10.5826/dpc.1303a131
Introduction: Superficial folliculitis of the scalp (SFS) is a common complaint in clinical practice, and initial presentation may be difficult to differentiate as they may appear very similar to each other.
Objectives: The aim of this thesis is to describe the pathologies that occur clinically as folliculitis of the scalp, identify their causes and characteristics and create a standardized classification.
Methods: This is a retrospective clinical, dermoscopic and histopathological study over 10 years of dermatologic consultations. Only individuals with a confirmed diagnosis of SFS (updated diagnostic criteria or biopsy) were included.
Results: In this review, we describe the various clinical features of different causes of SFS in ninety-nine cases and divided into infectious due to fungus, bacteria, or virus and inflammatory conditions such as rosacea, acneiform eruption and Ofuji syndrome.
Conclusions: The clinician must differentiate SFS from other underlying scarring disorders to prevent poorer outcomes. We created an algorithm to help the clinician reach a proper diagnosis.
text/xml
2160-9381
2854
en
Bianca Maria Piraccini
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
seborrheic dermatitis
A Practical Algorithm for the Management of Superficial Folliculitis of the Scalp: 10 Years of Clinical and Dermoscopy Experience 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-09-18
2023-07-31
2023-08-24
e2023131
Dermatol Pract Concept
Introduction: Superficial folliculitis of the scalp (SFS) is a common complaint in clinical practice, and initial presentation may be difficult to differentiate as they may appear very similar to each other.
Objectives: The aim of this thesis is to describe the pathologies that occur clinically as folliculitis of the scalp, identify their causes and characteristics and create a standardized classification.
Methods: This is a retrospective clinical, dermoscopic and histopathological study over 10 years of dermatologic consultations. Only individuals with a confirmed diagnosis of SFS (updated diagnostic criteria or biopsy) were included.
Results: In this review, we describe the various clinical features of different causes of SFS in ninety-nine cases and divided into infectious due to fungus, bacteria, or virus and inflammatory conditions such as rosacea, acneiform eruption and Ofuji syndrome.
Conclusions: The clinician must differentiate SFS from other underlying scarring disorders to prevent poorer outcomes. We created an algorithm to help the clinician reach a proper diagnosis.
Bianca Maria Piraccini
2023/07/31
10.5826/dpc.1303a131
e2023131
Dermatology - IRCCS Azianda Ospedaliero-Universitaria di Bologna; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
2160-9381
seborrheic dermatitis
en
e2023131
Nervi Sj, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40-year retrospect. J Am Acad Dermatol. 2006;55(2):285-289. DOI: 10.1016/j.jaad.2006.02.034. PMID: 16844513.
A Practical Algorithm for the Management of Superficial Folliculitis of the Scalp: 10 Years of Clinical and Dermoscopy Experience 
https://dpcj.org/index.php/dpc/article/download/2854/2225
         A Practical Algorithm for the Management
       of Superficial Folliculitis of the Scalp: 10 Years
           of Clinical and Dermoscopy Experience
     Michela Starace1,2, João Paulo Yamagata3, Rita Fernanda Cortez de Almeida3, Simone
    Frattini4, Francesca Bruni1,2, Aurora Alessandrini1,2, Matilde Iorizzo5, Daniel Fernandes
                          Melo3, Iria Neri 1,2,Bianca Maria Piraccini1,2


1 Dermatology - IRCCS Azianda Ospedaliero-Universitaria di Bologna, Bologna, Italy
2 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
3 Department of Dermatology, State University of Rio de Janeiro – UERJ, Rio de Janeiro – RJ, Brazil
4 Mental Health Department, Guelph General Hospital, Guelph, ON, Canada
5 Private Dermatology Practice, Bellinzona/Lugano, Switzerland



Key words: folliculitis, scalp, dermoscopy, rosacea, seborrheic dermatitis
Citation: Starace M, Yamagata JP, Cortez de Almeida RF, et al. A Practical Algorithm for the Management of Superficial Folliculitis of the
Scalp: 10 Years of Clinical and Dermoscopy Experience . Dermatol Pract Concept. 2023;13(3):e2023131.
DOI: https://doi.org/10.5826/dpc.1303a131
Accepted: January 17, 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: João Paulo Yamagata, Department of Dermatology, State University of Rio de Janeiro – UERJ, Rio de Janeiro – RJ,
Brazil. E-mail: jpyamagata@gmail.com




