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doi:
10.25259/IJDVL_694_20
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Folliculitis decalvans with exclusive beard involvement

Department of Health Sciences, Section of Dermatology, University of Florence, Italy
Department of Health Sciences, Section of Pathological Anatomy, University of Florence, Florence, Italy
Corresponding author: Dr. Stefano Senatore, Viale Michelangiolo 41, Florence, Italy. stef.senatore@gmail.com
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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Senatore S, Maglie R, Maio V, Montefusco F, Antiga E. Folliculitis decalvans with exclusive beard involvement. Indian J Dermatol Venereol Leprol, doi: 10.25259/IJDVL_694_20

Sir,

Folliculitis decalvans is an inflammatory chronic disease of the hair which evolves irreversibly in atrophy and scarring alopecia. It represents approximately 11% of all the cases of primary scarring alopecia and usually occurs in young- and middle-aged adults.1 Clinically, it presents with pustules, erosions and scaly-crusty lesions localized on the scalp. Anecdotally, folliculitis decalvans can affect other hairy body areas. Herein, we reported a case of folliculitis decalvans with exclusive involvement of the beard.

A 45-year-old man was referred for erythematosus-pustular lesions appeared bilaterally on the cheeks, in the beard area. The lesions occurred six months before and were associated with scarring alopecia [Figures 1a and b]. The patient did not show similar lesions in other body regions. The trichoscopy of the beard area showed tufted hair, perifollicular scales and some follicular pustules.

Figure 1a:: Folliculitis decalvans of the beard before treatment: central scarring alopecia area surrounded by scaly-crusty lesions and pustules of the right cheek
Figure 1b:: Folliculitis decalvans of the beard: detail of the left cheek

Given a clinical suspicion of dermatophytosis, he was prescribed three months before our observation with an empirical treatment with terbinafine 250 mg per day, itraconazole 50 mg per day and topical antiseptics with no response. To exclude a fungal etiology, we performed a direct and cultural mycological examination that gave negative result.

Moreover, a skin biopsy for histopathological investigation was made which showed exudative-necrotic and angiogenic inflammation together with epidermal erosion, folliculitis and perifolliculitis, as well as an intraepidermal pustule. The infiltration was mainly composed by neutrophil and eosinophil granulocytes and plasma cells [Figures 2a and b]. Histochemical periodic acid-Schiff (PAS) staining was negative for fungal infection.

Figure 2a:: Follicular and perifollicular infiltration surrounding a hair follicle (H and E, ×100)
Figure 2b:: Detail of perifollicular infiltration showing the presence of plasma cells, neutrophil and eosinophil granulocytes (H and E, ×400)

Based on the clinical features and histologic findings, a diagnosis of folliculitis decalvans of the beard was made and oral doxycycline 200 mg daily was started, in association with topical antiseptic treatment. After six weeks, no signs of inflammatory lesions nor extension of scarring were observed and the patient remained disease free in the following four months of follow-up.

Folliculitis decalvans is a form of scarring alopecia primarily involving the scalp. Histologic features show an acute suppurative folliculitis with a dense perifollicular lymphocytic and neutrophilic infiltrate which leads to abscesses formation and fibrotic replacement. The etiology is not fully understood, but S. aureus, and a genetic predisposition, seem to play a pivotal pathogenic role.2

In literature, cases of folliculitis decalvans involving unusual sites such as groin, axillae and beard were anedoctically reported; in particular, only two cases of folliculitis decalvans of the beard have been reported, both in association with scalp involvement.2-4 Cases of folliculitis decalvans with exclusive involvement of the beard have not been reported yet. The differential diagnosis of cases with isolated beard involvement, as the one described herein, includes pseudofolliculitis barbae, sycosis barbae, dermatitis cruris pustulosa et atrophicans, eosinophilic folliculitis and fungal infection, among others [Table 1].2,5 Histopathologic examination is mandatory to achieve a clear-cut diagnosis, thus avoiding empirical and ineffective treatments.6

Table 1:: Differential diagnosis of pustulosis of the beard
Diseases Morphology of the lesions Sites of involvement Histopathological features
Folliculitis decalvans Follicular pustules surrounding oval patches Scalp; rarely beard, axillae, pubis, thighs Follicular neutrophilic abscesses; granulomatous folliculitis with lymphocytes, plasma cells and giant cells
Tinea barbae Papules, follicular pustules with exudation and crusts Beard Parakeratosis, spongiosis, perivascular neutrophilic and eosinophilic infiltration
Sycosis barbae Follicular papules or pustules centered on hair, raised plaques, crusts and scales Beard, scalp; rarely axillae, pubis and limbs Neutrophilic infiltration of follicle wall, chronic granulomatous perifollicular infiltration by lymphocytes, plasma cells, histiocytes and foreign body giant cells
Pseudofolliculitis barbae Papules, pustules, post-inflammatory hyperpigmentation Beard; rarely other areas with terminal hairs Neutrophilic perifollicular infiltration, epidermal microabscesses; infiltration of lymphocytes, plasma cells, histiocytes and foreign body giant cells
Eosinophilic folliculitis Follicular pustules and erythematous plaques with centrifugal extension Face, trunk, limbs Inflammatory dermal and follicular infiltration composed of eosinophils, neutrophils and mononuclear cells
Dermatitis cruris pustulosa et atrophicans Follicular pustules, scales, shiny edema, follicular atrophy Usually lower third of legs; rarely thighs, forearms, face Parakeratosis, neutrophilic infiltration of hair follicle ostium, subcorneal pustule containing neutrophils and lymphocytes

To conclude, folliculitis decalvans of the beard is a very rare entity, but more likely underdiagnosed. Awareness of this variant of the disease is important to provide an early diagnosis and an effective treatment, preventing disfiguring sequelae in a very sensitive area like the face.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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