FOLLICULITIS DECALVANS

In recent years cases have been reported,⁶ chiefly by French writers,
under the names folliculite épilante (Quinquaud) ,⁷ folliculites et péri-
folliculites décalvantes agminées (Brocq),⁸ alopécie cicatricielle innominée
(Besnier), acné decalvante (Lailler⁹ and Roberts),¹⁰ lupoid sycosis (Mil­
ton, Brocq), ulerythema sycosiforme (Unna), which represent somewhat

¹ Jamieson, Diseases of the Skin.

² Rietema, “Rep. Netherlands Derm. Soc’y,” in Brit. Jour. Derm., 1898, p. 268.

³ Balzer and Stoianowitch, Jour, des pracliciens, Feb. 11, 1899, p. 81.

⁴ Jersild, “Quelques cas de palade traités par les rayons chimiques concentrés,”
Annales, 1899, p. 20.

⁵ Jackson, “Notes on the Treatment of Alopecia Areata,” Jour. Cutan. Dis., Jan.,
1910.

⁶1 am indebted for some of the information in this article to Robinson’s excellent
résumé of the subject in Morrow’s System, vol. iii, p. 873, and also to Hallopeau and
Leredde’s description, Traitê pratique de Dermatologie, 1900, p. 391, and Sabouraud’s
recent work.

⁷ Quinquaud, Bull, de la Soc. Med. des Hôp., 1888, p. 395; Annales, 1888, p. 657,
and 1889, p. 99.

⁸ Brocq, Bull, de la de Méd. des Hôp., 1888, p. 400, and Annales, 1889, p. 467.

⁹ Lailler, Annales, 1889, p. 100.

¹⁰ Roberts, These de Paris, 1889.

FOLLICULITIS DECALVANS                           1011

varied but allied conditions (Ducrey and Stanziale),¹ of which the chief
symptom is follicular destruction with scarring. Ulerythema sycosi-
forme and lupoid sycosis will be found referred to under Sycosis. The
acné décalvante of Lailler and Roberts and Quinquaud’s disease are the
same affection. The various cases, not considered elsewhere, can be
conveniently divided into two varieties, both doubtless the one disease,
with differences in the degree of follicular inflammation.

In one—the variety especially described by Quinquaud (Quinquaud’s
disease) and which probably furnishes the most cases—the follicular
inflammation, sycosiform in character, is a readily perceptible feature
of the malady. The scalp,
and more especially ante­
riorly, is its usual site, but it
is also observed in the beard,
and may even occur in the
pubic and axillary regions.
On examination the inflam­
matory lesion is noted to be
a small papule, scarcely as
large as a pin-head, or
merely a red follicular eleva­
tion; or it is, as in the typical
cases, distinctly a pustule,
small, and, like the pustule
in sycosis, usually without
basal infiltration. These pus­
tules dry to thin crusts. In
some instances the lesion ap­
pears to be a mere pin-point-
to pin-head-sized crusted
abrasion. Whatever its char­
acter, the center is pierced
by a hair, as in sycosis. This
soon loosens, however, and falls out, and finally a minute cicatrix results.
The lesions may be discrete and scattered, but commonly the adjoining
follicles take on the same action, and gradually there presents the picture
usually seen when the patient seeks advice: there is a central, dime-
to silver-quarter-sized or larger, irregularly rounded, depressed, bald,
cicatricial patch, white and often glistening, usually smooth, and the
peripheral portion studded here and there with the minute red follicular

Fig. 252.—Folliculitis decalvans (courtesy of Dr.
G. T. Jackson).

¹ Ducrey and Stanziale, Giorn. ital., 1892, p. 239; abs. in Annales, 1893, p. 498
(8 personal cases and a review of the subject). In a recent valuable paper on alopecias
with atrophy (“pseudo-pelade” variety) Brocq, Lenglet, and Ayrignac (Annales, 1905,
pp. 1, 97, and 209) review and analyze reported cases (29) and 22 new cases (Brocq);
about 80 per cent, of the cases were males, and only 1 case was observed in a child;
syphilis had no etiologic relationship, but tuberculosis has been a somewhat frequent
association; the infiltration was made up chiefly of lymphocytes, but plasma-cells, mast-
cells, and eosinophiles were also found, and a number of pigment-cells in the papillary
zone and corium was a constant finding; bacteriologic investigations have disclosed noth­
ing definitely. Grünfeld, “Ueber Folliculitis Decalvans,” Archiv, 1909, vol. xcv, p. 333,
reports 5 cases (3 case illustrations), reviews the subject, and gives full bibliography.

1012                     DISEASES OF THE APPENDAGES

elevations, pustules, or crusted points. In this manner the malady ad­
vances, leaving destroyed follicles and cicatricial tissue. Occasionally
some of the central follicles may have been missed, and the area thus
shows one or two islets of hair centrally. The disease is generally ex­
tremely slow in its progress, and there may be periods of quiescence;
and in some cases, after a time, the malady ends spontaneously, but this
is not its ordinary course, for, as a rule, it is slowly progressive or appears
at new points. As the follicles are destroyed there is no new hair growth;
in fact, the destruction usually involves all the dermic tissues. In most
instances there are no subjective symptoms—occasionally, in some cases,
slight itching.

