Improvement of Recalcitrant Dissecting Cellulitis of the Scalp After a Trial of Upadacitinib

Dissecting cellulitis of the scalp (DCS) is a rare condition characterized by painful inflammatory nodules and abscesses on the scalp, often leading to sinus tracts and scarring alopecia. We present a case of DCS in a 26-year-old male who experienced significant clinical improvement following a short course of upadacitinib, a Janus kinase (JAK) inhibitor. The patient received multiple standard treatments such as topical antimicrobials, oral antibiotics, corticosteroids, and intralesional triamcinolone injections, with limited success. However, following the initiation of upadacitinib, the patient reported reduced pain, pustular draining, and bleeding, with significantly improved quality of life. To our knowledge, there is currently a paucity of literature documenting the use of JAK inhibitors for DCS. This case aims to highlight the potential of JAK inhibitors as a therapy for refractory DCS, a condition with limited treatment options.

EGFR inhibitor-induced folliculitis decalvans: a case series and management guidelines

Epidermal growth factor receptor (EGFR) is one of therapeutic targets in oncology for solid tumors originating from epithelial tissue, such as non-small-cell lung carcinoma (NSCLC) and breast cancer. EGFR inhibitors used in cancer treatment may cause a broad spectrum of dose-dependent cutaneous adverse events, including acneiform papulopustular rash, nail and hair disturbances, xerosis, and mucositis. The pathogenesis of the EGFR inhibitor-induced adverse reactions originates from disturbances in keratinocyte differentiation, cytokine secretion, and neutrophil chemotaxis. One of the rare, yet distressing adverse events may be folliculitis decalvans, a progressive neutrophil-driven scarring alopecia with hair tufts formation resembling doll's hair. Early diagnosis and introduction of treatment are crucial for disease prognosis since a long course of the disease leads to decreased quality of life. Here, we review the literature cases of EGFR inhibitor-induced folliculitis decalvans and provide guidance on management and prevention of this condition in oncologic patients. Furthermore, we report the first afatinib-associated folliculitis decalvans in three female patients with NSCLC.

Refractory Folliculitis Decalvans Treatment Success with a Novel Surgical Excision Approach Using Guarded High-Tension Sutures

Purpose

Folliculitis decalvans (FD) is a difficult-to-treat, localized scarring alopecia characterized by an expanding area of chronically inflamed purulent plaques or masses. Current treatment modalities vary and often result in only temporary remission. There are no reports of surgical therapies for FD. Here, we describe FD treatment using surgical excision and second-intention healing aided by guarded high-tension sutures.

Methods

Five patients (one woman and four men) with histologically confirmed FD were treated by surgical lesion excision. All wounds were allowed to heal via second-intention. Guarded high-tension sutures were employed to minimize tissue tears while aiding and guiding wound contraction.

Results

All wounds healed with a 47-83% spatial contraction of the maximum wound diameters. Three patients healed entirely by second-intention, while two required a minor skin graft to close the wound completely. No disease recurrence was noted at 10-24 months.

Conclusion

Surgical excision with second-intention healing aided by guarded high-tension sutures effectively treated small and extensive FD lesions with no recurrence at long-term follow-up. To our knowledge, this is the first report of successful surgical treatment of FD.

Unveiling a Shared Precursor Condition for Acne Keloidalis Nuchae and Primary Cicatricial Alopecias

Purpose

Small observational studies suggest subclinical disease occurrence in the normal-appearing scalp zones of several primary cicatricial alopecias. To aid patient management, we began routinely evaluating the entire scalp of patients with acne keloidalis nuchae (AKN), including trichoscopy-guided biopsies.

Patients and Methods

This retrospective study evaluated 41 patients sequentially presenting with AKN at a single clinic between June and December 2022. Primary lesions and normal-appearing scalp in the superior parietal scalp at least 5 cm away from AKN-affected zones were clinically evaluated, and areas showing perifollicular erythema or scales/casts on trichoscopy were biopsied and histologically analyzed.