  ABSTRACT              Introduction: Superficial folliculitis of the scalp (SFS) is a common complaint in clinical practice,
                        and initial presentation may be difficult to differentiate as they may appear very similar to each other.
                        Objectives: The aim of this thesis is to describe the pathologies that occur clinically as folliculitis of
                        the scalp, identify their causes and characteristics and create a standardized classification.
                        Methods: This is a retrospective clinical, dermoscopic and histopathological study over 10 years of
                        dermatologic consultations. Only individuals with a confirmed diagnosis of SFS (updated diagnostic
                        criteria or biopsy) were included.
                        Results: In this review, we describe the various clinical features of different causes of SFS in ninety-nine
                        cases and divided into infectious due to fungus, bacteria, or virus and inflammatory conditions such as
                        rosacea, acneiform eruption and Ofuji syndrome.
                        Conclusions: The clinician must differentiate SFS from other underlying scarring disorders to prevent
                        poorer outcomes. We created an algorithm to help the clinician reach a proper diagnosis.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023131                                                                               1
Introduction                                                         clinical, dermoscopic and histopathological images from the
                                                                     dermatology electronic medical records were conducted, and
Folliculitis means the presence of inflammatory cells in the         only those individuals with a confirmed diagnosis of SFS
wall and lumen of a hair follicle. Superficial folliculitis of the   (updated diagnostic criteria or biopsy) were included. The
scalp (SFS) is a frequent disorder and describes inflammatory        cases were divided into infectious due to fungus, bacteria, or
infiltrate in the upper portion [1].                                 virus and inflammatory conditions such as rosacea, acnei-
    SFS is characterized by erythema, pustules and/or vesicles       form eruption and Ofuji syndrome.
- typical of the acute phase, with possible chronic evolution
into perifollicular hyperkeratosis and keratin plugs. The
course is chronic-recurrent, interspersed with acute phases -
                                                                     Results
sometimes difficult to manage [1].                                   Between 2010 and 2020, 58 males and 41 females, aged be-
    Despite several types of SFS reported in the literature,         tween 1 and 80 years (mean 35 years), were referred to our
there is no official classification yet. Usually, the one by         attention due to SFS (Table 1). According to our findings, we
Herman et al, a modification of Ackerman one, is the most            divided SFS into 9 groups as following.
widely known and identifies 2 major groups: superficial fol-
liculitis (infectious and noninfectious forms) and perifollic-       Dermatophytes
ulitis [1,2]. A classification based on the histopathological
                                                                     Tinea Capitis was diagnosed in 28 patients, 17 Caucasian
characterization of the inflammatory process (neutrophilic,
                                                                     and 11 Afro-descendant ones, respectively. A fungal search
lymphocytic, eosinophilic, or mixed) is also possible, which
                                                                     (microscopic and culture) was performed in all cases to con-
is reasonable to identify the etiological agent and the best
                                                                     firm the clinical diagnosis and allow an etiological differen-
corresponding therapeutic option [2].
                                                                     tiation, important to set the most appropriate treatment. In
                                                                     16 Caucasian patients, the etiologic agent was Microsporum
Objectives                                                           canis, while in the others, the culprit came from the Trico-
                                                                     phyton family (violaceum, soudanense, tonsurans).
With this paper, we aimed to report 10 years of out-patients
                                                                        Dermoscopy was fundamental to support the clinical sus-
experience with SFS, showing the most common clinical pic-
                                                                     picion (Figure 1A), enlightening the presence of typical hair
tures and dermoscopy patterns. Besides, according to their
                                                                     shaft abnormalities. However, three patients still needed a
age, we created a practical algorithm for managing SFS.
                                                                     confirmatory biopsy due to an atypical clinical presentation
                                                                     with diffuse alopecia and crusts on an erythematous base.
Methods
We performed a retrospective medical record review of pa-            Candida
tients with a confirmed diagnosis of SFS over 10 years of            Folliculitis due to Candida albicans was diagnosed in
dermatologic consultations. Chart review and evaluation of           an 84-year-old Caucasian male with an itchy scalp.



