10.5826/dpc.1303a180
text/xml
2160-9381
2958
en
Zoe Apalla
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
antibiotic therapy
Folliculitis Decalvans-like Alopecia During Treatment With EGFR Inhibitors for Lung Cancer: A Case Series of 6 Patients
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-07-31
2022-11-08
2023-07-31
2023-08-24
e2023180
Dermatol Pract Concept
Zoe Apalla
2023/07/31
10.5826/dpc.1303a180
e2023180
Second Dermatology Department, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Greece
2160-9381
antibiotic therapy
en
e2023180
Hoekzema R, Drillenburg P. Folliculitis decalvans associated with erlotinib. Clin Exp Dermatol. 2010;35(8):916-918. DOI: 10.1111/j.1365-2230.2010.03852.x. PMID: 20456379.
Folliculitis Decalvans-like Alopecia During Treatment With EGFR Inhibitors for Lung Cancer: A Case Series of 6 Patients
https://dpcj.org/index.php/dpc/article/download/2958/2254
       Folliculitis-Decalvans Like Alopecia During
    Treatment with EGFR Inhibitors for Lung Cancer:
                A Case Series of 6 Patients
               Michela Starace1,2, Bianca Maria Piraccini1,2, Miriam Anna Carpanese1,2,
                                     Matilde Iorizzo3, Zoe Apalla4


1 Dermatology Unit - IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
2 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
3 Private Dermatology Practice, Bellinzona/Lugano, Switzerland
4 Second Dermatology Department, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Greece



Key words: folliculitis decalvans; EGFR inhibitors; drug-induced alopecia; cancer patients; antibiotic therapy
Citation: Starace M, Piraccini BM, Carpanese MA, Iorizzo M, Apalla Z. Folliculitis-Decalvans Like Alopecia During Treatment With EGFR
Inhibitors for Lung Cancer: A Case Series of 6 Patients. Dermatol Pract Concept. 2023;13(3):e2023180.
DOI: https://doi.org/10.5826/dpc.1303a180
Accepted: March 15, 2023; Published: July 2023
Copyright: ©2023 Starace et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Michela Starace, MD PhD, Dermatology Unit - IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy Via Massarenti 1, 40100 Bologna, Italy.
E-mail: michela.starace2@unibo.it




Introduction                                                             mimicked Folliculitis Decalvans (FD) in all patients, with 4
                                                                         of them presenting a more severe, diffuse and debilitating
Epidermal growth factor receptor inhibitors (EGFRi) repre-               picture showing erythema, pustules, crusts and patches
sent a valid therapeutic option for the treatment of cancers             of scarring alopecia (Figure 1A). The other patients had a
caused by EGFR dysregulation. Skin toxicity is the most                  milder, less defined areas of alopecia not yet scarring, but
common adverse event related to EGFRi, and even though                   with a prominent erythema, telangectasia, casts and scales.
rarely life-threatening, it can seriously affect patients quality        Trichoscopy confirmed the clinical picture, highlighting
of life and their compliance to treatment, often leading to              findings as erythema, telangiectasia, scales, haemorrhagic
treatment modification or discontinuation [1].                           and serum crusts, perifollicular hyperkeratosis and pili torti
                                                                         (Figure 1B). Histology showed keratin aggregation and
Case Presentation                                                        a dilatation of the infundibulum in combination with nu-
                                                                         merous intraluminal neutrophils. Sebaceous glands are de-
We report 5 patients developing alopecia during treat-                   stroyed early in the process. Additionally, an intrafollicular
ment with EGFRi for non-small-cell lung carcinoma (NS-                   and perifollicular predominately neutrophilic infiltrate could
CLC) (Table 1). The clinical and trichoscopic presentations              be found (Figure 2) Based on the clinical, trichoscopic, and


