Folliculitis decalvans microbiologic signature is specific for disease clinical phenotype
2020; Elsevier BV; Volume: 85; Issue: 5 Linguagem: Inglês
10.1016/j.jaad.2020.10.073
ISSN1097-6787
AutoresÓscar M. Moreno‐Arrones, Rosa del Campo, David Saceda‐Corralo, Juan Jimenez‐Cauhe, Manuel Ponce‐Alonso, Sergio Serrano‐Villar, Pedro Jaén, John Paoli, Sergio Vañó‐Galván,
Tópico(s)Dermatological and Skeletal Disorders
ResumoTo the Editor: Folliculitis decalvans (FD) is a rare, primary neutrophilic scarring alopecia whose etiology has not been completely elucidated.1Saceda-Corralo D. Moreno-Arrones O.M. Rodrigues-Barata R. et al.Trichoscopy activity scale for folliculitis decalvans.J Eur Acad Dermatol Venereol. 2020; 34: e55-e57Crossref PubMed Scopus (9) Google Scholar, 2Matard B. Donay J.L. Resche-Rigon M. et al.Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota.Exp Dermatol. 2020; 29: 295-298Crossref PubMed Scopus (22) Google Scholar, 3Samrao A. Mirmirani P. Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment.Dermatol Online J. 2020; 26 (13030/qt6nw2h5rh)Crossref PubMed Google Scholar, 4Egger A. Stojadinovic O. Miteva M. Folliculitis decalvans and lichen planopilaris phenotypic spectrum—a series of 7 new cases with focus on histopathology.Am J Dermatopathol. 2020; 42: 173-177Crossref PubMed Scopus (11) Google Scholar, 5Yip L. Barrett T.H. Harries M.J. Folliculitis decalvans and lichen planopilaris phenotypic spectrum: a case series of biphasic clinical presentation and theories on pathogenesis.Clin Exp Dermatol. 2020; 45: 63-72Crossref PubMed Scopus (15) Google Scholar Although Staphylococcus aureus colonization has been invoked as its main trigger,1Saceda-Corralo D. Moreno-Arrones O.M. Rodrigues-Barata R. et al.Trichoscopy activity scale for folliculitis decalvans.J Eur Acad Dermatol Venereol. 2020; 34: e55-e57Crossref PubMed Scopus (9) Google Scholar recent findings suggest that its importance could have been overstated.2Matard B. Donay J.L. Resche-Rigon M. et al.Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota.Exp Dermatol. 2020; 29: 295-298Crossref PubMed Scopus (22) Google Scholar,3Samrao A. Mirmirani P. Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment.Dermatol Online J. 2020; 26 (13030/qt6nw2h5rh)Crossref PubMed Google Scholar Here, we hypothesize that the clinical spectrum of the disease could be associated with a distinct microbiologic signature. We designed a study that recruited patients with a previous diagnosis of FD based on typical histopathologic, clinical, and trichoscopic findings.1Saceda-Corralo D. Moreno-Arrones O.M. Rodrigues-Barata R. et al.Trichoscopy activity scale for folliculitis decalvans.J Eur Acad Dermatol Venereol. 2020; 34: e55-e57Crossref PubMed Scopus (9) Google Scholar Clinical and trichoscopic images were taken from affected scalp and healthy scalp. Trichoscopy-guided follicular biopsies were taken from both sites. The samples were processed, cultured, and sequenced. The complete methodology is described in the Supplemental data set (available via Mendeley at https://doi.org/10.17632/yrpmwhw5dg.2). Epidemiologic and clinical characteristics of the patients are described in Table I. Half of the patients presented a typical pattern of FD (eg, pustules or yellowish purulent exudate), and the rest of the patients presented FD associated with lichenoid features (folliculitis decalvans and lichen planopilaris phenotypic spectrum [FDLPPPS])4Egger A. Stojadinovic O. Miteva M. Folliculitis decalvans and lichen planopilaris phenotypic spectrum—a series of 7 new cases with focus on histopathology.Am J Dermatopathol. 2020; 42: 173-177Crossref PubMed Scopus (11) Google Scholar,5Yip L. Barrett T.H. Harries M.J. Folliculitis decalvans and lichen planopilaris phenotypic spectrum: a case series of biphasic clinical presentation and theories on pathogenesis.Clin Exp Dermatol. 