A 35-year-old man presented with about two decades history for pruritic pustular eruptions on his scalp that produced a disfiguring alopecia. The conditions failed to respond to a variety of medications including different antibiotics and both topical and systemic steroids. What is your diagnosis? and what do you recommend in managing this patient?

Diagnosis: Folliculitis Decalvans (FD)

FD probably is a heterogenous group of disease in which chronic folliculitis leads to progressive scarring alopecia. The exact cause of FD is still unclear and is proposed to be due to a local failure in the immune response. Based on this possiblity, all patients should be investigated for underlying immune deficiency, although in my experience almost always this investigation is normal!

Perifolliculitis capitis is a similar condition that should be differentiated from FD. To compare please see the quiz of september 2004. 

In treating FD, systemic antibiotics, dapsone and retinoids reported to be effective.

Here are some of the experts' recommendations:

Farzaneh Farahani, MD: treatment: if no response to any antibiotics so Ro_accutane is choice

Sana Mostafa, MD: dx:folliculitis decalvans,treatment is isotretinoin if does not respond to rifampicin

M.T. Noorbala, MD : recent case is a good sample of decalvans folliculitis. systemic antibiotic with or whitout rifampin ,systemic and/or topical steroied, and systemic retinoids may also be helpful.