Tufted Hair Folliculitis

Tufted hair folliculitis is an inflammatory scalp disorder in which several hairs (usually 6 to 20) emerge from a single, dilated follicular opening, with pustules, crusting and progressive scarring alopecia.

It occurs mostly in adults, with a peak in young to middle aged adults, and affects the vertex and occiput. It is regarded as a variant or end stage of folliculitis decalvans by many authors, and may coexist with it.

Staphylococcus aureus is often cultured. Scarring can progress for years.

Pathophysiology.

Chronic inflammation around the follicle, with infection and a neutrophilic and later lymphoplasmacytic infiltrate, destroys the follicles. Fibrosis draws the surviving hair shafts together, giving the tuft. Bacterial biofilm and an abnormal host response are suspected.

• Tufts of hairs from a single follicular opening, with perifollicular erythema, scale, yellow crusts and sometimes pustules, on a scarred, atrophic scalp.
• Tenderness, itching, and purulent discharge in some.
• Scarring alopecia that slowly extends, mainly at the vertex and occiput.

Red flags.

• Rapidly advancing scarring, deep abscesses or sinus tracts.

• Clinical diagnosis from tufting, scarring and inflammation. Trichoscopy shows tufted hairs, perifollicular scale and yellow crusts.
• Swab for bacterial culture from pustules (including nasal carriage). Biopsy (4 mm punch) from an active area, with horizontal sections, shows follicular dilatation with tufted hairs, neutrophilic then lymphoplasmacytic inflammation and fibrosis.

Differential diagnosis.

• Folliculitis decalvans, dissecting cellulitis and acne keloidalis nuchae.
• Lichen planopilaris, discoid lupus erythematosus and tinea capitis.
• Pseudofolliculitis and psoriasis of the scalp.

• Treat early, since scarring cannot be reversed.
• Topical: clindamycin 1% lotion twice daily, potent topical corticosteroid (clobetasol 0.05%) or intralesional triamcinolone 10 mg/mL for active areas, and antiseptic shampoo (chlorhexidine or ketoconazole).
• Systemic antibiotics: doxycycline 100 mg twice daily for 3 months, or clindamycin 300 mg twice daily with rifampicin 300 mg twice daily for 10 weeks for resistant disease. Test for bacterial sensitivity.
• Oral isotretinoin 0.5 mg/kg daily for 6 months in resistant cases, avoiding pregnancy. Dapsone has been used.
• Decolonisation of nasal carriage with mupirocin 2% to the nostrils twice daily for 5 days when cultures are positive.
• Surgery (excision or hair transplantation) after the disease has been quiet for at least 1 to 2 years.

Special groups. Women who may become pregnant: effective contraception with isotretinoin, and avoid doxycycline in pregnancy.

Monitoring. Review every 3 months, with trichoscopy and photographs.

Referral and escalation. Dermatology with trichology interest.