and clindamycin (300 mg) twice daily for 10 weeks. The combination of these two lipophilic drugs has been successfully applied in many cases.[4]

Perifolliculitis capitis abscedens et suffodiens (of Hoffman), or dissecting folliculitis, is an even more severe inflammatory condition. Compared with folliculitis decalvans the inflammatory infiltrate reaches deeper structures of the skin (Figure 1). It predominantly occurs in African-American men between ages 20 and 40 years.[5] Suppurative follicular and perifollicular abscesses lead to sinus tract formation, which is not found in folliculitis decalvans. Foreign body giant cells can be found in great numbers. Histologically, the follicles are invaded by inflammatory cells, especially the lower portions. Once the follicles are destroyed, the inflammatory process is replaced by dense fibrosis of the dermis.

Perifolliculitis abscedens et suffodiens (of Hoffman). The scalp is covered by boggy, fluctuant nodules. Dissecting cellulitis finally results in dermal fibrosis, sinus tract formation, hypertrophic scarring, and permanent hair loss.

The treatment of choice for dissecting folliculitis is antibiotic therapy. Improvement was also shown by systemic retinoids, dapsone[6] and short-time steroids. Topical treatment alone is not effective but disinfectants can support the systemic therapy. Some authors suggest x-ray, surgery, or laser therapy as an alternative to systemic medication. Interestingly, the presence of hair follicles seems to be essential for the perpetuation of the disease: after depilation of all follicles by x-ray, the inflammatory process declines and finally stops.[7]

Also called folliculitis scleroticans nuchae, this disease presents with follicular-based papules concentrated on the lower occiput.[8] Acne keloidalis nuchae is easily recognized and responds to the same therapy regimens as folliculitis decalvans and dissecting folliculitis.


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