Results

Forty-one men with AKN, including 20 men of African descent, 17 Hispanic, and 4 European-descended Whites, were evaluated. All patients, including 22% with associated folliculitis decalvans, showed scalp-wide trichoscopy signs of perifollicular erythema or scaling in normal-appearing scalp areas. All patients showed histologic evidence of perifollicular infundibulo-isthmic lymphocytoplasmic infiltrates and fibrosis (PIILIF), with 96% showing Vellus or miniaturized hair absence. PIILIF was often clinically mistaken for seborrheic dermatitis (44-51%). All White patients had mild papular acne keloidalis nuchae lesions mistaken for seborrheic dermatitis.

Conclusion

PIILIF may be a precursor to a wide spectrum of primary cicatricial alopecias, including AKN and folliculitis decalvans. This finding carries implications for the early diagnosis and management of AKN and other primary cicatricial alopecias.

The dermatoscope in the hair clinic: Trichoscopy of scarring and nonscarring alopecia

Trichoscopy is currently regarded as an essential part of the hair loss consultation. It allows visualization of morphologic structures that are not obvious to the naked eye, including peri- and interfollicular skin surface abnormalities and changes to hair shaft thickness and shape. In this paper, we aim to discuss current knowledge on trichoscopy of the most common forms of scarring and nonscarring alopecias.

Comment on Topical Dapsone for Folliculitis Decalvans

Folliculitis decalvans (FD) represents a chronic and recurrent pustulofollicular scalp inflammation resulting in scarring alopecia. The presence of a bacterial bioflilm at the interface of the hair shaft may provide an explanation for the chronicity and high relapse rate of FD, even after prolonged systemic antibiotic treatments. We originally read with enthusiasm Melián-Olivera et al.'s retrospective study of patients with FD treated with topical dapsone published in the Journal of the American Academy of Dermatology. However, we experienced an unsuccessful trial of 5% dapsone gel in a patient with FD resulting in worsening of the disease with a pustular flareup and questioned why positive study reports with novel therapeutic options in dermatology often fail in practice. The authors admitted the limitations of their study: small sample size, retrospective, uncontrolled nature of the study, and concomitant use of other treatments. Clinical research ultimately aims at improving the patient outcome. For this purpose, trials must evaluate the outcomes that genuinely reflect the clinical utility of drugs. Therefore, we postulate stricter criteria for treatment trials and statistics in dermatology before publication in peer-reviewed scientific journals to avoid frustrations of physicians and patients alike.

Antibiotic Resistance in Dermatology Part 2: Combating Resistance

Virtually any antibiotic can be used in dermatology given the broad range of conditions treated. With the widespread use of antibiotics and the rapid emergence of resistant organisms, it is important to understand how dermatologists can combat this issue.

Tufted hairs: A bouquet of flowers in different hair diseases

Tufted hairs, an unusual hair follicle dysplasia, are characterized by several hair shafts grouped together, emerging from a single hair follicle-like "doll's hair". This clinical picture is considered characteristic of folliculitis decalvans (FD). However, the emergence of grouped hair shafts from a single follicle can also be observed in other hair disorders, even if not as a distinctive diagnostic sign. This paper aims to collect and analyze all clinical and trichoscopic features of different hair diseases with tufted hairs to find distinctive features, helping the clinician with the diagnosis.

Histopathologic and dermoscopic features of 42 cases of folliculitis decalvans: A case series

BACKGROUND

Folliculitis decalvans (FD) is a form of inflamed primary cicatricial alopecia (PCA). FD is classified as a neutrophilic PCA; however, only a few previous studies have described its histopathology, including the assessment of systematically evaluated and quantified follicular changes in horizontally sectioned biopsy specimens with clinical and dermoscopic findings of the early and advanced stages.

OBJECTIVE

We aimed to clarify the histopathologic and dermoscopic features of early and advanced active stage FD.

METHODS

We conducted a case series study of 42 patients with FD by dermoscopy and both horizontally and vertically sectioned biopsy specimens.

RESULTS

The histopathologic findings of the early-stage lesions included loss of sebaceous glands; interfollicular acanthosis; and fibrosis with depressed, fused follicular infundibula showing thickened interfollicular keloid-like areas with tufted hairs on dermoscopy. Active lesions showed a greater number of hair clusters, clefting, and fused infundibula with dense inflammation predominantly in the upper follicles. Neutrophil-predominant infiltrates were observed in fewer than half of the patients, including those with early-stage lesions.

