Folliculitis decalvans (FD) is a rare and chronic inflammatory dermatosis which pathogenesis
remains unclear. It is classified as primary neutrophilic cicatricial alopecia presented
clinically with follicular pustules and papules, hemorrhagic crusts, erosions and
scarring within scalp. Orofacial granulomatosis (OFG) is a recurrent or persistent
orofacial swelling histopathologically presented with non-caseating granulomas. The
etiology of the disease is not fully understood. There are hypotheses concerning pathogenesis
of the disease including genetic, allergic, infectious and immunological factors.
We report a case of a patient with FD and concomitant orofacial granulomatosis successfully
treated with dapsone.
A 32-year-old man was admitted to the Department of Dermatology to diagnose follicular
pustules, erosions, yellow scales, crusts with scarred areas and focal hair loss within
the scalp, especially within vertex and accompanying persistent lip swelling with
normal appearance of the tongue and no oral lesions (Figure 1). Moreover, we observed
erythrosquamous lesions and papules on the lateral surfaces of the trunk, within groins
and armpits. The lesions on the scalp occurred in childhood and the lip swelling persisted
for 3 years. Except skin eruptions the patient did not report any other complaints.
He was initially treated in another clinic for seborrheic dermatitis and acne inversa
topically with antibiotics, glucocorticosteroids, tacrolimus and orally with antibiotics
(doxycycline), antihistamines with temporary improvement. The patient suffered from
post-traumatic epilepsy and was treated with carbamazepine. He had a craniotomy due
to head injury (concussions and subdural hematoma of the left temporo-parietal brain
region, basilar skull fracture and squamous part of the right temporal bone fracture)
during the traffic accident 20 years earlier. During the hospitalization routine laboratory
tests showed an elevated C-reactive protein level and erythrocyturia which occurred
to be irrelevant (the patient was consulted by the urologist). Swabs from erosions
and pustules were collected and two types of bacteria were cultured – Staphylococcus
aureus and Streptococcus agalactiae. To exclude concomitant systemic diseases, we
performed additional examinations. There were no abnormalities in abdominal ultrasonography
or chest X-ray. Antinuclear antibodies, lupus anticoagulant, cardiolipin antibodies
(IgG and IgM), β2-glycoprotein 1 antibodies (IgG and IgM), anti-Borrelia spp. antibodies
tests (IgG and IgM), concentration of C1 esterase inhibitor and Quantiferon-TB Gold
test in patient’s serum were negative or within normal values. Patch tests with 30
allergens were negative in every disc in 48 and 72 h tests. The patient was consulted
neurologically to exclude paralysis of the facial nerve, which is one of the symptoms
of Melkersson-Rosenthal syndrome. The neurological examination revealed slight features
of the central nervous system failure which most likely occurred due to the head injury,
there were no signs of facial palsy. Histopathology of the scalp skin lesion revealed
absence of hair follicles, epidermal pustules, dermis infiltrations of lymphocytes,
plasmocytes and neutrophils, stains for fungi infection were negative (Figure 2 A).
Histopathology of the lip showed non-caseating granulomatous inflammation (Figure
2 B). Indirect and direct immunofluorescence were negative. Based on the patient history,
physical examination, histopathology and laboratory analysis we identified FD and
orofacial granulomatosis. Treatment with dapsone of 100 mg/day combined with topical
corticosteroids (betamethasone, clobetasol) and antibiotics (gentamicin, detreomicin)
was started and led to significant improvement.
Figure 1
A, B – Lesions within scalp, C – persistent lip swelling, D–F – improvement of skin
lesions in the course of treatment with dapsone
Figure 2
H + E staining. A – Histopathological image of the scalp lesion with epidermal pustules,
dermis infiltrations of lymphocytes, plasmocytes and neutrophils, absence of hair
follicles, B – histopathological image of the lip showing noncaseating granulomas
Folliculitis decalvans mostly occurs in young and middle-aged adults with a slight
predilection to men [1]. Its pathogenesis is not clear. Familial cases of the disease
were reported [2, 3]. Moreover it seems that the disease is a hypersensitivity reaction
to Staphylococcus aureus follicle infection as in majority of patients the bacteria
are isolated from lesions as it was in our case [3, 4]. There are single reported
cases where the lesions occurred after scalp injuries what may be relevant as our
patient had a head injury and craniotomy in the childhood [5, 6]. In majority of cases,
FD is clinically presented with pustules, tufted hairs, alopecic patches, erosions
and crusts especially within the vertex, what is consistent with our case [1, 3].
Histopathological examination of early lesions reveal papular lesions, perifollicular
infiltration mainly consisted of neutrophils lymphocytes and plasma cells and early
scarring, in long lasting lesions the infiltration extend deeper into the dermis [1,
3]. The treatment of FD is a challenge because there is no single therapy which leads
to long-term remission. In reported cases various therapies were conducted for example
systemic antibiotics (especially rifampicin with clindamycin, doxycycline) [3, 7],
isotretinoin [8], dapsone [9], frequently in combination with topical corticosteroids
and antibiotics. What is important, regular monitoring of the patient is necessary
as there are reports on squamous cell carcinoma arising within FD [10]. The term of
orofacial granulomatosis was introduced in 1985 by Wiesenfeld et al. to describe idiopathic
orofacial edema with granulomatous inflammation in the absence of systemic diseases,
what is consistent with our case [11]. Orofacial granulomatosis encompasses other
known granulomatous diseases such as Melkersson-Rosenthal syndrome which consists
of three symptoms: persistent orofacial edema, recurrent facial paralysis and fissured
tongue and Miescher’s cheilitis, which refers to a condition when lip swelling is
an isolated symptom or granulomatous cheilitis [12, 13]. Oral granulomas may occur
in systemic conditions such as Crohn’s disease, sarcoidosis or tuberculosis so they
must be excluded during diagnostic procedures [12]. The etiology of the disease is
not fully understood. There are hypotheses concerning pathogenesis of the disease
including genetic, allergic (food allergy, allergy to dental materials), infectious
(especially tuberculosis) and immunological factors [12]. In our patient we observed
erythrosquamous lesions and papules on the lateral surfaces of the trunk, within groins
and armpits, what suggested concomitant contact dermatitis although patch tests were
negative, further allergy diagnostics would be required. Because etiology of the disease
is not clear, the treatment is difficult. When allergy is detected, avoidance of allergens
may lead to improvement. In most cases, oral and intralesional corticosteroids were
used, moreover there are some reports of topical tacrolimus, clofazimine, thalidomide,
dapsone, and infliximab treatment [12–15]. In our case, diagnosis and treatment of
two coexisting diseases which etiologies are not fully understood and require multidirectional
diagnostic procedures with no single therapies providing satisfying effects was a
great challenge. Fortunately, treatment with dapsone combined with topical ointments
led to significant improvement.