    Table 1. Numbers of superficial folliculitis of the scalp cases observed in 10 years (2010 – 2020)
                                     of dermatologic consultations.
                                                                                                           INFLAMMATORY
       DIAGNOSIS             CASES       MALES       FEMALES         AVERAGE AGE        BIOPSY                INFILTRATE
 Infective
 Dermatophytes                  28          13           15               16                3       mixed
 Candida spp.                    1           1            -               84                1       mixed
 Malassezia spp.                13           8             5              40                2       mixed
 Bacteria                       21          11           10               10                1       neutrophilic
 Herpes Zoster Virus             3           -             3              75                -       neutrophilic
 Pox Virus                       4           4            -                5                4       neutrophilic
 Non-infective
 Acneiform rash                 23          17             6              35                5       mixed
 Rosacea                         5           3             2              57                5       mixed
 Ofuji syndrome                  1           1            -                1                1       eosinophilic
 TOTAL                          99          58           41               35               22


2                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023131
Multiple whitish pinpoint folliculitis could be seen on an              Pox Virus
erythematous-squamous background. However, the clinical                 Molluscum contagiosum was diagnosed in 4 children. Two
and dermoscopic aspects were atypical, and only histological            presented whitish papules of a few mm in diameter visible to
examination confirmed the diagnosis.                                    the naked eyes but better defined at dermoscopy [5]. Despite
                                                                        the evident presence of molluscum body after curettage, pa-
Malassezia
                                                                        thology was required to make the differential diagnosis with
At dermoscopy, the typical arborized vessels were always pres-
                                                                        scalp nodules.
ent, as well as scales. Around the pustules were also evident
dotted vessels (Figure 1B). Dermoscopy facilitated the diagno-
                                                                        Acneiform Eruption
sis in 11 cases, while 2 needed histopathological examination.
                                                                        Pustules and follicular crusts are generally observed on an
Bacteria                                                                erythematous base, sometimes accompanied by pain or ac-
                                                                        cidental bleeding with minimal trauma. The culture was
Primary impetigo of the scalp is relatively rare, whereas it is
                                                                        always negative for bacteria. In milder cases, a biopsy was
much more common to see secondary forms where bacteria
                                                                        performed to support the differential diagnosis with sebor-
colonize the scalp after scratching due to itch.
                                                                        rheic dermatitis (SD) due to dilated and arborized capillaries.
    The most frequently isolated bacteria in our group were
                                                                            At dermoscopy, pustular lesions were clearly visible as
Staphylococcus aureus and Streptococcus pyogenes. All cases
                                                                        distributed on top of the follicular ostium. The roof of the
were primary form. Physical examination, facilitated by der-
                                                                        pustular lesions is very fragile, and easily ruptures with leak-
moscopy, always allowed the diagnosis except for 1 patient.
                                                                        age of serum material (Figure 1C).
    At dermoscopy, single exudative to crusted yellowish
-colored lesions, sometimes trapping tufts of hair, and sur-
rounded by erythema with sparsely dotted vessels, were                  Rosacea
clearly visible.                                                        The presence of Demodex folliculorum (tails) was identified
                                                                        in five patients referred for red and itchy scalp. Skin biopsy
Herpes Zoster Virus                                                     was performed in all cases as the clinical picture and der-
All patients reported during the vesicular phase evolved into           moscopy pattern did not provide a conclusive diagnosis de-
a crusty phase subsequently. The associated neuritis helped             spite the presence of diffuse erythema, branching vessels and
define the diagnosis. A confirmatory PCR was, however,                  small dry scales (Figure 1D). In some areas of the scalp, the
made in all patients.                                                   most sun-exposed, we have also identified a diffuse vascular




   Figure 1. (A) Dermoscopic image of tinea capitis (kerion). Culture of the lesion confirmed the presence of Microsporum canis.
   (B) Dermoscopic image of dilated and arborizing vessels with dotted vessels around the pustule, which are typical of seborrheic derma-
   titis. (C) Dermoscopic image of folliculitis during the acute phase of a histologically confirmed acneiform eruption. (D) Dermoscopic
   image of scalp rosacea: erythematous round lesions with a central yellowish area.


