Treatment of folliculitis decalvans with photodynamic therapy: Results in 10 patients
2015; Elsevier BV; Volume: 72; Issue: 6 Linguagem: Inglês
10.1016/j.jaad.2015.02.1120
ISSN1097-6787
AutoresLaura Miguel‐Gomez, Sergio Vañó‐Galván, Bibiana Pérez‐García, R. Carrillo‐Gijón, Pedro Jaén‐Olasolo,
Tópico(s)Autoimmune Bullous Skin Diseases
ResumoTo the Editor: Different therapies such as doxycycline, rifampicin, isotretinoin, or intralesional corticosteroids have been used for folliculitis decalvans (FD) with poor results.1Ross E.K. Tan E. Shapiro J. Update on primary cicatricial alopecias.J Am Acad Dermatol. 2005; 53: 1-37Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar It has been suggested that scalp colonization by Staphylococcus aureus induces an intense inflammatory reaction leading to scarring alopecia with erythema, pustules, and yellowish crusts around hair follicles.2Otberg N. Kang H. Alzolibani A.A. Shapiro J. Folliculitis decalvans.Dermatol Ther. 2008; 21: 238-244Crossref PubMed Scopus (106) Google Scholar, 3Chiarini C. Torchia D. Bianchi B. Volpi W. Caproni M. Fabbri P. Immunopathogenesis of folliculitis decalvans: clues in early lesions.Am J Clin Pathol. 2008; 130: 526-534Crossref PubMed Scopus (43) Google Scholar Photodynamic therapy (PDT) has immunomodulatory, antiinflammatory, and bactericidal activity4Wan M.T. Lin J.Y. Current evidence and applications of photodynamic therapy in dermatology.Clin Cosmet Investig Dermatol. 2014; 7: 145-163PubMed Google Scholar due to its phototoxic effects, preventing the proliferation of S aureus. The objective of our study was to analyze the effectiveness of PDT in the treatment of FD.A prospective study was performed from 2011 to 2014 including 10 adult patients diagnosed clinically and histologically with FD. Cultures of S aureus were obtained in 7 patients, with a positive result in 4 (57%) of them. All patients had previously been treated with at least 3 months of doxycycline 100 mg daily. In all, 5 women and 5 men (mean age 38 years, range 33-58 years) were treated with PDT. Methyl aminolevulinate (MAL, Metvix) 160 mg/g cream was applied to the area of inflammation and covered with an occlusive nonabsorbent dressing (Oper film) for 3 hours. After incubation, the area was irradiated with a red light from a light-emitting diode lamp at a wavelength of 630 nm with a total light dose of 37 J/cm2. Clinical and fluorescence photographs through ultraviolet light were obtained before and after illumination (Fig 1, A and B). Physicians and patients also reported perceived improvement. The protocol included 4 sessions of PDT at 4-week intervals. If patients responded to PDT at 4 weeks and symptoms subsequently returned, they were re-treated with PDT. Patients were assessed at week 16. A patient was considered to have responded to therapy if all of the following criteria were met: (1) absence of progression of scarring alopecia; (2) disappearance of pustules, erythema, hyperkeratosis, and yellowish crusts around hair follicles; (3) decrease in fluorescence intensity of protoporphyrin IX.Nine of 10 (90%) patients achieved clinical improvement. Four months following the first treatment, the clinical response persisted in 6 patients. However, 3 of these patients required another therapy to maintain the response (oral doxycycline and intralesional corticosteroids in 2 patients and oral azithromycin in 1 patient). One patient remained disease-free at 36 months without the use of any additional therapies (Table I). Four patients experienced pain and 2 patients demonstrated a local inflammatory reaction following treatment.Table ISummary of demographics, treatment regimen, and responseAge/SexPrevious treatmentsConcurrent treatmentsNumber of sessionsInitial response to treatment at 16 weeksDuration of response with PDT without concurrent treatmentsAdverse effects58/FemaleDoxycyclineCloxacillinDoxycyclineIntralesional corticosteroids13Yes17 monthsLocal inflammatory reaction post-PDT31/MaleDoxycyclineTopical corticosteroids-3No-Local inflammatory reaction post-PDT30/FemaleDoxycyclineTopical corticosteroids-3Yes3 monthsPain37/FemaleDoxycyclineTopical and intralesional corticosteroidsDoxycyclineIntralesional corticosteroids4Yes2 months-39/MaleDoxycyclineIsotretinoinRifampicinTopical corticosteroids-5Yes4 monthsPain38/FemaleDoxycyclineTopical corticosteroidsIsotretinoinAzithromycin9Yes15 months-41/FemaleDoxycyclineTopical corticosteroids-4Yes2-3 monthsPain33/MaleDoxycycline-6Yes4 months-38/MaleDoxycyclineIsotretinoin-4Yes36 months-36/MaleDoxycyclineTopical corticosteroids-15 Vertex2 Right parietal3 Left parietalYes15 monthsPainPDT, Photodynamic therapy. Open table in a new tab PDT may allow periods of stabilization of the disease without also taking systemic drugs.5Castaño-Suárez E. Romero-Maté A. Arias-Palomo D. Borbujo J. Photodynamic therapy for the treatment of folliculitis decalvans.Photodermatol Photoimmunol Photomed. 