Portal de Periódicos da CAPES

Refractory folliculitis decalvans treated with adalimumab: A case series of 23 patients

2022; Elsevier BV; Volume: 87; Issue: 3 Linguagem: Inglês

10.1016/j.jaad.2022.02.044

1097-6787

Matilde Iorizzo, Michela Starace, Sergio Vañó‐Galván, Bianca Maria Piraccini, Pascal Reygagne, Lidia Rudnicka, Tatiana Silyuk, Rodney Sinclair, Antonellá Tosti,

Autoimmune Bullous Skin Diseases

To the Editor: Folliculitis decalvans (FD) is a primary cicatricial neutrophilic alopecia that clinically starts as painful purulent folliculitis with tufts of hairs and perifollicular crusts. Because of psychologic consequences for affected patients, this dermatosis deserves full attention and immediate care to turn off the inflammatory process and stop disease progression. However, its not-well–known pathogenesis always makes treatment success very difficult and frustrating.1Miguel-Gómez L. Rodrigues-Barata A.R. Molina-Ruiz A. et al.Folliculitis decalvans: Effectiveness of therapies and prognostic factors in a multicenter series of 60 patients with long-term follow-up.J Am Acad Dermatol. 2018; 79: 878-883Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar It has been suggested that bacterial “superantigens” bind major histocompatibility complex class II molecules, escaping host immune system detection and stimulating T-cell homing.2Matard B. Meylheuc T. Briandet R. et al.First evidence of bacterial biofilms in the anaerobe part of scalp hair follicles: a pilot comparative study in folliculitis decalvans.J Eur Acad Dermatol Venereol. 2013; 27: 853-860Crossref PubMed Scopus (36) Google Scholar Staphylococcus aureus is frequently cultured from typical FD-affected hair follicles, and its eradication is one of the major goals of treatment with antibiotics as the first-line option. Unfortunately, gram-negative bacteria can also be isolated, and bacterial biofilms may develop, increasing treatment resistance, promoting recurrences, and requiring different treatment strategies. Here, we report a case series of 23 patients affected by biopsy-proven FD, treated with adalimumab alone, due to the failure of conventional treatments (Table I). Before starting the treatment, all the patients underwent a skin swab test from pustular areas, and, interestingly, the group was predominantly S aureus-positive; nevertheless, previously prescribed antibiotics had failed. Adalimumab was administered as subcutaneous injections of 160 mg at week 0, 80 mg at week 2, and 80 mg every other week. All necessary workup was performed before starting the treatment, including a pregnancy test. Adalimumab has been well tolerated by all our patients, and no major side effects have been reported till now, except for mild gastrointestinal symptoms in 2 male patients aged 55 and 58 years. Clinical improvement was evident (Fig 1) in all the patients, starting from the first month, and was maintained during the treatment. The drug was used for a period of time ranging from 6 to 24 months (median: 8 months; SD: 6.65 months), and it is still ongoing. Only 2 patients discontinued the treatment because of insufficient improvement: these 2 had a mixed-culture swab consisting of S aureus and gram-negative bacteria (Enterobacter, Klebsiella, and Escherichia coli). However, it was difficult to assess whether this was the reason for the patients being nonresponders.Table IDisease history of patients with refractory folliculitis decalvans treated with adalimumabSex/age at diagnosisEthnicityDisease duration, ySeverity∗Severity was determined based on the maximum diameter of the largest alopecic patch (grade I or mild: 5 cm) and the presence of the following trichoscopic signs: pustules, yellow tubular scaling, yellow crusts, perifollicular erythema (>50% follicular units) and hemorrhages, and thin arborizing vessels. Mild outbreaks may be detected based on the presence of any of the trichoscopic findings proposed, except pustules. Moderate and severe outbreaks can be established based on a combination of the findings.Previous treatmentsTime to improvement, moResponse to treatment†Treatment responses graded relative to baseline disease severity: −3, much worse; −2, moderately worse; −1, mildly worse; 0, no change; +1, mildly improved; +2, moderately improved; +3, greatly improved. The parameters evaluated were as follows: erythema, pustules and crusts, pruritus, trichodynia, and the extension of the alopecic patch.Adalimumab treatment duration1. M/21Caucasian1ModerateClindamycin/rifampicine;Triamcinolone i.l.1+35 mo - ongoing2. M/22Hispanic4SevereDoxycyclinee; minocycline3+38 mo - ongoing3. M/25Caucasian2ModerateClindamycin/rifampicineTriamcinolone oral2+26 mo - ongoing4. M/27Caucasian3ModerateClindamycin/rifampicine;Trimetoprim sulfametoxazole;Isotretinoin oral1+215 mo - ongoing5. M/28Caucasian2SevereClindamycin/rifampicine;Fusidic acid topicalClobetasol topical; dapsone