Systemic photodynamic therapy in folliculitis decalvans

Abstract

SummaryFolliculitis decalvans (FD) is classified as a primary neutrophilic cicatricial alopecia, and is estimated to account for approximately 10% of all cases of primary cicatricial alopecia. 1 The role of dysfunctional immune activity and the presence of bacteria, particularly Staphylococcus aureus, appear pivotal. We describe a 26-year-old man with a 4-year history of FD that was recalcitrant to numerous systemic and topical therapies, whose disease was virtually cleared during a follow-up of 25 months following a course of treatment with systemic photodynamic therapy (PDT) using ultraviolet light (100-140 J/cm 2 ) with porfimer sodium 1 mg/kg as monotherapy. This is the first report of the use of systemic PDT as a treatment for FD. Systemic PDT has potent antibacterial effects with little or no resistance. In addition, systemic PDT provides local immunomodulation and improved scar healing. Significant adverse effects following systemic PDT with appropriate aftercare are rare. This case demonstrates that systemic PDT is a useful therapy option in the treatment of recalcitrant FD.Folliculitis decalvans (FD) is classified as a primary neutrophilic cicatricial alopecia, which accounts for approximately 10% of all cases of primary cicatricial alopecia.1 Dysfunctional immune activity and the presence of bacteria, particularly Staphylococcus aureus, appear to play pivotal roles. We report a case of FD in a young man who was successfully treated with systemic photodynamic therapy (PDT). ReportA 26-year-old man presented in 2011 with a 4-year history of waxing and waning painful pustulation, hair tufting and scarring, all affecting the vertex of the scalp. He was otherwise healthy. Histological examination of a biopsy taken from the scalp showed evidence of scarring alopecia with superficial follicular and perifollicular abscesses (Fig. 1a). Staining showed Numerous gram-positive bacteria within inflamed hair follicles, and an absence of fungi were evident. Multiple microbacterial swabs from active scalp pustules grew methicillin-sensitive S. aureus. Fungal cultures were negative, as was a screen of connective tissue and skin autoantibodies for bullous pemphigoid and pemphigus.Treatment over the next 3 years involved oral antibiotics (doxycycline, rifampicin and clindamycin), retinoids (isotretinoin and acitretin), prednisolone and ciclosporin. Topical treatments included antibacterial washes, topical antibiotics and topical corticosteroids. Despite these treatments, the disease remained active, with a significant impact on quality of life. The patient was referred for consideration of radiotherapy, a treatment with previously demonstrated effectiveness in FD. 2During the assessment, the patient's youth made it preferable to avoid radiotherapy and instead he was offered a trial of systemic PDT with porfimer sodium (Photofrin, Axcan Pharma Inc, Quebec, Canada) as a novel alternative.

Folliculitis decalvans: a case report of satisfactory recovery after implementing isotretinoin therapy

“…Regarding prognostic factors for severe folliculitis decalvans, our patient presented with tufted hairs (polytrichia); besides it had an early onset (age < 25 years old) and had lasted several years. (20) As mentioned above, proper treatment of this condition has proven to be a challenge (1,7,12), as several therapies have been reported with a varying range of success; in this regard the main clinical characteristics of folliculitis decalvans, as well as some of the therapies described for its treatment (including doses) are available in Table 4. Other therapeutic alternatives include medical honey (27) and adipose tissue transplantation.…”

“…Presence of tufted hairs (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), which act as a portal of entry for staphylococci.…”

“…(2,10,11) Folliculitis decalvans management has proven to be a challenge since there is a wide range of treatment alternatives, including antibiotic therapy (tetracycline, trimethoprim/sulfamethoxazole, cephalosporins, ciprofloxacin, minocycline or clindamycin or clarithromycin plus rifampicin) (1,6,9), the use of topical antibiotics (for example erythromycin, mupirocin and clindamycin) (1), antifungals, retinoids, corticosteroids (topical or oral), phototherapy, and laser depilation. (1,7,12) The occipital region and the vertex are usually the most affected areas in patients with this condition. Generally, folliculitis decalvans starts as a single lesion and then spreads in a centrifugal progression with the development of painful follicular papules and pustules.…”

Aminolevulinic acid photodynamic therapy for folliculitis decalvans: A case report

“…Thus, it would be more convincing to culture and quantify S. aureus in samples from the lesional skin before and after treatment. Second, topical PDT and systemic PDT have been used to treat FD with greatly improvement, but well‐controlled studies, as opposed to a single case report, are needed to further clarify the role of ALA‐PDT in the treatment of FD 10 …”

Reply to: “Comment on ‘Folliculitis decalvans: Effectiveness of therapies and prognostic factors in a multicenter series of 60 patients with long-term follow-up’”

“…Recently, the use of photodynamic therapy for the treatment of FD has been described with promising results in select patients. 6,7 In addition, the tumor necrosis factor inhibitors adalimumab and infliximab have been used in recalcitrant cases of FD. 8 Ongoing and future studies about cutaneous microbiota in patients with FD could give us more clues about its pathogenesis, opening new lines of research for finding new therapies.…”