Hair Transplants for Folliculitis Decalvans: Yes or No?

Can patients with folliculitis decalvans have a hair transplant?

Folliculitis decalvans (FD) is a type of scarring alopecia. It is less common than scarring alopecias such as lichen planopilaris. Treatments, such as oral antibiotics and oral isotretinoin, are viewed as the main (so called “first line”) treatments for folliculitis decalvans. They may help slow disease progression and in some cases stop the disease altogether. However, it can takes many months to even many years to stop the disease- and permanent arrest does not happen in all cases. When the disease completely settles and stops and the patient demonstrates that they are able to come off all medications (without their disease flaring) it may be possible for a hair transplant to be considered. Until that time, a hair transplant is contraindicated.

When might a hair transplant be possible?

In general, hair transplants for scarring alopecias are sometimes associated with poor growth. However, very carefully selected patients can sometimes do well with surgery and have reasonably good results - although in my opinion far too often patients with scarring alopecias undergo surgery when they are not (yet) good candidates. Some of the patients who undergo surgery when their disease is not yet calm (ie burnt out) have less than optimal outcomes. Large studies of hair transplant outcomes for patients with folliculitis decalvans have not been published in the medical literature but certainly I see the phenomenon routinely in my clinic (Post operative Complications Clinic, POCC).

Is poor growth the worst that can happen?

In contrast to the scarring alopecia lichen planopilaris, patients with folliculitis decalvans are more likely to have thick scar tissue in the scalp which further limits growth and survival of grafts. In addition to poor growth, disease reactivation can potentially occur after surgery. Most patients, and sometimes their surgeons too, incorrectly approach hair transplantation for patients with scarring alopecia with the overriding view that “the worst that can happen is poor hair growth.” This is incorrect as sometimes the disease reactivates even worse than if the patient had not gone ahead with surgery. The worst that can happen for the patient is persistent redness, pustules, itching, scalp itching, burning, pain and marked hair loss not to mention the psychological consequences. Of course extreme examples like this are uncommon but the point has been made. Severe complications and disease reactivation/flares are unlikely if the patient and his or her disease meets the criteria outlined below. FD must be inactive before surgery is considered.

Hair transplants are not often done in folliculitis decalvans.The medical literature contains few reports of successful hair restoration surgery in FD. In 2010, Tyagi reported 40 % graft survival in a patient with folliculitis decalvans who underwent FUE (follicular unit extraction). Follow up was only 6 months in duration which is insufficient follow up time for scarring alopecia. Some scarring alopecias reactivate 1-3 years following surgery leading the patient to lose all their grafts. 6 months carries little meaning in the world of scarring alopecia. If surgery is performed, I can not emphasize enough the importance of a consultation with a dermatologist prior to the procedure to confirm that the patient truly is a good candidate (and that they meet the five criteria below). This is too often overlooked as patients are eager to move forward with surgery. Such a consultation is essential. In addition, the importance of having an experienced surgeon perform the surgery. It is essential as grafts must be prepared properly, handled properly and inserted at the correct densities.

Criteria for Hair Transplant Candidacy in Folliculitis Decalvans

Several years ago, I published a set of helpful five criteria which helps guide physicians about whether or not they are good candidates for surgery.

1.  The PATIENT should be off all hair-related medications.

2. The PATIENT must not report symptoms related to the FD in the past 24 months. 

3. The PHYSICIAN must make note of no clinical evidence of active disease in the past 24 months. 

4. Both the PATIENT and PHYSICIAN must demonstrate no evidence of ongoing hair loss over the past 24 months. 

5. The patient must have sufficient donor hair for the transplant. 

interested readers can read more in the following link:

Donovan Hair Transplant Criteria - Folliculitis Decalvans

Conclusion

Hair transplants are possible for folliculitis decalvans but only for a subset of patients who have proven, beyond any doubt, that their disease is inactive. The patient and surgeon might hope for the best but be aware that outcomes and graft survival in folliculitis decalvans may be suboptimal.

Reference

Tyagi V, Singh PK: A new approach to treating scarring alopecia by hair transplantation and topical minoxidil. Indian J Dermatol Venereol Leprol 2010; 76: 215.