Treatment Survival and Reasons for Discontinuation in Patients with Recalcitrant Folliculitis Decalvans
DOI:
https://doi.org/10.2340/actadv.v105.44185Keywords:
discontinuation, efficacy, folliculitis decalvans, treatment survivalAbstract
Due to the risk of scarring and the psychological impact on affected patients, folliculitis decalvans (FD) requires prompt and focused care to control inflammation and prevent disease progression. This study aimed to provide a comprehensive long-term evaluation of treatment outcomes in difficult-to-treat cases of FD by analysing the effectiveness of various therapies and identifying reasons for treatment switches or discontinuation. The single-centre, retrospective cohort study collected information on patient characteristics and management strategies, focusing on different treatment groups and reasons for discontinuation or switching. Eighteen patients with biopsy-confirmed FD were included in the study because of their recalcitrant course (38.9% females, median age 33.0 years), with a median follow-up period of 1.5 years. During the study period, all patients received at least one pre-scription for topical therapies, primarily non-antibiotic disinfectants, topical corticosteroids, topical antibiotics, and topical dapsone. Systemic antibiotics were prescribed for 88.9% of patients, predominantly tetra-cyclines and a combination of rifampicin and clindamycin. Non-biological systemic therapies, excluding steroids, were used in 61.1% of patients, with isotretinoin being the most common (27.8%). Among immunomodulatory drugs, apremilast was prescribed to 11.1% of patients. Overall, the highest treatment discontinuation rates were observed with systemic antibiotics (risk ratio: 1.63; 95% confidence interval: 1.46–1.82), followed by systemic steroids. The treatment of patients with severe FD requires a personalized, multifaceted approach, typically involving a combination of local and systemic therapies. Antibiotics are often used as a first-line treatment, but they are associated with a high rate of discontinuation. This highlights the urgent need for effective immunomodulatory treatments, either as alternatives or as adjuncts to current options.
Downloads
References
Vañó-Galván S, Saceda-Corralo D, Blume-Peytavi U, Cucchía J, Dlova NC, Gavazzoni Dias MFR, et al. Frequency of the types of alopecia at twenty-two specialist hair clinics: a multicenter study. Skin Appendage Disord 2019; 5: 309–315. DOI: https://doi.org/10.1159/000496708
Moreno-Arrones OM, Del Campo R, Saceda-Corralo D, Jimenez-Cauhe J, Ponce-Alonso M, Serrano-Villar S, et al. Folliculitis decalvans microbiologic signature is specific for disease clinical phenotype. J Am Acad Dermatol 2021; 85: 1355–1357. DOI: https://doi.org/10.1016/j.jaad.2020.10.073
Jahns AC, Lundskog B, Nosek D, Killasli H, Emtestam L, Alexeyev OA. Microbiology of folliculitis decalvans: a histological study of 37 patients. J Eur Acad Dermatol Venereol 2015; 29: 1025–1026. DOI: https://doi.org/10.1111/jdv.12448
Chiarini C, Torchia D, Bianchi B, Volpi W, Caproni M, Fabbri P. Immunopathogenesis of folliculitis decalvans: clues in early lesions. Am J Clin Pathol 2008; 130: 526–534. DOI: https://doi.org/10.1309/NG60Y7V0WNUFH4LA
Sarkis A, Cortez de Almeida RF, Lemes LR, Obadia DL, Machado CJ, Müller-Ramos P, et al. Folliculitis decalvans in women: a retrospective multicentre study of 150 patients. J Eur Acad Dermatol Venereol 2024; 38: e66–70. DOI: https://doi.org/10.1111/jdv.19434
Kashikar Y, Saoji V, Madke B, Chandak MS, Meghe S. Successful management of folliculitis decalvans. Cureus 2024; 16: e52881. DOI: https://doi.org/10.7759/cureus.52881
