Management of Folliculitis Decalvans: A Systematic Review.

Folliculitis decalvans (FD) and Tufted Hair Folliculitis (THF) present with recurrent episodes of follicular inflammation, pustules and crusting, predominantly of the scalp, leading to scarring alopecia. With no specific or optimal treatment available, FD/THF is difficult to treat and significantly impacts patients' quality of life. As new treatments have been reported for FD/THF management in recent years, we conducted a systematic review aiming to identify the types of treatments used in FD/THF, their effect, duration of effect (DoE), impact on patients' quality of life and any adverse effects impacting treatment. Registered with PROSPERO (CRD42023459898), we used PRISMA and SWiM guidelines, and Joanna Briggs Institute Critical Appraisal tools. We found 113 articles involving 728 patients, reporting on 2041 treatment episodes for 246 different treatments. Reported treatment effects were assessed, and descriptive statistics were used to calculate the median DoE for each. A mean age of 38.3 years with predominantly male (3.3:1) and Fitzpatrick I-IV skin type (85.2%) was noted. Reported treatments included systemic and topical antibiotics, corticosteroids, retinoids and ciclosporin, as well as biologic agents, photodynamic therapy, laser therapies, topical calcineurin inhibitors, radiation therapy, surgical procedures, platelet-rich-plasma injections, botulinum toxin A injections, Manuka honey and Ayurvedic treatments with leech therapy. Although limitations exist due to GRADE level of evidence being low to very low, our findings suggest systemic antibiotic monotherapy may not be as beneficial as previously reported. Combination therapy with systemic antibiotics, topical, local and/or other systemic agents may provide the best outcome and longest DoE for FD/THF patients, with a greater role for biologic agents and laser therapy in their management.