LAUSR

Dear Editor, Folliculitis decalvans (FD) is the most common neutrophilic scarring alopecia, presenting with tufted hairs, follicular papules or pustules. Scalp colonization by Staphylococcus aureus in combination with hypersensitivity reaction to “superantigens” and defect in host cellmediated immunity seems to induce a severe inflammatory reaction with consequent destruction of hair follicles. Different treatment options exist, nevertheless they are often disappointing and unsatisfactory. We report a recalcitrant case of FD focusing our attention on laser treatment, monitoring efficacy by noninvasive diagnostic imaging as dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT). A 46-year-old man presented with a 15-year history of FD characterized by recurrent purulent follicular lesions on occipital side of the scalp and consequent scarring alopecia. His medical history was unremarkable, but he was distressed by the appearance of the lesions and hair loss. In addition, the patient complained of itch and constant burning in the injured area with significant repercussions on his daily life. He was treated with different therapies such as doxycycline, rifampicin and hydroxychloroquine with poor results. He underwent two sessions of photodynamic treatment with methyl aminolevulinate at 2-week intervals. At first, he benefitted from the treatment, but after 2 months recurrence occurred, along with the progression of the disease. Based on literature, we decided to treat with long-pulse neodymium-doped yttrium aluminum garnet (Nd:Yag) laser (1064 nm). We started at 30 J/cm and then we improved the dose until 80 J/cm, 50 ms and 4 mm of spot size. A total of seven laser sessions in a 6to 8-week intertreatment interval were performed with successful outcome, without relapse for more than 36 months of clinical follow-up after the end of the therapy (Figure 1). The notable aspect was the symptomatologic response which occurred already between the first and the second laser sessions, and completely resolved at the end of the therapy. In addition, we monitored scalp inflammation with dermoscopy, RCM and OCT during patient's laser treatment, at baseline and after 1 month at the end of the laser treatment in the same target area (Figures 2-5 and Videos S1 and S2). These technologies represent noninvasive diagnostic tools and their applications on inflammatory skin diseases have increased in the last years, especially to monitor treatment response in different cutaneous diseases. In trichologic field, dermoscopy is widely used in dermatologic practice and it is a very helpful tool for assisting in the diagnosis of some forms of folliculitis as FD. On the other side, RCM is not widely used in trichology; however, few recent reports and preliminary data suggest the effectiveness of RCM for diagnosis of general scarring alopecia and related therapeutic monitoring. Indeed, RCM provides an excellent assessment of morphological changes occurring in scalp area during treatment and in long-term follow-up, providing the possibility to closely monitor the response to therapy in course of alopecia.