2012; 28: 102-104Crossref PubMed Scopus (17) Google Scholar Nevertheless, it is an uncomfortable therapy with transient results, so its use should be limited to selected patients resistant to classical therapies or patients with early relapses requiring continuous oral antibiotics. Further randomized control studies are required to determine the long-term effectiveness and the factors that would predict the therapeutic response to PDT in patients with FD. To the Editor: Different therapies such as doxycycline, rifampicin, isotretinoin, or intralesional corticosteroids have been used for folliculitis decalvans (FD) with poor results.1Ross E.K. Tan E. Shapiro J. Update on primary cicatricial alopecias.J Am Acad Dermatol. 2005; 53: 1-37Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar It has been suggested that scalp colonization by Staphylococcus aureus induces an intense inflammatory reaction leading to scarring alopecia with erythema, pustules, and yellowish crusts around hair follicles.2Otberg N. Kang H. Alzolibani A.A. Shapiro J. Folliculitis decalvans.Dermatol Ther. 2008; 21: 238-244Crossref PubMed Scopus (106) Google Scholar, 3Chiarini C. Torchia D. Bianchi B. Volpi W. Caproni M. Fabbri P. Immunopathogenesis of folliculitis decalvans: clues in early lesions.Am J Clin Pathol. 2008; 130: 526-534Crossref PubMed Scopus (43) Google Scholar Photodynamic therapy (PDT) has immunomodulatory, antiinflammatory, and bactericidal activity4Wan M.T. Lin J.Y. Current evidence and applications of photodynamic therapy in dermatology.Clin Cosmet Investig Dermatol. 2014; 7: 145-163PubMed Google Scholar due to its phototoxic effects, preventing the proliferation of S aureus. The objective of our study was to analyze the effectiveness of PDT in the treatment of FD. A prospective study was performed from 2011 to 2014 including 10 adult patients diagnosed clinically and histologically with FD. Cultures of S aureus were obtained in 7 patients, with a positive result in 4 (57%) of them. All patients had previously been treated with at least 3 months of doxycycline 100 mg daily. In all, 5 women and 5 men (mean age 38 years, range 33-58 years) were treated with PDT. Methyl aminolevulinate (MAL, Metvix) 160 mg/g cream was applied to the area of inflammation and covered with an occlusive nonabsorbent dressing (Oper film) for 3 hours. After incubation, the area was irradiated with a red light from a light-emitting diode lamp at a wavelength of 630 nm with a total light dose of 37 J/cm2. Clinical and fluorescence photographs through ultraviolet light were obtained before and after illumination (Fig 1, A and B). Physicians and patients also reported perceived improvement. The protocol included 4 sessions of PDT at 4-week intervals. If patients responded to PDT at 4 weeks and symptoms subsequently returned, they were re-treated with PDT. Patients were assessed at week 16. A patient was considered to have responded to therapy if all of the following criteria were met: (1) absence of progression of scarring alopecia; (2) disappearance of pustules, erythema, hyperkeratosis, and yellowish crusts around hair follicles; (3) decrease in fluorescence intensity of protoporphyrin IX. Nine of 10 (90%) patients achieved clinical improvement. Four months following the first treatment, the clinical response persisted in 6 patients. However, 3 of these patients required another therapy to maintain the response (oral doxycycline and intralesional corticosteroids in 2 patients and oral azithromycin in 1 patient). One patient remained disease-free at 36 months without the use of any additional therapies (Table I). Four patients experienced pain and 2 patients demonstrated a local inflammatory reaction following treatment. PDT, Photodynamic therapy. PDT may allow periods of stabilization of the disease without also taking systemic drugs.5Castaño-Suárez E. Romero-Maté A. Arias-Palomo D. Borbujo J. Photodynamic therapy for the treatment of folliculitis decalvans.Photodermatol Photoimmunol Photomed. 2012; 28: 102-104Crossref PubMed Scopus (17) Google Scholar Nevertheless, it is an uncomfortable therapy with transient results, so its use should be limited to selected patients resistant to classical therapies or patients with early relapses requiring continuous oral antibiotics. Further randomized control studies are required to determine the long-term effectiveness and the factors that would predict the therapeutic response to PDT in patients with FD. Failure of photodynamic therapy (PDT) in 3 patients with folliculitis decalvansJournal of the American Academy of DermatologyVol. 74Issue 4PreviewTo the Editor: We greatly appreciated the article by Miguel-Gomez et al1 on “Treatment of folliculitis decalvans with photodynamic therapy: results in 10 patients” and we report herein our experience, which is somewhat different. Full-Text PDF
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