Folliculitis decalvans

A guide to understanding folliculitis decalvans

Folliculitis decalvans is a rare form of primary cicatricial (scarring) alopecia that most commonly affects young patients, particularly men, although women may also develop this condition.

This type of alopecia often begins as what appears to be a conventional folliculitis affecting the crown of the scalp, characterised by an inflammatory process associated with pustules and varying degrees of discomfort or burning sensation. Over time, the inflammation may spread to other areas of the scalp and progressively destroy the hair follicle, leading to irreversible hair loss and scarring, as occurs in other forms of cicatricial alopecia.

A characteristic feature of this condition is the presence of so-called tufted hairs, in which several hair shafts emerge from a single follicular opening. Crusting and inflammatory lesions around the areas of hair loss are also common, causing symptoms of varying severity such as intense itching, burning, stinging or irritation.

Folliculitis decalvans often has a profound emotional impact on affected patients and may significantly impair quality of life, as the areas of hair loss can become extensive and lead to considerable cosmetic disfigurement.

As with other forms of cicatricial alopecia, early diagnosis and prompt initiation of treatment are particularly important to slow disease progression and to mitigate both the aesthetic and psychological impact. Once scarring develops in the affected areas of the scalp, hair regrowth is no longer possible.

The Hair Disorders and Hair Transplant Unit at Grupo Pedro Jaén participates in scientific research aimed at improving understanding of this condition and contributing to the development of effective treatments. The team has published some of the most relevant data regarding the origin, clinical course and therapeutic approaches to folliculitis decalvans.

Causes of folliculitis decalvans

The exact causes of folliculitis decalvans are not yet fully understood. Data obtained from various studies conducted on this topic—some of them led by specialists from the Hair Disorders and Hair Transplant Unit at Grupo Pedro Jaén in collaboration with their counterparts at Hospital Universitario Ramón y Cajal—suggest that the inflammatory process responsible for follicular destruction may begin with a bacterial infection. In genetically predisposed patients, this infection could trigger an immune response aimed at eliminating the bacteria, but which may also inadvertently damage the hair follicle, ultimately leading to hair loss.

This inflammatory response is chronic and may persist for years in the form of recurrent flare-ups, even after the initial infection has been eradicated. Although folliculitis decalvans may be associated with a bacterial trigger, it is important to note that this hair disorder is not contagious.

Diagnosis of folliculitis decalvans

The diagnosis of folliculitis decalvans can be established clinically during consultation using digital trichoscopy, a magnification device that allows the trichologist to examine the scalp and hair shaft structure in detail. In many cases, an experienced specialist may be able to make the diagnosis through direct clinical observation alone. However, digital trichoscopy enables a more comprehensive assessment of both the hair shaft and scalp, while also allowing documentation and monitoring of disease progression, treatment response and the need for therapeutic adjustments when necessary.

In certain cases, histological analysis may be required. This involves performing a scalp biopsy to assess the degree of inflammation or to clarify specific diagnostic uncertainties. It is a straightforward procedure carried out under local anaesthesia in the outpatient setting, usually taking less than 15 minutes and requiring only a single suture after sample collection.

“Folliculitis decalvans is a hair disorder that can have a significant emotional impact on affected patients”

Treatment of folliculitis decalvans

There is currently no curative treatment for folliculitis decalvans. However, at the Hair Disorders and Hair Transplant Unit of Grupo Pedro Jaén, we offer the most advanced and effective therapeutic options to stabilise the clinical condition and prevent further progression of this form of alopecia.

Treatment considerations

In all cases, as with any form of cicatricial alopecia, the primary therapeutic goal is to control the inflammatory process responsible for follicular destruction and to prevent further hair loss.

Once the disease has been medically stabilised, hair transplantation may be considered. However, an individualised assessment is essential, as there is a risk of losing transplanted hair if a new inflammatory flare of folliculitis decalvans occurs.

The main prognostic factor in preventing progression of alopecia is therefore the early treatment of inflammatory flare-ups, as hair does not regrow once scarring tissue has developed.

Over time, the activity of folliculitis decalvans often decreases spontaneously. In a significant proportion of patients, inflammatory episodes may eventually resolve completely. Nevertheless, more severe forms of this cicatricial alopecia may require long-term treatment over months or even years.

More information

Below you will find the authorship and references for the information provided on this page: