Chronic folliculitis of the scalp: New classification of one spectrum related variants
DOI:
https://doi.org/10.66344/jpad.v32i2.1871Abstract
Background
Chronic scalp folliculitis is a chronic inflammatory process of hair follicles that results from a change in the microbiome of hair follicles rather than actual pathogenic microbial infection.
Objective
To gather all cases that present with chronic folliculitis of the scalp and the associated related diseases like acne vulgaris and hidradenitis suppurativa and classify them.
Patients and methods
This is case series descriptive study that was carried out during the period from 2014-2021 where all patients with chronic scalp folliculitis were collected and analyzed. Full history and examination were done including the types of folliculitis whether superficial or deep, widespread or localized, scarring or none scarring and moth eaten pattern hair alopecia or not. In addition to record and evaluate the associated skin disease like acne vulgaris and hidradenitis suppurativa (HS).
Results
Analysis of eighty-seven patients with chronic scalp folliculitis showed that 85(97.7%) males and 2(2.29%) females, their ages ranged from 18-36 years. The duration of the disease ranged from 0.6-4 years. Three types of scalp folliculitis were recognized: The first one ,superficial folliculitis in 23(26.43%) patients, with 22(95.65%) males and one(4.34%) female while 16(69.56%) cases had also associated acne vulgaris with varying severity including two patients with HS.The second type, deep superficial folliculitis so called folliculitis decalvans were noticed in 28( 32.18% ) patients, with 27(96.42%) males and one (3.57%) female. These patients had usually single patches in 22(78.57%) cases while multiple in 4(14.28%) cases and 2(7.14%) cases presented with diffuse moth eaten alopecia. Concomitant facial acne vulgaris was seen in 2 (7.14%),truncal folliculitis in 2 (7.14%) and HS in 2(7.14%)cases.
The third type so called deep cystic folliculitis(dissecting cellulitis) accounting for 36(41.37%) patients that presented with deep cystic masses in variable severity, and all cases were males. It was associated with 10 (27.77%) cases of HS involving axillae, buttocks and groins and 26 (72.22%) cases with cystic acne vulgaris of face and trunk.
Conclusion
Chronic scalp folliculitis is a common skin problem consisting of three variants and was commonly associated with acne vulgaris and hidradenitis suppurativa. These variants share the same etiopathogenesis and the clinical pictures hence they are parts of one spectrum. Alopecia usually a moth eaten pattern was seen in all these 3 types of scalp folliculitis but was permanent in folliculitis decalvans and non-scarring in superficial type and deep cystic folliculitis.
References
1. Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and management. Am J Clin Dermatol. 2004;5(5):301-10.
2. Bosch TCG, McFall-Ngai MJ. Metaorganisms as the new frontier. Zoology. 2011;114:185–90.
3. Rosenberg E, Koren O, Reshef L, et al. The role of microorganisms in coral health, disease and evolution. Nat Rev Microbiol. 2007;5:355-62.
4. Borbet TC, Zhang X, Müller A, Blaser MJ. The role of the changing human microbiome in the asthma pandemic. J Allergy Clin Immunol. 2019;144:1457-66.
5. Thomas RM, Jobin C. Microbiota in pancreatic health and disease: the next frontier in microbiome research. Nat Rev Gastroenterol Hepatol. 2020;17:53-64.
6. Chiller K, Selkin BA, Murakawa GJ. Skin microflora and bacterial infections of the skin. J Investig Dermatol Symp Proc. 2001;6(3):170-4.
7. Wagner DK, Sohnle PG. Cutaneous defenses against dermatophytes and yeasts. Clin Microbiol Rev. 1995;8:317-35.
8. Porter CD, Archard LC. Characterization by restriction mapping of three subtypes of molluscum contangiosum virus. J Med Virol. 1992;38:1-6.
9. Alexander H, Paller AS, Traidl-Hoffmann C, et al. The role of bacterial skin infections in atopic dermatitis: expert statement and review from the international eczema council skin infection group. Br J Dermatol. 2019;182:1331-42.
10. Burns EM, Ahmed H, Isedeh PN, et al. Ultraviolet radiation, both UVA and UVB, influences the composition of the skin microbiome. Exp Dermatol. 2019;28:136-41.
11. Szabó K, Erdei L, Bolla BS, et al. Factors shaping the composition of the cutaneous microbiota. Br J Dermatol. 2017;176:344-51.
12. Wikramanayake TC, Borda LJ, Miteva M, Paus R. Seborrheic dermatitis-looking beyond Malassezia. Exp Dermatol. 2019;28:991-1001.