LIMITATIONS

This was a retrospective study.

CONCLUSION

FD has the features of mixed-cell PCA. The features of early-stage FD are thickened interfollicular keloid-like areas with tufted hairs and loss of sebaceous glands.

Folliculitis decalvans-like pustular plaques on the limbs sparing the scalp

Folliculitis decalvans is a neutrophilic cicatricial alopecia characterised by progressive pustular folliculitis. Folliculitis decalvans is seen as a condition usually limited exclusively to the scalp and rarely affects the limbs. We present a case of a 63-year-old man with a 3-year history of progressive pustular folliculitis with inflammatory patches and central scarring alopecia on both forearms and a circumscribed patch on his right lower leg. His presentation, clinical course and isolation of Staphylococcus aureus together with the histopathological findings all supported a folliculitis decalvans-like pustular folliculitis limited to the limbs. Biopsies revealed follicular pustules, gross interfollicular fibrosis with plasma cells and concentric perifollicular fibrosis with lymphocytes, all features seen with folliculitis decalvans. The positive response to antibiotics combined with topical corticosteroids mirrored the response seen with scalp folliculitis decalvans. In contrast to the previously reported cases, the patient had no evidence of folliculitis decalvans on the scalp.

Downregulation of integrin-αvβ6 on keratinocytes in the scar of lichen planopilaris and folliculitis decalvans: Relevance for the disappearance of epidermal Langerhans cells

Primary cicatricial alopecia (PCA) is a group of poorly understood mechanisms in which the destruction of hair follicles leads to permanent hair loss. Lichen planopilaris (LPP) is a type of lymphocytic PCA and it has been known for epidermal Langerhans cells (LC) to disappear in the scar of LPP. We also found that epidermal LC also disappeared in the scar of folliculitis decalvans (FD), a type of neutrophilic PCA. Of note was that epidermal LC did not disappear in the scar of discoid lupus erythematosus, another type of lymphocytic PCA, suggesting that LC disappearance in the scar was not always a common feature of PCA. We found that the expression of integrin (ITG)-αvβ6 in scar epidermis was significantly diminished in LPP and FD, but not in other PCA and disorders accompanied with scar formation. We also found that exogenous interleukin-1β and α-interferon downregulated ITG-αvβ6 expression in normal human epidermal keratinocytes. These data suggest that downregulation of ITG-αvβ6 may be one of the causes of LC disappearance in the scar of LPP and FD.

Autistic-Undisciplined Thinking in the Practice of Medical Trichology

Medical trichology is the branch of dermatology that deals with the scientific study of the hair and scalp in health and disease. As any discipline, the practice of medical trichology is not immune to malpractice, either deliberately or carelessly. In his publication "Autistic Undisciplined Thinking in Medicine and How to Overcome It," Swiss psychiatrist Eugen Bleuler describes yet another form of malpractice in medicine reflecting autistic-undisciplined thinking. Autism is not limited to psychopathology, but inherent to the thinking of man throughout history in his drive for knowledge, with thousands of theories lacking any basis in reality. Bleuler recognized the drive character of autistic thinking and how it leads to conclusions that are unshakable because they are determined by, and fulfill, emotional needs, rather than rational argumentation. Even with correct questions, the complexity and incalculability of some problems are often so great that it cannot do justice to realistic thinking and the boundaries between inadequately substantiated hypothesis and autistic sham explanation disappear. Statistics, careful research design, and the attempt to impose stringent methods on our thinking are to be commended. The habituation of the public to useless medicine, to misconceptions, is not hygiene, but negligent endangerment. It has created an industry that largely lives on the autistic thinking of patients and doctors and because it is prosperous, makes propaganda among lay people as well as among doctors that necessarily leads to abuses. This article aims at exposing the most prevalent among abuses in trichological practice due to autistic-undisciplined thinking, specifically: iron supplementation, antiandrogenic treatment, and individualized cell-based therapy in female androgenetic alopecia, treatment of folliculitis decalvans with retinoids, and the value of nutritional therapies.

