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). 102 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 资料来自互联网，仅供科研和教学使用，使用者请于24小时内自行删除 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 103 资料来自互联网，仅供科研和教学使用，使用者请于24小时内自行删除 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. 104 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 therapy with methyl aminolevulinate for resistant scalp folliculitis secondary to Demodex infestation. 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