10.5826/dpc.1302a100
text/xml
2160-9381
2722
en
Lekshmipriya Krishnan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
trichoscopy
Folliculitis Decalvans in Father and Son – Genes, Environment or Both?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-04-29
2022-07-26
2023-04-29
2023-06-05
e2023100
Dermatol Pract Concept
Lekshmipriya Krishnan
2023/04/29
10.5826/dpc.1302a100
e2023100
Armed Forces Medical College, Pune, India
2160-9381
trichoscopy
en
e2023100
Douwes KE, Landthaler M, Szeimies RM. Simultaneous occurrence of folliculitis decalvans capillitii in identical twins. Br J Dermatol. 2000;143(1):195-197. PMID: 10886161.
Folliculitis Decalvans in Father and Son – Genes, Environment or Both?
https://dpcj.org/index.php/dpc/article/download/2722/2114
     Folliculitis Decalvans in Father and Son – Genes,
                    Environment or Both?
         Shekhar Neema1, Senkadhir Vendhan1, Biju Vasudevan1, Lekshmipriya Krishnan1


1 Armed Forces Medical College, Pune, India



Key words: folliculitis decalvans, familial, genetic, trichoscopy
Citation: Neema S, Vendhan S, Vasudevan B, Krishnan L. Folliculitis Decalvans in Father and Son – Genes, Environment or Both?
Dermatol Pract Concept. 2023;13(2):e2023100. DOI: https://doi.org/10.5826/dpc.1302a100
Accepted: September 15, 2023; Published: April 2023
Copyright: ©2023 Neema 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: Dr Shekhar Neema, MD, FEBDV, Assoc Prof (Dermatology), Armed Forces Medical College, Pune, India.
Email: shekharadvait@gmail.com




Introduction                                                             culture grew Staphylococcus aureus. The patient was treated
                                                                         with oral rifampicin and clindamycin 300 mg twice daily
Folliculitis decalvans (FD) is a chronic recurrent inflamma-             with good response.
tion of the scalp leading to cicatricial alopecia, which pre-                 A 8-year-old male, son of the index case presented with
dominantly occurs in young individuals. Staphylococcus                   asymptomatic patch loss of hair over the vertex of the scalp
aureus infection and abnormal alteration of the patient im-              for 3 years. Dermatological examination showed vertex in-
mune response play important role in the etiopathogenesis                volvement with patchy scarring alopecia with (Figure 1B).
of FD. We hereby report a rare case of FD that occurred in               Dermoscopy showed loss of follicular ostia, tufted hairs and
both father and son.                                                     perifollicular erythema (Figure 2B). The patient was also
                                                                         treated with rifampicin and clindamycin with significant
                                                                         improvement.
Case Presentation
A 37-year-old male presented with a history of patchy loss of
                                                                         Conclusions
hair over the scalp of 12 years. Examination showed involve-
ment of vertex and occiput in the form of a well-defined                 FD is a predominantly neutrophilic, chronic, and recurrent
patch of scarring alopecia with erythematous to violaceous               cicatricial alopecia of the scalp that predominantly occurs
boggy plaque over mid occiput measuring 8 × 8 cm with                    in young and middle-aged men [1]. Staphylococcus aureus
tufted hairs and pustules in the periphery (­Figure 1A). Der-            acts as superantigens and stimulate T-cells. Genetic predispo-
moscopy showed loss of follicular ostia, pustules, tufted                sition may play a role as colonization with Staphylococcus
hairs and perifollicular erythema (Figure 2A). Histopathol-              aureus is common while FD is an uncommon disease [2]. It
ogy was consistent with the diagnosis of FD and pus swab                 is characterized by alopecia surrounded by crops of follicular




Research Letter | Dermatol Pract Concept. 2023;13(2):e2023100                                                                        1
Figure 1. (A) Clinical image of case 1 during presentation showing scarring alopecia over the vertex and occipital regions of the scalp with
tufted hairs and pustules. (B) Clinical image of case showing patchy scarring alopecia over vertex with tufted hairs.