13. Zaidi AK, Spaunhurst K, Sprockett D, et al. Characterization of the facial microbiome in twins discordant for rosacea. Exp Dermatol. 2018;27:295-8.
14. Romero-Maté A, Arias-Palomo D, Hernández-Núñez A, et al. Chronic nonscarring scalp folliculitis: Retrospective case series study of 34 cases. J Am Acad Dermatol. 2019;81:1023-4.
15. Matard B, Donay JL, Resche-Rigon M, et al. Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota. Exp Dermatol. 2020;29:295-8.
16. Kurzen H, Kurokawa I, Jemec GBE, et al. What causes hidradenitis suppurativa? Exp Dermatol. 2008;17:455-72.
17. Guet-Revillet H, Jais J-P, Ungeheuer M-N, et al. The Microbiological Landscape of Anaerobic Infections in Hidradenitis Suppurativa: A Prospective Metagenomic Study. Clin Infect Dis. 2017;65:282-91.
18. Langan EA, Recke A, Bokor-Billmann T, et al. The Role of the Cutaneous Microbiome in Hidradenitis Suppurativa-Light at the End of the Microbiological Tunnel. Int J Mol Sci. 2020;21:1205-19.
19. Jafari SMS, Hunger RE, Schlapbach C. Hidradenitis suppurativa: current understanding of pathogenic mechanisms and suggestion for treatment algorithm. Front Med. 2020;7:68.
20. Polak-Witka K, Rudnicka L, Blume-Peytavi U, Vogt A. The role of the microbiome in scalp hair follicle biology and disease. Exp Dermatol. 2019;29:286-94.
21. Ramasamy S, Barnard E, Dawson TL, Li H. The role of the skin microbiota in acne pathophysiology. Br J Dermatol. 2019;181:691-9.
22. Yu Y, Dunaway S, Champer J, et al. Changing our microbiome: probiotics in dermatology. Br J Dermatol. 2020;182:39-46.
23. O’Neill AM, Gallo RL. Host-microbiome interactions and recent progress into understanding the biology of acne vulgaris. Microbiome. 2018;6:177.
24. Li C-X, You Z-X, Lin Y-X, et al. Skin microbiome differences relate to the grade of acne vulgaris. J Dermatol. 2019;46:787-90.
25. Karoglan A, Paetzold B, Pereira de Lima J, et al. Safety and efficacy of topically applied selected cutibacterium acnes strains over five weeks in patients with acne vulgaris: An open-label, pilot study. Acta Derm Venereol. 2019;99:1253-7.
26. Bay L, Barnes CJ, Fritz BG, et al. Universal dermal microbiome in human skin. mBio. 2020;11:e02945-19.
27. Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol. 2011;9:244-53.
28. Byrd AL, Belkaid Y, Segre JA. The human skin microbiome. Nat Rev Microbiol. 2018;16:143-55.
29. Hall JB, Cong Z, Imamura-Kawasawa Y, et al. Isolation and Identification of the Follicular Microbiome: Implications for Acne Research. J Invest Dermatol. 2018;138:2033-40.
30. Ring HC, Thorsen J, Saunte DM, et al. The follicular skin microbiome in patients with hidradenitis suppurativa and healthy controls. JAMA Dermatology. 2017;153: 897-905.
31. Scholz CFP, Kilian M. The natural history of cutaneous propionibacteria, and reclassification of selected species within the genus propionibacterium to the proposed novel genera acidipropionibacterium gen. nov., cutibacterium gen. nov. and pseudopropionibacterium gen. nov. Int J Syst Evol Microbiol. 2016;66:4422-32.
32. Jahns AC, Alexeyev OA. Three dimensional distribution of Propionibacterium acnes biofilms in human skin. Exp Dermatol. 2014;23:687-9.
33. Otberg N, Kang H, Alzolibani AA, Shapiro J. Folliculitis decalvans. Dermatol Ther. 2008;21:238-244.
34. Harries MJ, Trueb RM, Tosti A, et al. How not to get scar(r)ed: pointers to the correct diagnosis in patients with suspected primary cicatricial alopecia. Br J Dermatol. 2009;160:482-501.
35. Navarini AA, Trüeb RM. 3 Cases of dissecting cellulitis of the scalp treated with adalimumab: control of inflammation within residual structural disease. Arch Dermatol. 2010;146(5):517-520.
36. Melnik BC. Acne vulgaris: The metabolic syndrome of the pilosebaceous follicle. Clin Dermatol. 2018;36:29-40.
37. Clayton RW, Göbel K, Niessen CM, et al. Homeostasis of the sebaceous gland and mechanisms of acne pathogenesis. Br J Dermatol. 2019;181:677-90.
