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Anais Brasileiros de Dermatologia

On-line version ISSN 1806-4841

An. Bras. Dermatol. vol.88 no.5 Rio de Janeiro Sept./Oct. 2013 


Folliculitis decalvans: the use of dermatoscopy as an auxiliary tool in clinical diagnosis*

Foliculite decalvante: o uso da dermatoscopia como ferramenta auxiliar no diagnóstico clínico

Mariana Rocha  Fabris1 

Clarisse Pereira  Melo2  4 

Daniel Fernandes  Melo3  5 

1Medical Doctor. Dermatology Resident, Marcílio Dias Naval Hospital, Rio de Janeiro (RJ), Brazil.

2Residency in Clinical Medicine at the Federal Hospital of Andaraí. Routine clinical medicine at Rios D'or Hospital, Rio de Janeiro (RJ), Brazil.

4Routine clinical medicine, Rios D'or Hospital, Rio de Janeiro, (RJ), Brazil

3Professor in the Department of Alopecia and General Dermatology of the Marcílio Dias Naval Hospital, Rio de Janeiro (RJ), Brazil; Dermatologist and Staff Member of the Dermatology Residency Program of the Marcílio Dias Naval Hospital, Rio de Janeiro (RJ), Brazil

5Dermatology Residency Program, Marcílio Dias Naval Hospital, Rio de Janeiro, RJ, Brazil


Folliculitis decalvans is an inflammatory presentation of cicatrizing alopecia characterized by inflammatory perifollicular papules and pustules. It generally occurs in adult males, predominantly involving the vertex and occipital areas of the scalp. The use of dermatoscopy in hair and scalp diseases improves diagnostic accuracy. Some trichoscopic findings, such as follicular tufts, perifollicular erythema, crusts and pustules, can be observed in folliculitis decalvans. More research on the pathogenesis and treatment options of this disfiguring disease is required for improving patient management.

Key words: Dermoscopy; Hair diseases; Scalp dermatoses

Key words: Dermatoses do couro cabeludo; Dermoscopia; Doenças do cabelo


A foliculite decalvante é uma forma inflamatória de alopecia cicatricial caracterizada por pápulas e pústulas inflamatórias perifoliculares. Ocorre mais comumente em adultos do sexo masculino,envolvendo predominantemente o vértice e a região occipital do couro cabeludo. O uso da dermatoscopia nas doenças dos cabelos e do couro cabeludo melhora a precisão diagnóstica. Alguns achados tricoscópicos como tufos foliculares, eritema perifolicular, crostas e pústulas podem ser observados na foliculite decalvante.Mais pesquisas sobre patogênese e opções de tratamento desta doença desfigurante são necessárias para uma melhor gestão dos pacientes.


Folliculitis decalvans (FD) is an inflammatory presentation of cicatrizing alopecia characterized by inflammatory perifollicular papules and pustules. It accounts for approximately 11% of all primary cicatrizing alopecia cases. 1 , 2 The disease was first described by Quinquaud in the 19th century. In 1905, Brocq et al named Quinquaud's clinical findings as Folliculitis decalvans. 2 It occurs predominantly in young and middle-aged adults, with a slight preference for the male gender, and appears to be more frequent in people of Afro-American stock. 3 The etiology of this inflammatory process is not fully understood. However, Staphylococcus aureus scalp colonization has been implicated as a contributing factor. It has been suggested that the mechanism of "superantigens" or cytotoxins that bind to class II MHC can play a role in the pathogenesis of the disease. 1 , 2 The theory of genetic predisposition is supported by reports of FD familial cases. 4 The vertex and occipital areas of the scalp are especially involved. There is usually only one focus of the disease, which begins with painful follicular papules and pustules and spreads to the back. A large erythematous, thick and hardened alopecia plaque appears, with a centrifugal progression. The hallmark of FD is the development of scars and areas of follicular pustules. Follicular keratosis, erosions and hemorrhagic crusts can be observed. Some patients occasionally report spontaneous bleeding, pain, itching or a burning sensation. 1 , 2 Tuffed folliculitis is a common finding in FD patients, characterized by multiple hairs emerging from one single dilated follicular orifice (polytrichia) (Figure 1). 5 The patient's detailed clinical history, together with a thorough examination of the entire scalp, are important for diagnosis. 1 , 2 , 4 Pictures of the scalp should be taken at the first clinical visit. A sketch, as well as measurements of the scarred areas, is also a useful aid for monitoring disease progression. Bacterial cultures should be performed from an intact pustule, and a nasal swab with antibiotic sensitivity tests should also be done in order to identify an occult S. aureus strain. 2 Trichoscopy is a non-invasive method that can be used in the differential diagnosis of most diseases affecting the hair and scalp. This method improves diagnostic accuracy and may contribute to a better understanding of the pathogenesis of these disorders. 3 , 5 , 6 , 7 , 8