Moreno-Arrones OM, Garcia-Hoz C, Del Campo R, Roy G, Saceda-Corralo D, Jimenez-Cauhe J, et al. Folliculitis decalvans has a heterogeneous microbiological signature and impaired immunological response. Dermatology 2023; 239: 454–461. DOI: https://doi.org/10.1159/000529301
Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis decalvans. Dermatol Ther 2008; 21: 238–244. DOI: https://doi.org/10.1111/j.1529-8019.2008.00204.x
Hoy M, Böhm M. Therapy-refractory folliculitis decalvans treated with certolizumab pegol. Int J Dermatol 2022; 61: e26–28. DOI: https://doi.org/10.1111/ijd.15914
Rambhia PH, Conic RRZ, Murad A, Atanaskova-Mesinkovska N, Piliang M, Bergfeld W. Updates in therapeutics for folliculitis decalvans: a systematic review with evidence-based analysis. J Am Acad Dermatol 2019; 80: 794–801.e1. DOI: https://doi.org/10.1016/j.jaad.2018.07.050
Alsantali A, Baghdadi R, Alghamdi Y, Abbas EB, Ghazi R. Folliculitis decalvans managed with adalimumab: a case report. Clin Case Rep 2023; 11: e8193. DOI: https://doi.org/10.1002/ccr3.8193
Lobato-Berezo A, Pujol RM. Refractory folliculitis decalvans treated with biologics: case series in 4 situations. Dermatol Ther 2022; 35: e15778. DOI: https://doi.org/10.1111/dth.15778
Moussa A, Asfour L, Eisman S, Bhoyrul B, Sinclair R. Successful treatment of folliculitis decalvans with baricitinib: a case series. Australas J Dermatol 2022; 63: 279–281. DOI: https://doi.org/10.1111/ajd.13786
Kromer C, Wilsmann-Theis D, Gerdes S, Philipp S, Schaarschmidt ML, Schmieder A, et al. Drug survival and reasons for drug discontinuation in palmoplantar pustulosis: a retrospective multicenter study. J Dtsch Dermatol Ges 2019; 17: 503–516. DOI: https://doi.org/10.1111/ddg.13834
Schulte-Oestrich L, Cazzaniga S, Hunger RE, Seyed Jafari SM. Treatment survival in patients with hidradenitis suppurativa. JEADV Clin Pract 2025; 4: 751–758. DOI: https://doi.org/10.1002/jvc2.70027
Moore SF, Price S, Konya J, Blummers S, Walter FM, Neal RD, et al. Risk factors for pancreatic cancer in electronic health records: an umbrella review of systematic reviews and meta-analyses. EClinicalMedicine 2025; 85: 103297. DOI: https://doi.org/10.1016/j.eclinm.2025.103297
Edmonds J. Optimum branchings. J Res Natl Inst Stand Technol Section B. 1967; 71B: 233–240. DOI: https://doi.org/10.6028/jres.071B.032
Vañó-Galván S, Molina-Ruiz AM, Fernández-Crehuet P, Rodrigues-Barata AR, Arias-Santiago S, Serrano-Falcón C, et al. Folliculitis decalvans: a multicentre review of 82 patients. J Eur Acad Dermatol Venereol 2015; 29: 1750–1757. DOI: https://doi.org/10.1111/jdv.12993
Waśkiel-Burnat A, Starace M, Iorizzo M, Katoulis A, Apalla Z, Asfour L, et al. Management of folliculitis decalvans: the EADV task force on hair diseases position statement. J Eur Acad Dermatol Venereol 2025; 39: 1385–1394 DOI: https://doi.org/10.1111/jdv.20687
Fakhoury T, Urban K, Ettefagh L, Nami N. Recalcitrant folliculitis decalvans treatment outcomes with biologics and small molecule inhibitors. Cutis 2024; 113: E32–34. DOI: https://doi.org/10.12788/cutis.1023
Tietze JK, Heppt MV, von Preußen A, Wolf U, Ruzicka T, Wolff H, et al. Oral isotretinoin as the most effective treatment in folliculitis decalvans: a retrospective comparison of different treatment regimens in 28 patients. J Eur Acad Dermatol Venereol 2015; 29: 1816–1821. DOI: https://doi.org/10.1111/jdv.13052
Gemmeke A, Wollina U. Folliculitis decalvans of the scalp: response to triple therapy with isotretinoin, clindamycin, and prednisolone. Acta Dermatovenerol Alp Pannonica Adriat 2006; 15: 184–186.
