Folliculitis Decalvans: Causes, Symptoms, and Treatment Options

Folliculitis Decalvans is a rare but distressing chronic inflammatory condition of the scalp that leads to scarring and hair loss. Classified under the umbrella of cicatricial (scarring) alopecias, it results in the irreversible destruction of hair follicles. Unlike more common types of alopecia, such as androgenetic alopecia or alopecia areata, Folliculitis Decalvans tends to progress slowly but persistently, causing permanent hair loss, discomfort, and a negative impact on self-esteem. Early diagnosis and prompt treatment are critical to prevent extensive scarring and preserve remaining hair. 

In this blog, we will explore what causes Folliculitis Decalvans, the hallmark symptoms, how it is diagnosed, and the most effective treatment options available today.

What is Folliculitis Decalvans? 

Folliculitis Decalvans (FD) is a chronic, scarring folliculitis that primarily affects the scalp. It manifests as inflammation and infection of hair follicles, typically resulting in pustules, crusting, and eventual hair loss in the affected area. The term “decalvans” comes from Latin, meaning “to make bald,” which perfectly describes the long-term consequence of the condition. 

FD tends to occur in adults and can affect both men and women, although studies suggest it may be more common in males. Its exact prevalence is unknown due to underdiagnosis and misclassification, but it is considered rare. 

What Causes Folliculitis Decalvans? 

The exact cause of Folliculitis Decalvans is still under investigation. However, research points to a complex interplay between bacterial infection, immune dysfunction, and genetic predisposition. 

1. Bacterial Infection

The most commonly implicated bacteria in FD are Staphylococcus aureus. While this organism normally lives harmlessly on the skin, in patients with FD, it appears to trigger an exaggerated immune response. The bacteria invade the hair follicle, causing an inflammatory reaction that destroys the follicular structure and leads to scarring. 

2. Immune System Dysfunction

It’s believed that the immune system in individuals with FD reacts abnormally to the bacterial presence, launching an aggressive inflammatory response. This autoimmune-like process results in collateral damage to the follicle and surrounding tissue. 

3. Genetic and Environmental Factors

Although familial cases are rare, there may be a genetic predisposition that makes some individuals more susceptible to developing FD. Environmental factors, including stress, trauma to the scalp, and hygiene habits, may also play a role in triggering or exacerbating the condition. 

Symptoms of Folliculitis Decalvans 

Recognizing the early signs of Folliculitis Decalvans is crucial for limiting long-term damage. The condition often begins insidiously and may be mistaken for common scalp issues like dandruff or acne. 

Common Symptoms Include: 

• Pustules around hair follicles: These small pus-filled bumps are a classic sign and may be itchy or painful. 
• Crusting and scaling: The scalp often shows signs of crusty lesions and thickened skin. 
• Redness and inflammation: Affected areas appear red, swollen, and tender to touch. 
• Hair tufting: One of the distinguishing features, this is when several hairs emerge from a single follicular opening, resembling a “doll’s hair” tuft. 
• Scarring and permanent hair loss: Over time, inflammation destroys the follicle, leaving behind smooth, bald patches of scar tissue. 
• Itching or burning sensation: These may precede or accompany visible changes on the scalp. 

FD often progresses in flares, with periods of acute inflammation followed by a chronic, smoldering phase.

How is Folliculitis Decalvans Diagnosed? 

Diagnosis is primarily clinical, based on patient history and physical examination. However, due to its similarity to other scalp disorders, additional tests are often required to confirm the diagnosis. 

Diagnostic Tools: 

• Scalp biopsy: A small tissue sample is examined under a microscope to identify features typical of scarring alopecia and neutrophilic inflammation. 
• Bacterial cultures: A swab of the pustules may be taken to detect Staphylococcus aureus or other pathogens. 
• Trichoscopy (dermoscopy): This non-invasive technique helps visualize characteristic signs like perifollicular pustules, hair tufting, and yellowish scales. 

Accurate diagnosis ensures that appropriate treatment can be initiated to prevent further follicular destruction. 

Treatment Options for Folliculitis Decalvans 

There is no permanent cure for FD, but various treatment strategies aim to reduce inflammation, control bacterial infection, and prevent further hair loss. Treatment is typically long-term and may require combination therapy. 

1. Antibiotics

Oral antibiotics, particularly those targeting Staphylococcus aureus, form the mainstay of FD treatment. Common choices include: 

• Clindamycin and Rifampin combination 
• Tetracyclines (Doxycycline or Minocycline) 
• Erythromycin 

Topical antibiotics like mupirocin may also be used alongside oral agents. 

2. Anti-inflammatory Agents

To calm the immune response and reduce inflammation: 

• Topical corticosteroids 
• Intralesional steroid injections 
• Oral corticosteroids (in severe or refractory cases) 

3. Immunomodulatory Drugs

For patients who don’t respond to antibiotics or steroids, immunosuppressants like hydroxychloroquine, dapsone, or methotrexate may be prescribed. 

4. Biologics

Newer therapies targeting specific immune pathways, such as adalimumab or infliximab, have shown promise in managing refractory cases. 

5. Photodynamic Therapy (PDT)

This involves applying a photosensitizing agent to the scalp and exposing it to a specific light wavelength. PDT may help reduce bacterial load and inflammation. 

6. Surgical Options

In advanced stages with localized scarring, surgical excision of the affected scalp area followed by grafting may be considered. 

7. Scalp Care and Lifestyle Modifications

• Use of mild, non-irritating shampoos. 
• Avoidance of heat, tight hairstyles, and harsh hair treatments. 
• Stress management, as flare-ups may be stress-related. 
• Regular follow-up with a dermatologist to monitor progression.

Living with Folliculitis Decalvans 

Coping with a chronic, disfiguring condition like FD can be emotionally challenging. Support groups, counseling, and online communities can offer valuable emotional support and practical advice. Wearing hats, wigs, or scarves can help manage the cosmetic concerns until treatment stabilizes the condition. 

It’s essential to remember that FD is a manageable condition. With a combination of medical therapy, lifestyle changes, and emotional support, many individuals lead fulfilling lives despite the diagnosis. 

The Future of Treatment: Clinical Trials and Hope 

Research into scarring alopecias like Folliculitis Decalvans is ongoing. Scientists are working to better understand the underlying immune mechanisms and bacterial interactions. Newer therapies, including targeted immunomodulators and microbiome-based treatments, are being evaluated in clinical settings. 

Interestingly, because of overlapping mechanisms with other forms of alopecia, such as alopecia areata, participating in Alopecia Areata Clinical Trials may also offer insight or access to novel treatment options for those suffering from Folliculitis Decalvans.

You may also read: What are the 7 Levels of Lymph Nodes in the Neck?

Final Thoughts 

Folliculitis Decalvans may be rare, but its impact on quality of life can be significant. Early recognition, prompt treatment, and ongoing management are key to preventing scarring and preserving hair. If you or someone you know is dealing with persistent scalp inflammation and hair loss, consult a dermatologist for evaluation. And for those seeking cutting-edge treatment options, consider participating in Alopecia Areata Clinical Trials, which may open the door to innovative therapies and a brighter future.