Primary Cicatricial Alopecia: Clinical Features and Management

Elizabeth K. Ross, MD

Dermatology Nursing. 2007;19(2):137-143.

Folliculitis Decalvans

Folliculitis decalvans is a scarring folliculitis of the scalp in which Staphylococcus aureus is commonly cultured. The onset is typically in young and middle-aged adults who are otherwise healthy and not prone to S. aureus infection elsewhere on the body.

Patients typically present with a complaint of "pimples" and hair loss of the scalp, which can be very painful and/or pruritic. The disease causes perifollicular erythema, pustules, crusting, and oozing. Small areas of scarring alopecia gradually appear and may become extensive and impressive, leaving large areas of bare scalp with continued active disease at the periphery (see Figure 7). Tufted hair follicles, in which several hairs emerge from a single follicular opening, are seen in advanced disease, but this is a nonspecific feature seen in other scarring alopecias as well.

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Folliculitis decalvans. Source: Photo courtesy of Paradi Mirmirani, MD.

Management involves repeated culture of pustules to establish the identity and antibiotic sensitivity of the bacteria involved. An appropriate antibiotic is instituted (for example, cephalexin) usually for a prolonged period, as relapse is common once treatment is stopped. Addition of topical mupirocin can help to improve outcome. In those who fail this approach, a double antibiotic regimen with rifampin is used for 10 weeks (typically, with clindamycin, ciprofloxacin, or doxycycline; rifampin cannot be used alone because of rapid development of bacterial resistance). This regimen can produce a sustained disease-free period for months to years in some individuals. If nostril culture shows that the patient is a staph carrier, mupirocin ointment is applied in the nostrils twice daily for 5 days, and as indicated thereafter.

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Proposed Working Classification of Primary Cicatricial Alopecia
Lymphocytic Lichen planopilaris Lichen planopilaris Frontal fibrosing alopecia Graham-Little syndrome Classic pseudopelade (Brocq) Central centrifugal cicatricial alopecia Chronic cutaneous lupus erythematosus (discoid lupus erythematosus) Alopecia mucinosa Keratosis follicularis spinulosa decalvans Neutrophilic Folliculitis decalvans Dissecting cellulitis/folliculitis (perifolliculitis capitis abscedens et suffodiens) Mixed Folliculitis (acne) keloidalis Folliculitis (acne) necrotica Erosive pustular dermatosis Nonspecific (End Stage)

Note: Entities discussed are shown in italics.
Source: Adapted from Olsen et al., 2003.

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