Aksoy B, Hapa A, Mutlu E. Isotretinoin treatment for folliculitis decalvans: a retrospective case-series study. Int J Dermatol 2018; 57: 250–253. DOI: https://doi.org/10.1111/ijd.13874
Harries MJ, Paus R. Scarring alopecia and the PPAR-gamma connection. J Invest Dermatol 2009; 129: 1066–1070. DOI: https://doi.org/10.1038/jid.2008.425
Zouboulis CC. Isotretinoin revisited: pluripotent effects on human sebaceous gland cells. J Invest Dermatol 2006; 126: 2154–2156. DOI: https://doi.org/10.1038/sj.jid.5700418
Dispenza MC, Wolpert EB, Gilliland KL, Dai JP, Cong Z, Nelson AM, et al. Systemic isotretinoin therapy normalizes exaggerated TLR-2-mediated innate immune responses in acne patients. J Invest Dermatol 2012; 132: 2198–2205. DOI: https://doi.org/10.1038/jid.2012.111
Melián-Olivera A, Burgos-Blasco P, Selda-Enríquez G, Suárez-Valle A, Miguel-Gómez L, Vañó-Galván S, et al. Topical dapsone for folliculitis decalvans: a retrospective cohort study. J Am Acad Dermatol 2022; 87: 150–151. DOI: https://doi.org/10.1016/j.jaad.2021.07.004
Shireen F, Sudhakar A. A case of isotretinoin therapy-refractory folliculitis decalvans treated successfully with biosimilar adalimumab (Exemptia). Int J Trichology 2018; 10: 240–241. DOI: https://doi.org/10.4103/ijt.ijt_34_18
Ramos J, Silva AM, António AM, Alves J. Recalcitrant folliculitis decalvans successfully controlled with adalimumab. An Bras Dermatol 2024; 99: 480–482. DOI: https://doi.org/10.1016/j.abd.2024.02.001
Mihaljević N, von den Driesch P. Successful use of infliximab in a patient with recalcitrant folliculitis decalvans. J Dtsch Dermatol Ges 2012; 10: 589–590. DOI: https://doi.org/10.1111/j.1610-0387.2012.07972_suppl.x
Kreutzer K, Effendy I. Therapy-resistant folliculitis decalvans and lichen planopilaris successfully treated with adalimumab. J Dtsch Dermatol Ges 2014; 12: 74–76. DOI: https://doi.org/10.1111/ddg.12224_suppl
Iorizzo M, Starace M, Vano-Galvan S, Piraccini BM, Reygagne P, Rudnicka L, et al. Refractory folliculitis decalvans treated with adalimumab: a case series of 23 patients. J Am Acad Dermatol 2022; 87: 666–669. DOI: https://doi.org/10.1016/j.jaad.2022.02.044
Dupont A, Eyraud A, Milpied B, De Bataille S, Cassassa E, Darrigade AS, et al. Efficacy and safety of tumour necrosis factor-α antagonists for folliculitis decalvans: a retrospective case-series pilot study. Acta Derm Venereol 2023; 103: adv3713. DOI: https://doi.org/10.2340/actadv.v103.3713
Andrade A, Scuotto CRC, Da Silva DLF. Refractory folliculitis decalvans: new therapeutic horizons? Int J Trichology 2025; 17: 66–68. DOI: https://doi.org/10.4103/ijt.ijt_83_23
Alhameedy MM, Alsantali AM. Therapy-recalcitrant folliculitis decalvans controlled successfully with adalimumab. Int J Trichology 2019; 11: 241–243. DOI: https://doi.org/10.4103/ijt.ijt_92_19
Fässler M, Radonjic-Hoesli S, Feldmeyer L, Imstepf V, Pelloni L, Yawalkar N, et al. Successful treatment of refractory folliculitis decalvans with apremilast. JAAD Case Rep 2020; 6: 1079–1081. DOI: https://doi.org/10.1016/j.jdcr.2020.08.019
Dethier C, Azirar S, Verluyten L, Boonen H, Grosber M, Gutermuth J. Response to Fässler et al.’s “Successful treatment of refractory folliculitis decalvans with apremilast”. JAAD Case Rep 2025; 57: 122–123. DOI: https://doi.org/10.1016/j.jdcr.2024.10.036
de Viragh PA, Seyed Jafari SM. Response to Dethier et al., “Experience in nine additional cases of apremilast for therapy-resistant folliculitis decalvans”. JAAD Case Rep 2025; 57: 102. DOI: https://doi.org/10.1016/j.jdcr.2024.12.001
Agarwal P, Ajuchi O, Lukowiak TM, Rao BK. Off-label use of biologics and Janus kinase (JAK) inhibitors for scarring alopecias: a narrative review. Arch Dermatol Res 2025; 317: 803. DOI: https://doi.org/10.1007/s00403-025-04301-z
Jerjen R, Meah N, Trindade de Carvalho L, Wall D, Sinclair R. Folliculitis decalvans responsive to tofacitinib: a case series. Dermatol Ther 2020; 33: e13968. DOI: https://doi.org/10.1111/dth.13968
Ismail FF, Sinclair R. Successful treatment of refractory folliculitis decalvans with secukinumab. Australas J Dermatol 2020; 61: 165–166. DOI: https://doi.org/10.1111/ajd.13190
Piscazzi F, Franceschini C, Narcisi A, Valenti M, Rossi A, Ardigò M. Non-invasive assessment and management of folliculitis decalvans by trichoscopy and reflectance confocal microscopy. Dermatol Pract Concept 2024; 14: e2024167. DOI: https://doi.org/10.5826/dpc.1403a167
Additional Files
Published
How to Cite
Issue
Section
Categories
License
Copyright (c) 2025 Lena Farnina, Simone Cazzaniga, Robert E. Hunger, Kristine Heidemeyer, Pierre A. de Viragh, S. Morteza Seyed Jafari
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized ActaDV contents is available freely online. The Society for Publication of Acta Dermato-Venereologica owns the copyright for all material published until volume 88 (2008) and as from volume 89 (2009) the journal has been published fully Open Access, meaning the authors retain copyright to their work.
Unless otherwise specified, all Open Access articles are published under CC-BY-NC licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