2020; 45: 63-72Crossref PubMed Scopus (15) Google Scholar (Supplemental Fig 1).Table IClinical and epidemiologic characteristics of patientsPatientSexAge, yYears of evolution of FDFD patternPrevious treatment1Female3910FDLPPPSTopical corticosteroid. Hydroxychloroquine.2Male347FDLPPPSTopical corticosteroid. Oral doxycycline, rifampicin and clindamycin. Topical dapsone.3Male3914TypicalNone.4Male3910FDLPPPSTopical corticosteroid. Oral doxycycline, rifampicin, and clindamycin.5Male415TypicalIntralesional corticosteroid. Oral isotretinoin.6Female3910FDLPPPSTopical corticosteroid. Oral doxycycline.7Male376TypicalNone.8Male293TypicalTopical corticosteroid. Oral doxycycline, rifampicin, and clindamycin.9Male375TypicalTopical corticosteroid. Oral doxycycline, rifampicin, and clindamycin.10Male481FDLPPPSOral doxycycline.FD, Folliculitis decalvans; FDLPPPS, folliculitis decalvans and lichen planopilaris phenotypic spectrum. Open table in a new tab FD, Folliculitis decalvans; FDLPPPS, folliculitis decalvans and lichen planopilaris phenotypic spectrum. Staphylococcus represented 25.9% of the total count of follicular bacterial microbiota in affected biopsy samples but only 6.6% of the total bacteria in healthy follicles. In patients with the typical FD pattern, Staphylococcus bacteria in FD-affected hair follicles were statistically significantly increased compared with healthy hair follicles. In all of the patients with the typical FD pattern, >20% of the total follicular bacterial composition consisted of S aureus (Supplemental Figs 2 and 3). Statistically significant increased levels of S aureus (P = .02) were found in patients with a typical FD pattern compared with patients with FDLPPPS. The staphylococcal isolates remained susceptible to oxacillin, and presence of the mecA and pvl genes was not observed. We found that in typical neutrophilic FD, Staphylococcus bacteria were the best microbiologic biomarker to help distinguish FD from FDLPPS using the linear discriminant analysis effect size tool (Fig 1). Although FD is classified as a neutrophilic alopecia,1Saceda-Corralo D. Moreno-Arrones O.M. Rodrigues-Barata R. et al.Trichoscopy activity scale for folliculitis decalvans.J Eur Acad Dermatol Venereol. 2020; 34: e55-e57Crossref PubMed Scopus (9) Google Scholar, 2Matard B. Donay J.L. Resche-Rigon M. et al.Folliculitis decalvans is characterized by a persistent, abnormal subepidermal microbiota.Exp Dermatol. 2020; 29: 295-298Crossref PubMed Scopus (22) Google Scholar, 3Samrao A. Mirmirani P. Gram-negative infections in patients with folliculitis decalvans: a subset of patients requiring alternative treatment.Dermatol Online J. 2020; 26 (13030/qt6nw2h5rh)Crossref PubMed Google Scholar it is currently suspected that FD is probably a continuum of disease with eventual lichenoid features (FDLPPPS).4Egger A. Stojadinovic O. Miteva M. Folliculitis decalvans and lichen planopilaris phenotypic spectrum—a series of 7 new cases with focus on histopathology.Am J Dermatopathol. 2020; 42: 173-177Crossref PubMed Scopus (11) Google Scholar,5Yip L. Barrett T.H. Harries M.J. Folliculitis decalvans and lichen planopilaris phenotypic spectrum: a case series of biphasic clinical presentation and theories on pathogenesis.Clin Exp Dermatol. 2020; 45: 63-72Crossref PubMed Scopus (15) Google Scholar Levels of S aureus were >20% of the total follicular bacterial composition in typical FD patients but <20% in FDLPPPS patients. Additionally, the linear discriminant analysis effect size tool, an algorithm that identifies biomarkers between groups using relative abundances, clearly showed Staphylococcus as a bacterial biomarker of typical FD but not FDLPPPS (cladogram depicted in Supplemental Fig 4). Furthermore, patients affected with FD may have active disease in the absence of significant levels of this bacteria.1Saceda-Corralo D. Moreno-Arrones O.M. Rodrigues-Barata R. et al.Trichoscopy activity scale for folliculitis decalvans.J Eur Acad Dermatol Venereol. 2020; 34: e55-e57Crossref PubMed Scopus (9) Google Scholar Moreover, because the S aureus bacteria colonizing patients with FD are not more virulent than those present in the general population, it is reasonable to hypothesize that the bacteria could take advantage of an immunologic vulnerability or follicular structural alteration. Taking into consideration the findings of this study and recent publications, the real impact of S aureus on the development of FD may not be as significant as previously thought, and treatment could be changed accordingly: in the more neutrophilic and acute stages of FD, antibiotics should be prioritized, whereas in FDLPPPS, anti-inflammatory drugs could be the first choice.
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