FIGURE 1 A fibrotic erythematous alopecia plaque with polytrichia (dolly hair) 


The technique for performing dermatoscopy of the scalp consists of using optical devices with variable increase. For the analysis, dermatologists can use a manual dermatoscope (magnification x10) or a videodermatoscope equipped with a range of magnifying lenses (from X20 to X1000). 3 Both the trichoscopic dry exam and the one with interface liquid are important, because they show different dermatoscopic findings (Figure 2). The trichoscopic hallmark of folliculitis decalvans is the presence of multiple hairs emerging from one single dilated follicular orifice (polytrichia). Generally, these tufts vary from 5-20 hair shafts per follicular orifice. Additional trichoscopic findings include perifollicular erythema arranged in a starburst pattern, yellowish tubular scaling, crusting and follicular pustules. In long-lasting lesions, ivorywhite and milky-red areas without follicular orifices predominate in trichoscopic images. Dots are rare, present in fewer than 20% of patients, and there appears to be no characteristic vascular pattern (Figures 1, 3 and 4). 3 , 5 , 7 - 10 Undertaking dermatoscopy does not replace histopathological examination, and performing a skin biopsy of an active lesion is essential for diagnosing FD. Histopathologically, FD has been characterized as a neutrophilic primary cicatricial alopecia. Early lesions show keratin aggregation and a dilatation of the infundibulum, combined with numerous intraluminal neutrophils. Sebaceous glands are destroyed early in the process, and a predominant neutrophilic, intrafollicular and perifollicular infiltrate can be found. In advanced lesions, this infiltrate can consist of neutrophils, lymphocytes and numerous plasma cells extending into the dermis. The infiltrate may also be found around the blood vessels of the superficial and mid-dermis. 1 , 2 The differential diagnosis can be done with acne keloidalis nuchae, erosive pustular dermatosis of the scalp, lichen planopilaris, discoid lupus erythematous, pseudopelade of Brocq, central centrifugal cicatricial alopecia, among others. 1 , 2 , 6 FD can be very therapy resistant. Therapeutic options include oral and topical antibiotics, oral and topical corticosteroids, antiseptics, oral isotretinoin and dapsone. 1 , 2 , 4 More research on the pathogenesis and treatment options of this disfiguring disease is needed for improving patient management.

FIGURE 2 A - Trichoscopic exam without interface liquid showing the crusts and scales. B - Trichoscopic exam with interface liquid showing erythema, fibrosis and vessels 

FIGURE 3 Polytrichia (1), linear fibrotic bands around hair follicles (2) diffuse erythema (3) perifollicular scales (4) 

FIGURE 4 Perifollicular crusts (5, 6), diffuse erythema and Polytrichia 


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9. Wallace MP, de Berker DA. Hair diagnoses and signs: the use of dermatoscopy. Clin Exp Dermatol.2010;35:416. [ Links ]

10. Lacarrubba F, Dall'Oglio F, Rita Nasca M, Micali G. Videodermatoscopy enhances diagnostic capability in some forms of hair loss. Am J Clin Dermatol 2004;5:205-8. [ Links ]

Financial funding: None

* Work performed at the Hospital Naval Marcílio Dias (HNMD), Rio de Janeiro (RJ), Brazil.

Received: September 15, 2012; Accepted: October 24, 2012

MAILING ADDRESS: Mariana Rocha Fabris Rua Cezar Zama, 185 - Lins de Vasconcelos 20725-090 - Rio de Janeiro - RJ Brazil E-mail:

Conflict of interest: None