Folliculitis Devalvans in Females: Is it more severe than in males?

New Study Describes the Features of Folliculitis Decalvans in 150 women

Folliculitis decalvans is a scarring alopecia that affects both males and females. Males tend to be more affected than females and in some studies that ratio of males to females may be as high as 2:1 or even 3:1. Patients with folliculitis decalvans often present with itching, burning and tenderness in the crown or mid-scalp areas. Pustules are frequently present.

Sarkis et al 2023

Authors of a new study performed a retrospective study assessing the features of folliculitis decalvans in females. Researchers from 10 different counties submitted data.

Data from a total of 150 women were collected. The mean age of onset of the disease was 38.9 years. 88% of women had Caucasian hair and 12 % afro textured. 51 % had Fitpatrick type III skin.

The vertex scalp was involved in 81.3 % of patients and the mid scalp was involved in 42%. Clinical features included erythema (93.2%), pruritus (90.5%), pustules (60.1%), and pain (54%). 

The predominantly prescribed treatments were topical antibiotics in 73 % of patients and oral antibiotics in 71.8% of the cases. Topical steroids were used by 59.3 % of patients and intralesional corticosteroids were used by 45.3 %.

Is FD in Women More Severe than FD in Males ?

The authors compared their data to the 2015 Vano-Galvan et al study. If you’d like to pause and review the helpful 2015 study by Dr Vano and his colleagues, please do so now.

The authors of the Sarkis et al study proposed that severe disease (and more widespread disease) was more common in women with FD than was seen in the 2015 Vano et al study and there was also a more frequent occurrence of pain, pruritus and other autoimmune associated scalp conditions.

Comments

This is an interesting study. First off, let me reminder readers that it’s the largest study of folliculitis decalvans to date for males or females …. so the authors are commended for this nice paper.

It’s hard to know with 100% certainty if the clinical features of FD in women are different than in males. Probably it is.

This study by Sarkis et al uses the 2015 Vano -Galvan study as a comparison and there are limitations in doing this. First,  Sarkis et al compared all their data to a mixed group of males and females so it’s not just males.

It would seem that is it very much a possibility that more symptoms are present in females with FD and more mid scalp and vertex involvement is present in females with FD and more severe disease is present in females with FD.

However, one can’t totally ignore the fact that the Vano-Galvan 2015 study suggested that prevalence of severe disease is, in fact, similar in males and females with FD and so were symptoms. The 2015 study by Vano-Galvan suggested that of all the things that could differ - it was really only the age of onset and the presence of pustules that differed in males and females (Vano -Galvan et al suggested males with FD had younger age of onset and were more likely to have pustules than females). 

Clearly we don’t have all the answers.

I think that geography probably does matter when it comes to folliculitis decalvans. In fact, it probably matters with many hair diseases.

Is FFA in Asia different than FFA in Canada? It sure is!

Is FFA in black women different than FFA in white women? It sure it!

Is dissecting cellulitis in Brazil different than dissecting cellulitis in Sweden? It sure is!

Is FD in Europe different from FD in Brazil. Probably it is!

The Vano-Galvan study was 82 patients from Spain. The Sarkis et al study is 150 patient from 10 countries, including 12 patients from Brazil with afro textured hair.

Does this matter?

Well probably.

It certainly could be that women with darker colored skin have different FD characteristics than patients with lighter colored skin. That’s not a huge stretch.

In my experience,  crusting, pustules and bleeding are frequently present in women with afro textured hair who have FD that I provide care to.

Could it be that FD in women with lighter colored skin is different than women with darker colored skin?

Absolutely it could be.

The second point is that these retrospective studies are challenging. Charts are often incomplete.  We know that when you ask patients directly certain questions you’ll get dramatically different questions than you find in charts. So comparing two retrospective studies is just that much more challenging.

Could these impact these results?

Sure.

But all in all, there is some degree of suggestion here that involvement of the mid scalp zones of the scalp may be more common in women with FD than males and possibly females with FD may have a more symptomatic and severe disease.

To build their case that FD in females is potentially more severe, the authors use the argument that so many more females in the Sarkis et al paper had steroid injections than in the Vano-Galvan et al study. The authors point out that triamcinolone acetonide was used more often in females in the Sarkis et al paper (45 %) than used in the Vano-Galvan study (15 %). They feel this is a supporting feature for more severe disease in females. Treatments are hard to compare across different countries. Certain countries have regional differences in treatments. We see that all the time. It certainly could be that FD in females is more severe but there are tremendous regional variations in treatments for any disease.

The Future!

All in all, this is a very nice study. It would be nice to see data comparing FD in Brazilian women with darker skin types compared to lighter skin types (or what the authors call Caucasian hair). This would be helpful. I suspect there will be many differences. In other words, there is probably not just one FD phenotype in females.

Also, how wonderful it would be for Vano -Galvan et al to compare their 82 patients (or at least a proportion of them) some 10 years later and see where things are at. If FD in females in Spain is different than in males, perhaps there would be a difference.

There are many questions that this paper by Sakris et al raises for me … and that’s really a feature of all interesting papers.

We don’t really have a good sense in this paper how well treatments work for FD in females as this was not really a paper closely examining the effectiveness of treatments. This is more or less a paper describing the clinical features of FD in women across these 10 centers.

REFERENCE

Sarkis A et al. Folliculitis Decalvans in women: a retrospective multicenter study of 150 patients. J Eur Acad Dermatol Venereol. 2023 Aug 18.

Vañó-Galván S et al. Folliculitis decalvans: a multicentre review of 82 patients. J Eur Acad Dermatol Venereol. 2015 Sep;29(9):1750-7.