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

Figures & data

Figure 1 Hematoxylin and eosin-stained biopsy lesion taken from FD-diseased areas of the scalp showing follicular obliteration by acute and chronic inflammatory cell infiltrate (blue arrow) with dermal scarring (red arrows) magnification x2 (A) and inflammatory cell infiltrate composed of mature lymphocytes and neutrophils (green arrow) magnification x10 (B).

Abbreviation: FD, folliculitis decalvans.

Figure 2 Patient 1: Postoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp, immediately after excision (A); tension Suture guards to enable high-tension horizontal mattress suturing with less tissue tear-through or risk of tissue strangulation. Showing side (top) and top (bottom) views.(B), and postoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp immediately after applying high-tension sutures with guards in a horizontal mattress fashion and long suture tails to enable retightening as needed. The wound bed is filled with bacitracin antibiotic ointment (C).

Abbreviation: FD, folliculitis decalvans.

Figure 3 Patient 3: Postoperative FD plaque involving the vertex, and mid-scalp, immediately after applying high-tension sutures with guards in a horizontal mattress fashion. The wound bed is filled with bacitracin antibiotic ointment. (A) At eight weeks postoperatively, a small STSG derived from the anterior thigh is used to close the residual open wound (red arrow). Tenting of skin from tension suture effect is visible (yellow arrows) (B).

Abbreviations: FD, folliculitis decalvans; STSG, split-thickness skin graft.

Table 1 Demographic and Pre-Surgical Data on Five Patients That Underwent Surgical Excision of FD Lesions with SIH Aided by Guarded High-Tension Suturing

Parameter	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5
Age and sex	47 (Female)	33 (Male)	37 (Male)	32 (Male)	36 (Male)
Ethnicity	Hispanic	African Descent	Hispanic	African descent	African descent
Preoperative duration of disease	17 years	7 years	12 years	3 years	4 years
Symptoms	Itch, purulent and bloody discharge, pain	Itch, purulent and bloody discharge, pain	Itch, purulent and bloody discharge, pain	Itch, purulent and bloody discharge, pain	Itch, purulent and bloody discharge, pain
Prior treatments	Oral antibiotics, prescribed shampoos, steroid injections, topical steroids	Doxycycline, Clobetasol Ointment 0.05%, 5 sessions of ND:YAG laser hair removal treatment, Intralesional triamcinolone 40mg/cc	Isotretinoin, Doxycycline, Topical steroids, Intralesional triamcinolone	Topical steroids, steroid injections	Steroid injections every 2–3 months for 4 years, surgical excision with radiation, oral antibiotics
Size of lesion and morphology	Alopecic mass, 13×9 cm	Raised alopecic plaque	Raised plaque 14.5×10 cm	Raised alopecic plaque 8×5 cm	Raised Plaque 7×3 cm

Abbreviations: FD, folliculitis decalvans; SIH, second intention healing; planopilaris; Nd:YAG, neodymium-doped yttrium aluminium garnet.

Table 2 Surgical and Post-Surgical Data on Five Patients That Underwent Surgical Excision of FD Lesions with SIH Aided by Guarded High-Tension Suturing

Parameter	Patient 1*	Patient 2	Patient 3	Patient 4	Patient 5
Size of wound immediately after excision	14 cm × 10 cm	15 cm × 14 cm	15 X 10.5 cm	9 × 6 cm	7.5 X 3.5 cm
Split thickness Skin Graft Yes/No	No	3 cm x 2.5 cm	3cm X 5 cm	No	No
Final scar size	14cm X 5.0 cm	8 X 8 cm	7 X 9.5 cm	7 cm x 1 cm.	6 X 1 cm
Maximum diameter reduction	50%	47%	63%	83%	71%
Post-operative Follow up duration (Remission period)	20 months	21 months	10 months	24 months	12 months
Non-FD-associated scalp diseases and treatments	LPP- Like disease - scalp wide	AKN masses – occipital area	AKN papules - nape	Not assessed for LPP-like disease	AKN plaques - nape
	Cutis Verticis Gyrata	LPP- Like disease - scalp wide	LPP- Like disease - scalp wide	Topical botanicals	LPP- Like disease - scalp wide
	Topical botanicals	Topical botanicals	Topical tacrolimus, Topical botanicals		Topical tacrolimus, Topical botanicals

Note: *1 session of platelet-rich plasma applied on wound bed to hasten granulation at week 4.

Abbreviations: FD, folliculitis decalvans; SIH, second intention healing; AKN, acne keloidalis nuchae; LPP, lichen planopilaris.

Figure 4 Patient 1: Preoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp. (A) Thirteen months after complete excision of FD lesion and healing by second intention, aided by high-tension sutures with guards and a minor skin graft (B).

Abbreviation: FD, folliculitis decalvans.

Figure 5 Patient 2: Preoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp, and acne keloidalis nuchae in the nape area (A) and nineteen months after complete excision of FD lesion and healing by second intention, aided by guarded high-tension sutures and a minor STSG (Green arrow). The tenting skin has flattened out (yellow arrows (B).

Abbreviations: FD, folliculitis decalvans. AKN, acne keloidalis nuchae. STSG, split-thickness skin graft.

Figure 6 Patient 3: Preoperative FD plaque involving the entire vertex. (A) and eight months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures and a minor skin graft(B).

Abbreviations: FD, folliculitis decalvans. AKN, acne keloidalis nuchae. STSG, split-thickness skin graft.

Figure 7 Patient 4 with FD plaque involving the right parietal prominence area before surgical excision and AKN lesions in the nape zone. (A) and four months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures and a minor skin graft (B).

Abbreviations: FD, folliculitis decalvans; AKN, acne keloidalis nuchae.

Figure 8 Patient 5 with FD plaque involving the right parietal prominence area before surgical excision. (A) and nine months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures (B).

Abbreviation: FD, folliculitis decalvans.