Figure 2. (A) Dermoscopy of case 1 shows background erythema, loss of follicular ostia, follicular pustules, perifollicular erythema, perifol-
licular hemorrhage and crust (blue star), perifollicular white scale (blue arrow) and tufted hair (yellow circle) (Dermlite DL4, X10, polarized).
(B) Dermoscopy of case 2 showing loss of follicular ostia, perifollicular scale (blue arrow) and tufted hairs (yellow circle) (Dermlite DL4,
X10, polarized).



pustules with pain, itching, and burning sensations. Vertex               and perifollicular hemorrhages. Bacterial culture and sensi-
and occipital areas of the scalp are the most common areas                tivity from the intact pustule may identify Staphylococcus
affected, although beard, trunk, axilla, and pubic region can             aureus reservoir. Histopathological examination shows fol-
also be involved. Tufted folliculitis is characterized by mul-            licular neutrophilic abscesses in the infundibula, destruction
tiple hairs (5-20) emerging from the single dilated follicular            of sebaceous glands in early lesions and dermal lymphocytes,
orifice and is a common finding in FD. Trichoscopy is helpful             destruction of follicles and dermal scarring in advanced le-
in diagnosis and shows the absence of follicular ostia, tufted            sions [3]. Oral antibiotics, corticosteroids and isotretinoin
folliculitis, follicular hyperkeratosis, follicular pustules, yel-        have been reported to be effective. Rifampicin -clindamycin
low tubular scaling, yellow crusts, perifollicular erythema,              combination has the best evidence for effectiveness. Other



2                                                                              Research Letter | Dermatol Pract Concept. 2023;13(2):e2023100
treatments are intra-lesional triamcinolone acetonide, adali-             J Am Acad Dermatol. 2019;80(3):794-801.e1. DOI: 10.1016/j
mumab, infliximab, secukinumab, Nd:YAG Laser, and pho-                    .jaad.2018.07.050. PMID: 30092322. PMCID: PMC6363910.
                                                                       2. Brooke RC, Griffiths CE. Folliculitis decalvans. Clin Exp
todynamic therapy [4]. A novel TRAF3IP2 variant has been
                                                                          Dermatol. 2001;26(1):120-122. DOI: 10.1046/j.1365-2230.
reported to cause scarring alopecia with mixed features of
                                                                          2001.00746.x. PMID: 11260200.
discoid lupus erythematosus and FD [5]. Folliculitis decal-            3. Uchiyama M, Harada K, Tobita R, Irisawa R, Tsuboi R. Histo-
vans has also been reported in a 32-year-old, identical male              pathologic and dermoscopic features of 42 cases of folliculitis
twins staying apart, exploring possible genetic links.                    decalvans: A case series. J Am Acad Dermatol. 2021;85(5):1185-
   FD occurs due to immune response to Staphylococcus                     1193. DOI: 10.1016/j.jaad.2020.03.092. PMID: 32272176.
                                                                       4. Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis de-
aureus that may have a genetic basis as illustrated in our
                                                                          calvans. Dermatol Ther. 2008;21(4):238-244. DOI: 10.1111/j
cases. This occurrence may be due to chance, however, ge-
                                                                          .1529-8019.2008.00204.x. PMID: 18715292. PMID: 18715292.
netic basis of this rare disorder requires further evaluation.         5. Nemer G, El-Hachem N, Eid E, et al. A novel TRAF3IP2 vari-
                                                                          ant causing familial scarring alopecia with mixed features of
                                                                          discoid lupus erythematosus and folliculitis decalvans. Clin
References                                                                Genet. 2020;98(2):116-125. DOI: 10.1111/cge.13767. PMID:
                                                                          32350852.
 1. Rambhia PH, Conic RRZ, Murad A, Atanaskova-Mesinkovska             6. Douwes KE, Landthaler M, Szeimies RM. Simultaneous occur-
    N, Piliang M, Bergfeld W. Updates in therapeutics for folliculi-      rence of folliculitis decalvans capillitii in identical twins. Br J
    tis decalvans: A systematic review with evidence-based analysis.      Dermatol. 2000;143(1):195-197. PMID: 10886161.




Research Letter | Dermatol Pract Concept. 2023;13(2):e2023100                                                                              3
