Fig. 15.1
Upper panel demonstrates partial hair loss with underlying erythema and tufts of hair in tufted folliculitis. Lower panel demonstrates a Caucasian patient with sterile follicular pustules and mild hair loss; variant of folliculitis decalvans
Case
A patient presents with recurrent lesions over the scalp that start as pustules. Examination reveals crusted excoriations and a rare follicular papule or pustule. Few small hairless patches are also present. The remainder of skin examination is unremarkable.
Clinical differential diagnosis includes
bacterial folliculitis
folliculitis decalvans
erosive pustular dermatosis EPD
fungal folliculitis, and
acne necrotica.
Clinical Clues
Patients with bacterial folliculitis of the scalp frequently excoriate the lesions, so physical examination may not reveal intact pustules, making the diagnosis often difficult. In addition, patients with scalp pruritus may develop secondary bacterial folliculitis due to scratching. Determining whether the bacterial folliculitis is primary or secondary may be difficult. A therapeutic trial with antibiotics is justifiable in such cases. If intact pustules are present, bacterial cultures should be obtained.
In adults, fungal folliculitis (tinea capitis) is extremely rare. Clues to its diagnosis include breakage of hair close to the scalp and sometimes scaling. In adults, a kerion may be misdiagnosed as dissecting cellulitis. A high index of suspicion is required in order to make the diagnosis. Pityrosporum folliculitis involves the trunk most commonly, the face occasionally, and the scalp rarely.
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