What is folliculitis decalvans?
It’s typical to shed between 50 and 100 hairs a day However, noticeably thinning hair, baldness, and skin irritation may warrant an investigation.
Hair loss (alopecia) is a relatively common condition, according to the American Academy of Dermatology. Short-term conditions, such as pregnancy, may cause temporary hair loss. But long-term hair loss that leads to bald patches may stem from an underlying medical condition. Folliculitis decalvans (FD) is one of the possibilities.
FD stems from widespread inflammation within the hair follicles. This causes the follicles to lose hair and stop producing new ones. It can also lead to other inflammatory symptoms.
Learn more about FD and how you can manage this condition. While there’s no cure, treatment can prevent further balding, sores, and scarring.
Inflammation in the hair follicles eventually leads to a variety of noticeable symptoms. FD may cause itching, inflammation, tenderness, tight feeling scalp, and, rarely, you may have no symptoms at all. Unlike genetic hair loss in which you might only experience hair thinning, FD also includes inflammatory symptoms.
Over time, you may notice the following signs on the scalp:
- pustules (blister-like pimples that contain pus)
- tufting of hairs
Hair loss from this condition often occurs in irregular patches.
Alopecia is perhaps most noticeable on the scalp because that’s the area of the body with the most hair. However, alopecia can occur in the following areas:
- pubic areas
FD can develop in these same areas as well.
FD is a chronic inflammatory disease that leads to hair loss. It is a type of folliculitis, a term used to describe inflammation of hair follicles. It’s classified as a form of alopecia called cicatricial alopecia or scarring hair loss, where hair follicles are replaced with scar tissue.
While FD has components of both alopecia and folliculitis, they don’t always occur at the same time. The precise cause of FD is unknown.
FD is different from folliculitis because In addition to inflamed hair follicles, it can halt hair growth. As the condition progresses, your hair follicles are destroyed and can no longer produce hairs. Pustules, crusting, and sores are commonly seen. Scar tissue develops in place of dead hair follicles. This prevents any further hair growth in the affected areas.
FD can happen to anyone, even if those who are in overall good health. While middle-aged men are at greater risk of developing FD, it can affect women and men as early as adolescence. The condition is rare in children, and it’s not contagious. However, no other risk factors are known and there’s likely no single cause of FD.
Like other types of hair loss, FD is diagnosed and treated by a dermatologist. This type of medical doctor specializes in diseases of the hair and skin. Depending on your insurance, you may need a referral from your primary care doctor if you haven’t seen a dermatologist for this condition before. Your primary care doctor will perform a physical exam of the patches in question and make this determination.
A dermatologist will thoroughly examine your scalp, skin, and hair. They’ll examine the skin and note any rashes or scarring. Additionally, they’ll look at areas of pustules and thinning hair and may take a culture and/or biopsy.
Other possible causes for your hair loss
A dermatologist may rule out other causes of hair loss, such as:
- hormonal conditions related to pregnancy, menopause, and elevated androgen levels
- a recent acute illness, such as the flu or an infection
- underactive thyroid (hypothyroidism)
- radiation exposure
- cancer treatments
- certain medications, such as birth control pills, anabolic steroids, and blood thinners
- chronic stress
- stress from a recent traumatic event
- malnutrition (especially iron and protein deficiencies)
- vitamin A overdose
- weight loss
- eating disorders
- poor haircare
- tight hairstyles
Once other causes for your hair loss are ruled out, a dermatologist might recommend a biopsy and culture. This procedure involves taking a small sample of your scalp or your skin and sending it to a lab for testing. A blood test may also be ordered to help rule out any other underlying issues, such as thyroid disease.
Diagnosing FD can take time. Ultimately, the diagnosis is based on a combination of the following:
- medical history
- physical exam
- possible biopsy
- blood test
- skin culture
There is currently no cure for FD. The main goals of treatment are to reduce inflammation and prevent the condition from getting worse. Because FD is a rare condition, most treatment studies have been small, with no overwhelming consensus about the most effective option.
Some treatments are more effective for certain people than they are for others. You may need to pursue a variety of treatment options or a combination of two or more approaches to manage your symptoms. Among the more widely used treatments are:
Several types of antibiotics are used to treat FD, most with mixed results. A 2019 review of multiple FD studies, published in the Journal of the American Academy of Dermatology, found that one of the most effective combinations of antibiotics was a 10-week course of clindamycin and rifampicin. The treatment was associated with a remission phase of 7.2 months.
That same review found that another combination — doxycycline or azithromycin — led to a shorter remission period, even when corticosteroid injections and topical antibiotics were added to treatment.
One way to help reduce inflammation is with corticosteroid injections in the scalp or other area affected by FD. The use of steroids is typically part of a more comprehensive treatment plan involving oral and/or topical antibiotics.
Your dermatologist may also prescribe oral corticosteroids to help fight inflammation and stop the spread of FD.
Medicated shampoos and topical antibiotics are commonly used to treat FD but may be most effective when paired with oral antibiotics. There are also non-antibiotic topicals such as tacrolimus and calcipotriol that may help.
The use of special lights to fight skin infections — a process called photodynamic therapy — may be an option for people when other treatment options aren’t effective, especially for those having a poor response to antibiotics. A 2021 study found that photodynamic therapy is not only an effective option for some people with FD but may also fight FD flare-ups.
While medications and noninvasive therapies are the first line approach to treating FD, once the condition is under control you may want to consider hair restoration options. Many experts recommend hair transplant surgery only after the disease has shown no progression for a few years after the patient has stopped medication and no inflammation is found on a biopsy.
For some people with partial hair loss, a doctor can harvest healthy hair from part of the scalp and graft it onto an area of the scalp that is bald. A
Things you can do at home
In addition to taking the medications recommended by your physician, you can try to manage your symptoms at home by using an antiseptic shampoo. Shampoos with tar, typically used for scalp psoriasis and similar condition, may be appropriate. Check with your dermatologist first.
You may also want to explore ways to conceal your hair loss with wigs or by wearing hats or scarves. Hair loss clinics in your community may have some appealing options for you to consider.
Since there is no cure for FD yet, getting an early diagnosis and starting treatment as soon as possible may help minimize its impact.
The primary long-term risks of FD are scarring and permanent hair loss in the affected areas of the body. In some cases, the changes are limited to small patches of skin. For serious cases, widespread baldness and scarring may result.
Apart from the cosmetic concerns related to scarring and baldness, FD may lead to potentially severe health problems.
One of the most serious is squamous cell carcinoma. However, a 2021 study in JAAD Case Reports states that only three cases have been previously reported as a result of FD. Still, because the medical community is still learning about this rare form of scarring hair loss, it’s critical to work closely with your dermatologist to monitor any skin changes.
The emotional and psychological impacts of FD should not be ignored, either. The condition can affect self-esteem. You may find comfort in seeing a therapist, who can give you tools to manage your thoughts and emotions and help you reframe negative thinking associated with FD.