Original Article | Dermatol Pract Concept. 2023;13(3):e2023131                                                                              3
alteration, characterized by round lesions, frankly erythem-               instrumental techniques, helps determine the correct diagno-
atous and flat, painful if of recent onset, and with a cen-                sis. Also, very much important is not to miss another under-
tral yellowish area, as reported in the literature [6,7]. The              lying and potentially scarring disorder.
color of these spots turns brownish over time. All patients                    Etiological agents such as Malassezia, Demodex, etc, are
were classified as rosacea third stage due to a stable phase               common commensals of our scalp and live in the follicular
of vasodilation.                                                           infundibulum. When in excess, they can act as trigger factors,
      A variant of rosacea named glandular form, characterized             stimulating a perifollicular inflammatory reaction comprised
by edematous papules, large pustules, nodulocystic lesions,                of lymphocytes, neutrophils, and, occasionally, multinucle-
marked inflammation and hyperseborrhea has been de-                        ated histiocytes [10]. They can be treated but not removed.
scribed in the literature but never found in our practices [8].                Malassezia is implicated in the pathogenesis of SD. In the
                                                                           presence of significant refractory inflammation, folliculitis ap-
Eosinophilic Pustular Folliculitis (Ofuji Syndrome)                        pears. Because of the intense itch, scratching the pustules can
A 1-year-old child presented us with small scalp pustules                  frequently lead to bacterial superinfection and yellow crusts [4].
that tended to confluence and form an annular or polycy-                       Folliculitis in Tinea Capitis is generally present in acute
clic plaque. Yellow crusts were also present, possibly due to              stages and presents as a follicular micro papule that pro-
scratching. At dermoscopy, pustules and the erythematous                   gresses centrifugally to form a round or polycyclic plaque
base were more evident, as well as crusts and dilated vessels.             5-6 cm in diameter with hair shafts trapped inside [3].
Biopsy was, however, mandatory, and the pathology report                       Ofuji syndrome is characterized by four clinical signs and
confirmed eosinophilic pustular folliculitis. Cytology was                 symptoms: 1. sterile pustules in seborrheic areas, 2. intermittent
also important to reveal the presence of eosinophils and to                outbreaks accompanied by leukocytosis and eosinophilia, 3. pri-
allow differential diagnosis with infective forms.                         mary follicular eosinophilic pustules, 4. good response to small
                                                                           and prolonged doses of corticosteroids. Post-inflammatory hy-

Discussion                                                                 perpigmentation might follow as a sequela [9].
                                                                               From the data that emerged in this study, we created an
An early diagnosis of SFS is sometimes difficult as, ini-                  algorithm (Figure 2) based on the clinical and dermoscopic
tially, they may appear very similar to each other. An accu-               picture, to help reach the correct diagnosis. Table 2 summa-
rate clinical history, with careful physical examination and               rizes the main clinical, dermoscopic and histopathological




    Figure 2. Suggested algorithm to follow when dealing with superficial folliculitis of the scalp
    SFS = superficial folliculitis of the scalp.



