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Year : 2020  |  Volume : 12  |  Issue : 4  |  Page : 193-194  

Folliculitis decalvans in the era of antibiotic resistance: Microbiology and antibiotic sensitivities in a tertiary hair clinic

1 The Dermatology Centre, Salford Royal NHS Foundation Trust, Salford, UK
2 Department of Microbiology, Salford Royal NHS Foundation Trust, Salford, UK
3 The Dermatology Centre, Salford Royal NHS Foundation Trust, Salford; Centre for Dermatology Research, University of Manchester, MAHSC and NIHR Manchester Biomedical Research Centre, Manchester, UK

Date of Submission19-Jun-2020
Date of Acceptance20-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Leila Asfour
The Dermatology Centre, Salford Royal NHS Foundation Trust, Salford
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijt.ijt_98_20

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How to cite this article:
Asfour L, Trautt E, Harries MJ. Folliculitis decalvans in the era of antibiotic resistance: Microbiology and antibiotic sensitivities in a tertiary hair clinic. Int J Trichol 2020;12:193-4

How to cite this URL:
Asfour L, Trautt E, Harries MJ. Folliculitis decalvans in the era of antibiotic resistance: Microbiology and antibiotic sensitivities in a tertiary hair clinic. Int J Trichol [serial online] 2020 [cited 2022 Dec 6];12:193-4. Available from: https://www.ijtrichology.com/text.asp?2020/12/4/193/295413

Dear Editor,

Folliculitis decalvans (FD) is a rare scalp disorder characterized by cicatricial alopecia, hair-tufting, and pustule formation.[1] Staphylococcus aureus appears to be crucial in FD pathogenesis and may result from an abnormal host response to the bacterium.[1] Targeting S. aureus with prolonged/multiple antibiotics is the mainstay of therapy.[1] The World Health Organization's Global Antimicrobial Surveillance System recently highlighted the increasing antimicrobial resistance, with S.aureus being one of the most commonly reported resistant bacteria.[2]

We identified the levels of S.aureus resistance among FD patients by reviewing microbiological samples and antimicrobial sensitivities. We retrospectively reviewed all FD patients seen in a tertiary hair clinic from 2011 to 2017. For comparison, we reviewed all S.aureus-positive dermatology skin swabs analyzed in 2018, focusing on adult eczema patients. They also frequently receive prolonged/recurrent antibiotic courses. UK community antimicrobial resistance values were also explored.

A total of 43 FD patients were identified (males, n = 35). Their mean age was 42 years and the average disease duration was 8 years. The mean Dermatology Life Quality Index was 19, reflecting the immense impact on patients' lives. All patients had received one or more courses of antibiotics prior to referral.

The most common antibiotics used were lymecycline, rifampicin, and clindamycin in combination. Skin swabs were performed in all new cases; 22 patients (52%) were positive for S.aureus. Of these, seven (32%) had S.aureus-resistant to one (18%) or >1 antibiotic class (14%). Sensitivities varied, with resistance seen to macrolides (23%), tetracyclines (14%), flucloxacillin (5%), and rifampicin (5%). No resistance was found to trimethoprim. Resistance rates for S.aureus were significantly higher than the community reference values.[3]

In total, 285 dermatology patients with positive swabs for S.aureus were identified, with 71 (28%) having atopic eczema. Eczema samples showed the following S.aureus resistance rates: erythromycin (27%), fusidic acid (45%), clindamycin (18%), tetracyclines (11%), flucloxacillin (5%), rifampicin (1%), and trimethoprim/sulfamethoxazole (1%). Eighteen eczema patients (25%) had multidrug-resistant S.aureus, most commonly to fusidic acid and macrolides.

Scalp pustules in FD are associated with a poorer prognosis. Hair follicle (HF) bacterial biofilms,[4] presence of S.aureu s in nonlesional and subepidermal skin associated with a persistently abnormal microbiota, and clinical improvement following clearance of S.aureus all support its role in FD pathogenesis and may explain the incomplete bacterial eradication and disease recrudesce when suppressive therapies cease.[4]

We show significantly higher resistance rates to macrolides and tetracyclines in our FD cohort compared to those of community epidemiological baseline[2] and comparable levels of macrolide resistance to those seen in hospital eczema samples (which reflect the most severe/treatment-resistant patients).

These data highlight the urgent need for novel treatments to reduce antibiotic exposure. Surprisingly, bacterial resistance in FD is barely mentioned in the literature.[5] Antibiotic therapy will likely remain the gold standard for exacerbations. However, treatments should be based on bacterial culture/sensitivities, with the aim to transition to nonantibiotic medical therapies (e.g., isotretinoin/dapsone/photodynamic therapy) or destructive therapies (e.g., laser hair removal/surgery) to suppress inflammation and address hair follicle structural abnormalities and biofilm formation to induce long-term remission.[4] The challenge now is to optimize evidence-based treatments that are acceptable for our patients.


MJH is supported by the NIHR Manchester Biomedical Research Centre (BRC).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Meah N, Harries MJ. Folliculitis decalvans- management strategy. In: Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I, editors. The Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 5th ed., Ch. 86. London: Elsevier; 2017. p. 286.  Back to cited text no. 1
High Levels of Antibiotic Resistance Found Worldwide, New Data Shows WHO News Release; January, 2018.  Back to cited text no. 2
A Report from Public Health Wales Antimicrobial Resistance Programme Surveillance Unit: Antibacterial Resistance in Wales 2007-2016; 13 December, 2017.  Back to cited text no. 3
Matard B, Meylheuc T, Briandet R, Casin I, Assouly P, Cavelier-balloy B, 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;27:853-60.  Back to cited text no. 4
Matard B, Donay JL, Resche-Rigon M, Tristan A, Farhi D, Rousseau C, et al. Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota. Exp Dermatol 2020;29:295-8.  Back to cited text no. 5

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