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Presentation

Diagnosis and Treatment of Dissecting Cellulitis and Folliculitis Decalvans

Description

The speaker reviewed dissecting cellulitis and folliculitis decalvans, two scarring alopecias affecting mainly young men, though folliculitis decalvans is increasingly seen in women. Dissecting cellulitis often begins as non-scarring alopecia, so early recognition with trichoscopy is important; yellow dots with black centers and hairless areas with yellow dots suggest potential regrowth before permanent scarring develops. Because its pathogenesis resembles acne, isotretinoin is emphasized as effective, often at relatively low doses, with recurrence still possible. Other options include doxycycline, acitretin, antibiotics combined with retinoids, and in refractory cases adalimumab or infliximab; IL-17/23 inhibitors and JAK inhibitors have only limited case-report support. The presenter’s preferred approach is low-dose isotretinoin, adding steroids for marked inflammation and using adalimumab as a second-line option. For folliculitis decalvans, trichoscopy showing large hair tufts is a key sign. Recent EADV guidance suggests isotretinoin for mild disease, then dapsone, cyclosporine, TNF inhibitors, or JAK inhibitors if needed; moderate disease is treated with antibiotics, and severe disease with antibiotics plus glucocorticoids. Rifampicin alone or with clindamycin is the main antibiotic strategy, usually limited to 10–16 weeks and not repeated indefinitely. Adalimumab may work better at higher dosing (loading 160 mg, then 80 mg every two weeks) and may require several months for response. The speaker also prefers topical creams or ointments over alcohol-based solutions because patients often find them irritating.

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Conclusions

Dissecting cellulitis appears to progress from a potentially reversible early phase to a permanent scarring phase, so early recognition and treatment are critical.
Trichoscopy is useful for identifying early dissecting cellulitis, especially when yellow 3D dots with black centers are present.
Isotretinoin is one of the most effective treatments for dissecting cellulitis and can work well even at relatively low doses.
Mild dissecting cellulitis may respond to topical clindamycin or intralesional steroids, but these options appear less effective than systemic retinoids.
Doxycycline can improve dissecting cellulitis, but remission is often incomplete and relapse is more common than with isotretinoin.
Biologics such as adalimumab and infliximab are effective options for refractory dissecting cellulitis, while IL-17, IL-23, and JAK inhibitors remain supported mainly by case reports.
For folliculitis decalvans, trichoscopic hair tufts are a strong diagnostic clue and can help distinguish the disease from other tufting disorders.
Folliculitis decalvans is treated in a stepwise way, with isotretinoin for mild disease, antibiotics for moderate disease, and antibiotics plus glucocorticoids for severe disease.
Rifampicin, alone or combined with clindamycin, is a key antibiotic regimen for folliculitis decalvans, but courses should be limited in duration and repeated failures should prompt a switch in strategy.
Adalimumab can be effective for folliculitis decalvans, but meaningful response may require a higher dosing regimen and several months of treatment.
Patients with folliculitis decalvans may tolerate creams or ointments better than alcohol-based topical solutions, suggesting skin barrier sensitivity may contribute to irritation.

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