4                                                                               Original Article | Dermatol Pract Concept. 2023;13(3):e2023131
                      Table 2. Clinical, dermoscopic and histopathological features of SFS.
                         Clinical Features                       Dermoscopy                             Histopathology
Dermatophytes Follicular micropapule.               Comma, broken and corkscrew              Superficial and deep mixed
                                                    hair, black dots and pustules with       perifollicular infiltrate.
                                                    or without trapped hair.                 Positive PAS staining.
Candida            From small pustules to           Multiple whitish pinpoint pustules,      Dense perifollicular mixed-type
                   painful papules, nodules         scattered throughout the scalp.          infiltrate, edema, abscesses at the
                   and pustules with the            Peripheral erythematous halo with        follicular epithelium and PAS-positive
                   presence of itching.             small dilated capillaries.               staining.
Malassezia         Folliculitis with small          Furfuraceous scales, arborized           Mild to moderate lymphocytic
                   whitish scales on the            vascular and atypical reticular          inflammatory infiltrate at the
                   scalp, erythematous-             dilatations, small whitish               infundibular, peri-infundibular and
                   desquamative plaques with        folliculitis, centered by the hair and   peri-isthmic level, mild fibroplasia,
                   greasy appearance and            a small crust secondary to itching.      abscesses, dilation of the infundibulum
                   seborrhea with greasy and                                                 with laminated orthokeratosis and
                   opaque hair.                                                              focal parakeratosis of the epidermis.
Bacteria           A single lesion with a tuft      A crusty thickened exudative             Collection of neutrophils and bacteria
                   of hair. Yellowish-whitish       lesion, yellowish in color, with         in the epidermis with dilated vessels,
                   pustule with perifollicular      a central tuft and peripheral            edema, and mild-moderate mixed type
                   erythema, yellow-brownish        erythema; brownish yellow                -infiltrate in the papillary and middle
                   crusts, painful perifollicular   background with an aflegmasic            dermis.
                   papular lesions with             alopecia, atrophy, and absence of
                   peripheral erythema.             follicular openings.
Herpes Zoster      Multiple vesicles and            Herpetic polymorphism: vesicles,         Intraepidermal vesicles containing
                   subsequent pustules              pustules and crusts at the same          multinucleated keratinocytes with
                   following the innervation,       time and peripheral erythema with        a nucleus of grayish color, marginal
                   with neuritis of the scalp.      numerous dilated and superficial         chromatin, ballooning cytoplasm
                                                    capillaries, scabs and scarring          and acantholysis. A moderate-
                                                    lesions.                                 dense perivascular and interstitial
                                                                                             inflammatory infiltrate of mixed-type
                                                                                             fibrosis and destruction of the adnexal
                                                                                             structures.
Pox virus          Hemispherical and                Central umbilicated papule               Rounded basophilic bodies present
                   roundish papules, in pale-       surrounded by yellowish-white            among the keratinocytes are observed,
                   pink color, 2-3 mm in            polylobed amorphous structures.          grouped in a “crater” and in the
                   diameter, with a central         Crown vessels known as “red              infundibular hyperplastic areas of
                   navel and a smooth regular       corona” emerge from the periphery        the granular and spinous layer of the
                   surface.                         of the lesion and radiate towards        epidermis.
                                                    the center, rarely crossing each
                                                    other.
Acneiform          Papules, pustules or             Central pustular lesions, intensely      Suppurative folliculitis in the
Eruption           follicular crusts on             erythematous with dilated                superficial dermis with a
                   erythematous skin, pain          capillaries in the periphery, crusts     neutrophilic inflammatory
                   with possible bleeding or        of variable colors from intense          infiltrate, dilated sebaceous glands
                   leakage of pus.                  red to yellowish-brown, dilated          and hyperkeratinization of the
                                                    vessels with a lattice appearance        intrainfundibular epithelium and
                                                    throughout the scalp.                    retention of lamellae, plugs.
Rosacea            Diffuse erythema of the          Branching vessels with a yellowish       Vasodilation of the vessels of
                   scalp with small dry scales,     central area that turns brownish         the subpapillary plexus and a
                   painful flat erythematous        over time.                               polymorphic inflammatory infiltrate,
                   round lesions, and facial                                                 non-caseous granulomatous infiltrate
                   involvement.                                                              in the perifollicular and perivascular
                                                                                             areas, and the presence of Demodex
                                                                                             Folliculorum.
Ofuji              Plaque of small                  Central folliculitis with dilated        Massive mixed-type inflammatory
syndrome           erythematous-edematous,          capillaries in the periphery and         infiltrates, microabscesses, epithelial
                   sterile pustules in              yellowish crust.                         necrosis and intercellular edema.
                   seborrheic areas.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023131                                                                         5
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6                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023131