In the other variety of folliculitis decalvans, the pseudopelade of the
French, the follicular inflammation is not so apparent, and the patch
simulates alopecia areata. A slight rosy tint or faint redness, with a
trifling amount of tumefaction surrounding the follicles, indicative of a
mildly inflammatory action, is noted, and the hairs at the involved spot
or point can be readily withdrawn, or, as in the other variety, drop out
spontaneously. Robinson noted that the extracted hairs have a glossy
sheath, which is thickened and extended. The malady may present but
one or two spots, or it may be disseminated, and with small areas. The
process leaves behind polished cicatricial, hairless areas, smooth and ivory-
like. When an area has reached the size of a silver quarter, it usually
presents the following appearance: On first sight it strongly suggests
alopecia areata; it is observed to be white, smooth, glossy, with cicatricial
thinning and obliteration of the follicular openings; depressed, especially
centrally, and with, on close examination, a slightly raised, rose-tinted
or pale-red, tumefied border, from which some of the hairs can usually
be easily extracted; not infrequently there is a slight keratotic tendency
in the follicular outlets of the border, and there is, if the part has not
been recently washed, a faint suggestion of branny scaliness. The patch
bears a slight resemblance also to lupus erythematosus, except that the
cicatricial thickening usually observed in this latter affection on the scalp,
the dull white color, and the characteristic border are wholly wanting.
While the patches are sometimes well rounded, as in an instance recently
observed by myself, they are often irregular, and spread by jutting out
here and there. Quinquaud observed some cases in which the inflam­
matory characters were still less marked than here described, or almost
entirely lacking, the sole symptoms consisting of falling of the hair,
with disappearance of the pilosebaceous glands, and a resulting faintly
cicatricial-looking plaque.

Etiology and Pathology.—The malady is rare. It is more
common in males, and usually develops between the ages of thirty and
forty years (Brocq). Dubreuilh’s¹ 4 cases of the pseudopelade variety
were women. The patients under my own care were mostly adult
males and past thirty. The cases, for the most part, are found among
the working-classes. Payne² has, however, recently described a rather
markedly inflammatory and somewhat anomalous example in a young

¹ Dubreuilh, “Des alopécies atrophiques,” Annales, 1893, p. 329.

² Payne, Brit. Jour. Derm., 1895, p. 101.

FOLLICULITIS DECALVANS

1013

girl aged fourteen. Patients usually seem in good health, and it is diffi­
cult to assign a cause. Payne’s case was the subject of hereditary syphilis.
Fournier (quoted by Payne) also observed one similar instance. These
2 instances must, I believe, be considered exceptional, however, as the
malady is scarcely suggestive of a syphilitic nature. Besnier believes
that gastric, hepatic, and intestinal disturbances have an etiologic
bearing. Quinquaud found various organisms, one of which he consid­
ered etiologic; animal inoculation experiments were partially, but not
wholly, confirmatory of its causative relationship. His findings lack
corroborative testimony, however, although there is scarcely a doubt
that the disease is a parasitic one.

Histologically, according to this same observer, evidences of a mildly
inflammatory process are disclosed; in the earliest stage of the lesion,
consisting of a collection of young cells encompassing the hair-follicle,
especially at its upper part; the same, but only to less marked extent,
is observed about the sebaceous glands, and also in the immediately
adjacent rete and corium. The subsidence of the inflammatory action
is followed by atrophic changes in all the dermal parts, hair-follicles
and sebaceous glands disappearing.

Diagnosis.—The diagnostic characters are the hairless, atrophic,
or cicatricial spot or plaque and the bordering inflammatory follicular
lesions; these serve to distinguish it from alopecia areata; and these
with the other differences, already referred to, from lupus erythematosus.

Prognosis and Treatment.—The malady, as already indi­
cated, is usually a persistent one, with little if any tendency to spon­
taneous cure. It is also rebellious to treatment, but proper measures
are of benefit and may bring about a disappearance of the eruption.
Constitutional treatment seems of questionable value, but both cod-
liver oil and the hypophosphites with iron and arsenic may prove of
benefit. Payne’s case improved under potassium iodid and mercury.

The local treatment is essentially that of sycosis, a somewhat kindred
affection. The surrounding hair should be clipped, that in the per­
ipheral inflammatory lesions extracted (Pringle), and an advantage
also accrues, I believe, from depilating the surrounding healthy follicles.
A saturated solution of boric acid, with 3 to 20 grains (0.2-1.35) of
resorcin to the ounce (32.), is of service in some cases, supplemented
with a resorcin-salicylic acid salve: R. Ac. salicylici, gr. v-x (0.33-0.65);
resorcin, gr. iij-x (0.2-0.65); ung. aquæ rosæ, 5iv (16.). Painting on a
salicylic acid collodion, 2 to 5 per cent, strength, also occasionally seems
to act well. White precipitate, calomel, and sulphur ointments, from
10 to 60 grains (0.65-4.) to the ounce (32.) of vaselin, may also be tried.
Hallopeau and Leredde recommend an ointment made up of 50 grains
(3.) of ß-naphthol, 24 grains (1.5) of salicylic acid, 5 drams (20.) of
vaselin, and 2½ drams (10.) of talc. As some of the cases are easily irri­
tated, a smaller quantity of naphthol would be advisable at first. The
scalp or affected parts should be frequently washed with soap and water,
preferably the tincture of green soap, and a mild antiseptic applied every
day or so to the region generally.

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