Research Letter | Dermatol Pract Concept. 2023;13(3):e2023180                                                                        1
2
                                                                                       Table 1. Data of patients diagnosed with folliculitis decalvans-like alopecia during treatment with EGFR inhibitors.
                                                                                        Personal
                                                                   Sex                      or                                    Number         Body                                                                         Impact on
                                                                   Age                   family        Oncologic treatment        of EGFRi       areas                                                                        oncologic
                                                                 (years)   Neoplasia     history       (drug and dosages)          cycles      involved          Trichoscopy              Treatment           Outcome         treatment          Relapses
                                                                 M/57      Lung         No          Erlotinib at 150 mg once          1       Face         Absence of follicular      Doxycycline           PR              No                 Yes
                                                                           (NSCLC)                  daily + bevacizumab                                    ostia, pustules, crusts,   100 mgx2 and
                                                                                                    (15mg/Kg every 3 weeks)                                severe erythema,           clobetasol 1/day
                                                                                                                                                           perifollicular             for 1 month
                                                                                                                                                           hyperkeratosis, diffuse
                                                                                                                                                           desquamation, pili torti
                                                                 M/62      Lung         No          Erlotinib at 150 mg once          2       Face and     Absence of follicular      Doxycycline           PR              No                 Yes
                                                                           (NSCLC)                  daily + ramucirumab                       trunk        ostia, pustules, crusts,   100 mgx2 and
                                                                                                    (10 mg/kg every 2 weeks)                               mild erythema,             clobetasol 17day
                                                                                                                                                           perifollicular             for 1 month
                                                                                                                                                           hyperkeratosis, diffuse
                                                                                                                                                           desquamation
                                                                 M/58      Lung         No          Erlotinib at 150 mg once          2       Face         Absence of follicular      Doxycycline           PR              DR                 Yes
                                                                           (NSCLC)                  daily + bevacizumab                                    ostia, pustules, crusts,   100 mg/day and
                                                                                                    (15mg/Kg every 3 weeks)                                severe erythema,           clobetasol 1/day
                                                                                                                                                           perifollicular             for 2 months
                                                                                                                                                           hyperkeratosis, diffuse
                                                                                                                                                           desquamation, hair
                                                                                                                                                           tufted
                                                                 M/63      Lung         No          Gefitinib 250 mg once             2       Scalp        Absence of follicular      Doxycycline           PR              No                 Yes
                                                                           (NSCLC)                  daily                                                  ostia, pustules,           100 mg/day and
                                                                                                                                                           moderate erythema,         clobetasol 1/day
                                                                                                                                                           perifollicular             for 2 months
                                                                                                                                                           hyperkeratosis, diffuse
                                                                                                                                                           desquamation
                                                                 F/76      Lung         No          Gefitinib 250 mg                  2       Scalp        Vascular ectasia, hair     Ketoconazole          PR              No                 Yes
                                                                           (NSCLC)                  once daily                                             casts, mild keratotic      shampoo 2-3/
                                                                                                                                                           plugs                      week; doxicicline
                                                                                                                                                                                      100 mg/day for
                                                                                                                                                                                      2 months

                                                                CR = complete response; DR = dose reduction; DW = dose withholding; EGFRi = epidermal growth factor receptor inhibitor; NSCLC = non-small-cell lung carcinoma; PD = permanent discontinuation;
                                                                PR = partial response.




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023180
 A                                                   B




 C                                               D




Figure 1. (A) Scarring alopecia with erythema, pustules, crusts, and pili torti in a 57-years-old patient. A similar dermatitis was present
also on the face, especially in the beard area. (B) Trichoscopy of the same patient, showing lack of follicular ostia, yellowish serum crusts
and reddish hemorrhagic crusts. (C) Clinical picture of the same patient after one month of treatment showing a good improvement of the
inflammation. (D) Trichoscopy of the same patient, showing absence of inflammatory signs.



                                                                        histopathological features we established the diagnosis of
                                                                        folliculitis decalvans-like, scarring alopecia.
                                                                            In collaboration with the oncologists, the anticancer
                                                                        treatment was continued without modification in all indi-
                                                                        viduals, except for a patient who required a dose reduction.
                                                                        Management included systemic doxycycline in combination
                                                                        with topical clobetasol in 4 individuals, doxycycline alone
                                                                        and clobetasol shampoo alone in the patient with milder in-
                                                                        volvement. Follow-up period of patients included three vis-
                                                                        its, respectively after one month, six months and one year.
                                                                        We observed that all patients showed satisfactory response

Figure 2. H&E stain showed destructive suppurative folliculitis,
                                                                        after one month (Figure 1, C and D), except of one who
with dense neutrophilic infiltrate and tufted hairs, confirming the     showed only mild improvement and experienced frequent re-
diagnosis of folliculitis decalvans.                                    lapses, too, but with remission at the one year follow up visit.



Research Letter | Dermatol Pract Concept. 2023;13(3):e2023180                                                                              3
Conclusions                                                       recognize it and promptly start the treatment in order to pre-
                                                                  vent the scarring evolution. Unless no response to treatment
FD is a primary form of cicatricial alopecia, clinically start-   is evident, we discourage the discontinuation of the antican-
ing as a painful purulent folliculitis with tufts of hairs and    cer treatment. Multidisciplinary management, dermatologic
perifollicular crusts that eventually evolve in an irreversible   and oncologic in this case, is always advisable in presence of
scarring process, initially boggy and then atrophic [2]. The      skin toxicities from anticancer drugs.
main dermoscopic findings are characterized by lack of fol-
licular ostia, erythema, pustules, tuft of hairs emerging from    References
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