Photodynamic therapy for the treatment of folliculitis decalvans Summary

BRIEF COMMUNICATION
Photodynamic therapy for the treatment of folliculitis decalvans
Esther Castaño-Suárez, Alberto Romero-Maté, Dolores Arias-Palomo & Jesús Borbujo
Department of Dermatology, Hospital de Fuenlabrada, Fuenlabrada, Madrid, Spain
Summary
Key words:
folliculitis decalvans; photodynamic
therapy; treatment
Correspondence:
Folliculitis decalvans is a chronic form of deep folliculitis that occurs on the scalp as patches
of scarring alopecia at the expanding margins of which are follicular pustules. Treatment of
folliculitis decalvans is extremely difficult with a resultant poor prognosis. Photodynamic
therapy has been reported to be effective in disorders as acne or folliculitis. We report one
patient with folliculitis decalvans who was successfully treated with photodynamic therapy.
Dr Esther Castaño-Suárez, Department of
Dermatology, Hospital de Fuenlabrada, CAMINO
DEL MOLINO, 2, Fuenlabrada, Madrid 28942,
Spain.
Tel: +34 916006540
Fax: +34 913516373
e-mail: [email protected]
Accepted for publication:
2 November 2011
Conflicts of interest:
None declared.
F
olliculitis decalvans (FD) is a neutrophilic inflammation of
the scalp characterized by painful, recurrent purulent follicular exudation resulting in primary cicatricial alopecia (1). Bright
erythema together with yellow-gray scales can be present around
the follicles. Surviving hairs may group so that multiples hairs are
seen emerging from a single follicular orifice (tufted folliculitis).
FD predominantly occurs in young and middle-aged adults with
a slight preference of the male gender.
The early histopathologic features include an intrafollicular
infiltrate composed mainly of neutrophilic granulocytes. With
disease progression, the infiltrate becomes mixed with lymphocytes, neutrophils, and plasma cells and extends into the
intefollicular dermis. Granulomatous inflammation with foreignbody giant cells is a common finding. Advanced disease is characterized by follicular and dermal fibrosis.
Its etiology is still not clear, but it may represent an interaction
between bacteria and the host. It has been hypothesized that the
infection of hair follicles by Staphylococcus aureus induces an intense
migration of neutrophils, recruited in the perifollicular dermis
by innate immunity mechanisms such as production of interleukin (IL)-8 by epithelial cells. T lymphocytes may be activated
by microbial antigen and release several proinflammatory
[interferon-g (IFN-g) and tumor necrosis factor-a (TNF-a)] and
profibrotic mediators [tumor growth factor-b (TGF-b) and
IL-1b]. Activated fibroblasts overproduce the extracellular matrix
that leads to fibrosis (2).
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Case report
A 32-year-old woman presented with pain, itching, and
burning on the scalp of 1-year duration. The patient’s medical
history included asthma. A physical examination revealed areas
of pustules, scales, yellow crusts, perifollicular erythema,
scarred alopecia, and follicular tufting over the vertex and
occipital area (Fig. 1). Histopathologic findings of a punch
biopsy specimen from the scalp showed an intense follicular
and perifollicular infiltrate of neutrophils that disrupted the follicular wall. The dermis adjacent contained a perivascular infiltrate of lymphocytes and plasma cells and foreign body giant
cells around the hair shafts along with scarring. Periodic acidSchiff stain (PAS) preparation showed no fungal element. A
diagnosis of folliculitis decalvans was made. The results of laboratory investigations, including complete blood cell count, electrolytes, glucose, creatinine, and liver function tests, were
normal. Treatment with repeated short courses of topical corticosteroids showed temporary improvement but rapid relapse on
discontinuation. The patient underwent a 4-month course of
isotretinoin 30 mg daily with only limited response. As glucose6-phosphate dehydrogenase levels were within normal limits,
dapsone 50–100 mg daily was introduced and administered for
3 months with progressive worsening of her condition. Erythema, pustules, yellow crusts, and small patches of cicatricial
alopecia were present.
© 2012 John Wiley & Sons A/S
Photodermatology, Photoimmunology & Photomedicine 2012, 28, 102–104
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Folliculitis decalvans and PDT
papules, pustules, or crusts. She remains disease free 12 months
after last cycle without any other adjuvant care (Fig. 2).
Discussion
Fig. 1. Perifollicular erythema, scales, yellow crusts, scarred alopecia of
the scalp.
Fig. 2. After treatment, areas of scarring alopecia without
inflammatory papules or pustules.