topical3+26 mo - ongoing6. M/31Caucasian3ModerateClindamycin/rifampicine;Trimetoprim sulfametoxazoleTriamcinolone i.l.2+310 mo - ongoing7. M/36Hispanic4SevereDoxycycline; minocycline3+37 mo - ongoing8. M/38Hispanic6SevereDoxycycline; minocycline; CotrimoxazoleApremilast4+311 mo - ongoing9. M/42Caucasian10SevereClindamycin/rifampicine;Trimetoprim sulfametoxazoleTriamcinolone i.l.; isotretinoin oral3+110 mo of treatment discontinued because of insufficient improvement10. M/42Caucasian4SevereClindamycin/rifampicine;Fusidic acid topicalClobetasol topical; dapsone topical3+36 mo - ongoing11. M/45Caucasian3ModerateClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.l.; clobetasol topical; retinoids topical2+324 mo - ongoing12. M/46Caucasian8ModerateClindamycin/rifampicine; Trimetoprim sulfametoxazoleTriamcinolone oral; Isotretinoin oral3+28 mo - ongoing13. M/47Caucasian2ModerateClindamycin/rifampicine; Fusidic acid oral/topicalClobetasol topical; isotretinoin oral2+36 mo - ongoing14. M/55Caucasian5SevereClindamycin/rifampicine; Fusidic acid topicalClobetasol topical; isotretinoin oral2+324 mo - ongoing15. M/58Caucasian2ModerateClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.m.; Clobetasol topical; isotretinoin oral2+324 mo - ongoing16. M/60Caucasian4SevereClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.m.; Clobetasol topical; retinoids topical2+224 mo - ongoing17. M/67Caucasian5SevereClindamycin/rifampicine; Triamcinolone i.m./i.l.Retinoids oral; fusidic acid topical; clobetasol topical3+212 mo - ongoing18. F/35Caucasian4SevereClindamycin/rifampicine; Fusidic acid oralFusidic acid topical, Clobetasol topical, dapsone topical3+36 mo – ongoing19. F/37Caucasian2ModerateClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.m./i.l.; clobetasol topical2+26 mo - ongoing20. F/38Caucasian6ModerateClindamycin/rifampicineTriamcinolone i.l.; isotretinoin oral1+26 mo of treatment discontinued because of planned pregnancy21. F/47Caucasian5SevereClindamycin/rifampicine, Fusidic acid oralFusidic acid topical; dapsone topical; isotretinoin oral4+18 mo of treatment discontinued because of insufficient improvement22. F/56Caucasian2ModerateClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.l.; clobetasol topical2+310 mo - ongoing23. F/62Caucasian7ModerateClindamycin/rifampicine; Fusidic acid topicalTriamcinolone i.m.; clobetasol topical; retinoids topical4+16 mo - ongoingi.1., Intralesional; i.m., intramuscular.∗ Severity was determined based on the maximum diameter of the largest alopecic patch (grade I or mild: 5 cm) and the presence of the following trichoscopic signs: pustules, yellow tubular scaling, yellow crusts, perifollicular erythema (>50% follicular units) and hemorrhages, and thin arborizing vessels. Mild outbreaks may be detected based on the presence of any of the trichoscopic findings proposed, except pustules. Moderate and severe outbreaks can be established based on a combination of the findings.† Treatment responses graded relative to baseline disease severity: −3, much worse; −2, moderately worse; −1, mildly worse; 0, no change; +1, mildly improved; +2, moderately improved; +3, greatly improved. The parameters evaluated were as follows: erythema, pustules and crusts, pruritus, trichodynia, and the extension of the alopecic patch. Open table in a new tab i.1., Intralesional; i.m., intramuscular. Improvement meant either reduction or termination of the inflammatory process, stability of the size of the patch, and no new foci during the treatment course. Our data confirmed literature in which adalimumab was reported to be associated with a higher, even if limited, number of successfully treated FD patients,3Kreutzer K. Effendy I. Therapy-resistant folliculitis decalvans and lichen planopilaris successfully treated with adalimumab.J Dtsch Dermatol Ges. 2014; 12: 74-76PubMed Google Scholar,4Alhameedy M.M. Alsantali A.M. Therapy-recalcitrant folliculitis decalvans controlled successfully with adalimumab.Int J Trichology. 2019; 11: 241-243Crossref PubMed Scopus (4) Google Scholar and thus, we hope to increase the sample size to encourage larger studies. The rationale for its use is probably that tumor necrosis factor is an inflammatory cytokine commonly encountered in neutrophilic dermatoses,5Patel R. Cafardi J.M. Patel N. Sami N. Cafardi J.A. Tumor necrosis factor biologics beyond psoriasis in dermatology.Expert Opin Biol Ther. 2011; 11: 1341-1359Crossref PubMed Scopus (15) Google Scholar and tumor necrosis factor-α inhibitors have been successfully used in many of these. However, an extensive follow-up is needed because not enough data exist about possible flare-ups during the treatment and long-standing remission of the disease. Our sample group is still under treatment. According to the literature, treatment discontinuation means recurrence, but improvement is reported after restarting. None disclosed.