38. Petridis C, Navarini AA, Dand N, et al. Genome-wide meta-analysis implicates mediators of hair follicle development and morphogenesis in risk for severe acne. Nat Commun. 2018;9:5075.
39. Sharquie KE, Noaimi AA, Mijthab ZM. Chronic scalp folliculitis versus acne vulgaris (observational case series study). J Clin Exp Dermatol Res. 2012;3:153.
40. Lee AH. Staphylococcus aureus and chronic folliculocentric pustuloses of the scalp - cause or association? Br J Dermatol. 2016;175(2):410-3.
41. Sillani C, Bin Z, Ying Z, Zeming C, Jian Y, Xingqi Z. Effective treatment of folliculitis decalvans using selected antimicrobial agents. Int J Trichology. 2010;2:20-3.
42. Vañó-Galván S, Molina-Ruiz AM, Fernández-Crehuet P, et al. Folliculitis decalvans: a multicentre review of 82 patients. J Eur Acad Dermatol Venereol. 2015;29(9):1750-7.
43. Miguel-Gómez L, Rodrigues-Barata AR, Molina-Ruiz A, et al. Folliculitis decalvans: Effectiveness of therapies and prognostic factors in a multicenter series of 60 patients with long-term follow-up. J Am Acad Dermatol. 2018;79(5):878-83.
44. Bunagan MJ, Banka N, Shapiro J. Retrospective review of folliculitis decalvans in 23 patients with course and treatment analysis of long-standing cases. J Cutan Med Surg. 2014;18:1-5.
45. Tan E, Martinka M, Ball N, Shapiro J. Primary cicatricial alopecias: clinicopathology of 112 cases. J Am Acad Dermatol. 2004;50:25-32.
46. Sharquie KE. Noaimi AA, Hameed AF. Lichen planopilaris is a common alopecia among Iraqi population. J Cosmet Dermatol Sci App. 2013;5:35-9.
47. Matard B, Meylheuc T, Briandet R, et al. First evidence of bacterial biofilms in the anaerobe part of scalp hair follicles: a pilot comparative study in folliculitis decalvans. J Eur Acad Dermatol Venereol. 2013;27(7):853-60.
48. Jahns AC, Lundskog B, Nosek D, et al. Microbiology of folliculitis decalvans: a histological study of 37 patients. J Eur Acad Dermatol Venereol. 2015;29(5):1025-6.
49. Costerton W, Veeh R, Shirtliff M, et al. The application of biofilm science to the study and control of chronic bacterial infections. J Clin Invest. 2003;112(10):1466-77.
50. Badaoui A, Reygagne P, Cavelier-Balloy B, et al. Dissecting cellulitis of the scalp: a retrospective study of 51 patients and review of literature. Br J Dermatol. 2016;174(2):421-3.
51. Lee CN, Chen W, Hsu CK, Weng TT, Lee JY, Yang CC. Dissecting folliculitis (dissecting cellulitis) of the scalp: a 66-patient case series and proposal of classification. J Dtsch Dermatol Ges. 2018;16:1219-26.
52. Segurado-Miravalles G, Camacho-Martinez FM, Arias-Santiago S, et al. Epidemiology, clinical presentation and therapeutic approach in a multicentre series of dissecting cellulitis of the scalp. J Eur Acad Dermatol Venereol. 2017;31:e199-e200.
53. Kurokawa I, Hayashi N; Japan Acne Research Society. Questionnaire surveillance of hidradenitis suppurativa in Japan. J Dermatol. 2015;42(7):747-9.
54. Karagiannidis I, Nikolakis G, Zouboulis CC. Endocrinologic aspects of hidradenitis suppurativa. Dermatol Clin. 2016;34:45-9.
55. Wellen KE, Hotamisligil GS. Obesity-induced inflammatory changes in adipose tissue. J Clin Invest. 2003;112:1785-8.
56. Federico A, Rossi A, Caro G, et al. Are dissecting cellulitis and hidradenitis suppurativa different diseases? Clin Dermatol. 2021;39(3):496-9.
57. Kong HH, Segre JA. Skin microbiome: looking back to move forward. J Invest Dermatol. 2012;132:933-9.
58. Alexeyev OA, Jahns AC. Sampling and detection of skin Propionibacterium acnes: Current status. Anaerobe. 2012;18:479-83.
59. Rosenberg E, Koren O, Reshef L, et al. The role of microorganisms in coral health, disease and evolution. Nat Rev Microbiol. 2007;5:355-62.
60. Behrouzi A, Nafari AH, Siadat SD. The significance of microbiome in personalized medicine. Clin Transl Med. 2019;8:16.
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