Owing to the persistence of refractory cutaneous lesions, with
deep and inflammatory papules, erythema, and patches of alopecia adjacent to the areas of inflammation, photodynamic
therapy (PDT) was considered for our patient. Methyl aminolevulinate (MAL) (Metvix; Galderma, Paris, France) was applied to
the lesion and covered with occlusive film. After 3 h, the lesion
was irradiated with a light-emitting diode light source at a
wavelength of 630 nm at 37 J/cm2 (Aktilite lamp; PhotoCure
ASA, Oslo, Norway). We first performed a test site on a reduced
shaved area of approximately 4 cm2 to verify tolerance. She tolerated the test site without complications, so we performed three
cycles of PDT on disease area of 16 cm2 at 8-week intervals. Each
cycle involved two treatment sessions 2 weeks apart.After the first
cycle, the patient showed marked improvement, with clearing of
pustules and absence of pain. Only erythema and yellow scales
were present as well as mild itching.The patient’s scalp improved
significantly, with areas of cicatrical alopecia but without
© 2012 John Wiley & Sons A/S
Photodermatology, Photoimmunology & Photomedicine 2012, 28, 102–104
Treatment of folliculitis decalvans is extremely difficult with a
resultant poor prognosis (1). Disease activity can frequently be
noted over many years. Topical antibiotics, such as mupirocin,
fusidic acid, clindamycin, or ertyhromicin may be sufficient only
for very mild cases. Topical and intralesional corticosteroids can
help to reduce itching. Systemic corticosteroids should only be
considered for highly active cases and produce only a brief
response. Several combinations of oral antibiotics, as rifampin
and clindamycin, have been reported to achieve successful remission but may be associated with a high incidence of adverse
effects. Because isotretinoin can be effective in dissecting folliculitis of the scalp, it has been introduced as a treatment in several
cases of folliculitis decalvans. Dapsone has an antineutrophilic
activity useful in limited disease, but relapse is observed after
treatment withdrawal. Multiple surgical techniques, as marsupialization or surgical scalping with skin grafting, have been
reported with variable success. However, flare-ups of the
condition are known to have occurred after scalp surgery. Therefore, these therapies should only be considered for exceptional
cases. Several nonsurgical epilating procedures have been used.
X-ray therapy has been proven to be effective. Nevertheless,
increased risk for squamous cell carcinoma makes this modality
less useful. Laser hair removal has also been employed, and
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser has
shown the best results in follicular disorders.
PDT involves the light activation of a photosensitizer to create
cytotoxic oxygen species and free radicals that selectively destroy
rapidly proliferating cells. PDT using either aminolevulinic acid
or its ester MAL has become an established treatment modality
for oncologic conditions like actinic keratosis, Bowen’s disease,
and superficial basal cell carcinoma. PDT has also been found to
be effective for the treatment of several non-neoplastic dermatological diseases like photo-aged skin, leishmaniasis, or acne vulgaris. PDT in the treatment of acne is based on the fact that
Propionibacterium acnes contains endogenous porphyrins. The proposed mechanisms for injury in acne include suppression of
P. acnes, selective destruction of the sebaceous glands, and alteration of follicular keratinocyte shedding (3). As MAL has
enhanced lipophilicity, it could be high effective to treat disorders of the pilosebaceous unit. Wiegell and Wulf (4) reported a
68% reduction from baseline in inflammatory lesions in 21
patients with facial acne vulgaris employing two MAL-PDT treatments 2 weeks apart. However, this treatment option was limited
because of severe pain. Horn and Wolf (5) found a 58% reduction of inflammatory follicular lesions in seven patients suffering
from chronic folliculitis. These authors applied also MAL and a
single PDT session. Gilaberte et al (6) described a case of scalp
folliculitis with demodex infestation, which responded to a
single session of MAL-PDT.
To our knowledge, our patient represents the first case of FD
treated with PDT reported in the literature. PDT may be a safe and
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Castaño-Suárez et al.
effective therapeutic option for these patients. We have achieved
a good response and a prolonged disease-free period. Therefore,
our findings suggest that PDT can be a successful option in the
treatment of several diseases of pilosebaceous unit.
References
1. Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis decalvans.
Dermatol Ther 2008; 21: 238–244.
2. 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.
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3. Elsaie ML, Choudhary S. Photodynamic therapy in the management of acne: an update. J Cosmet Dermatol 2010; 9: 211–217.
4. Wiegell SR, Wulf HC. Photodynamic therapy of acne vulgaris
using methyl aminolevulinate: a blinded, randomized, controlled
trial. Br J Dermatol 2006; 154: 969–976.
5. Horn M, Wolf P. Topical methyl aminolevulinate photodynamic
therapy for the treatment of folliculitis. Photodermatol Photoimmunol
Photomed 2007; 23: 145–147.
6. Gilaberte Y, Frias MP, Rezusta A, Vera-Alvarez J. Photodynamic
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719.
© 2012 John Wiley & Sons A/S
Photodermatology, Photoimmunology & Photomedicine 2012, 28, 102–104
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