Therapy-Recalcitrant Folliculitis Decalvans Controlled Successfully with Adalimumab

Folliculitis decalvans (FD) is a rare idiopathic primary cicatricial alopecia which leads to permanent destruction of hair follicular stem cell. Staphylococcus aureus as well as autoimmunity has been implicated in the pathogenesis. Treatment options include topical antiseptics, topical and systemic corticosteroids, systemic antibiotics, isotretinoin, dapsone, hydroxychloroquine, and immunomodulators. We present the therapy-recalcitrant case of FD which is controlled successfully by subcutaneous injections of Adalimumab (Humira^®) with no serious adverse events throughout the treatment.

Adipose tissue transplant in recurrent folliculitis decalvans

Folliculitis decalvans is a rare clinical disorder classified as primary neutrophilic scarring alopecia with a slight preference for the male gender. Here, we report the use of autologous fat transplantation as a source of stem cell therapy for hair re-growth assisted by inflammatory action of the fat itself in a female patient. The patient underwent adipose transplantation in April and September 2017. After treatments, the patient had no new pustules and no longer had pain or burning sensation in the affected area. The hair has re-grown at the periphery area of alopecia appearing stronger and shinier.

Isotretinoin-induced acute severe myopathy involving pelvic girdle muscles: A case report

Oral isotretinoin has been in widespread use for more than three decades. It causes numerous side effects; skin and mucous membrane being commonly involved. Musculoskeletal adverse effects are also known to occur, but pelvic girdle myopathy is rarely reported. We report myopathy involving pelvic girdle muscles in a young male who received oral isotretinoin for folliculitis decalvans.

Extreme Phenotype of Epidermal Growth Factor Receptor Inhibitor-induced Destructive Folliculitis

Due to the increasingly widespread use and side effect profile of epidermal growth factor receptor inhibitors (EGFRIs), cutaneous side effects of these drugs are frequently encountered. The EGFR is expressed on keratinocytes and fibroblasts. Inhibition of EGFR can produce a range of cutaneous adverse effects, the most frequent being a characteristic acneiform skin eruption. As the latter is associated with good anti-neoplastic responses, the onset of EGFRI-induced acneiform skin eruption is typically viewed as a positive sign by patients and physicians. It can usually be treated well with standard acne drugs, but in rare cases, the skin eruption can be so severe that systemic therapy and/or interruption of EGFRI treatment are required. One of the severest forms of EGFRI-induced skin eruption occurring on the head and neck area resembles folliculitis decalvans. Here, we discuss the management of such a case seen in our department. In addition, we present an analysis of tumor necrosis factor-α, interleukin-1β (IL-1β), and IL-17A expression based on immunohistochemical stains and qPCR.

Primary cicatricial alopecias: a review of histopathologic findings in 38 patients from a clinical university hospital in Sao Paulo, Brazil

BACKGROUND

Scarring alopecias are classified into primary and secondary types according to the initial site of inflammation. In primary scarring alopecias, the hair follicle is the main target of destruction; the term secondary cicatricial alopecia implies that follicular destruction is not the primary pathologic event.

AIMS

To review the histopathologic diagnoses of cases of cicatricial alopecia in order to classify them according to the North American Hair Research Society.

PATIENTS AND METHODS

Patients with biopsy specimens diagnosed as cicatricial alopecia seen from 2000 to 2005 at the Dermatologic Department of Hospital das Clinicas, São Paulo University Medical School had hematoxylin and eosin, Periodic acid-Schiff and Weigert stained slides reevaluated and sub-typed into different primary cicatricial alopecias.

RESULTS

Thirty-eight cases of primary cicatricial alopecias were reclassified as: chronic cutaneous lupus (17), lichen planus pilaris (4), pseudopelade of Brocq (12), folliculitis decalvans (3), dissecting folliculitis (1), and non-specific scarring alopecia (1). In our cases, the methods employed allowed an accurate diagnosis in 12 of 13 cases (92.3%) previously classified as non-specific cicatricial alopecias.

CONCLUSIONS

Even in the late, pauci or non-inflammatory phases, an approach with systematic evaluation of a constellation of criteria in routine hematoxylin and eosin stain, Periodic acid-Schiff and Weigert stain allowed for a more accurate diagnosis of cicatricial alopecias.