Refractory Folliculitis Decalvans Treatment Success with a Novel Surgical Excision Approach Using Guarded High-Tension Sutures

Abstract

Purpose: Folliculitis decalvans (FD) is a difficult-to-treat, localized scarring alopecia characterized by an expanding area of chronically inflamed purulent plaques or masses. Current treatment modalities vary and often result in only temporary remission. There are no reports of surgical therapies for FD. Here, we describe FD treatment using surgical excision and second-intention healing aided by guarded high-tension sutures. Methods: Five patients (one woman and four men) with histologically confirmed FD were treated by surgical lesion excision. All wounds were allowed to heal via second-intention. Guarded high-tension sutures were employed to minimize tissue tears while aiding and guiding wound contraction. Results: All wounds healed with a 47–83% spatial contraction of the maximum wound diameters. Three patients healed entirely by second-intention, while two required a minor skin graft to close the wound completely. No disease recurrence was noted at 10–24 months. Conclusion: Surgical excision with second-intention healing aided by guarded high-tension sutures effectively treated small and extensive FD lesions with no recurrence at long-term follow-up. To our knowledge, this is the first report of successful surgical treatment of FD. Plain Language Summary: Current treatment modalities of folliculitis decalvans, including steroids, antibiotics, and isotretinoin, are suboptimal, typically resulting in recurrence following the withdrawal of treatments. In this case series, we report a first account of treatment success of refractory folliculitis decalvans using surgical excision with second intention healing aided by guarded hightension suturing. The outpatient procedure resulted in long-term remission at 10–24 months follow-up.