Topical dapsone for folliculitis decalvans: A retrospective cohort study

Abstract

To the Editor: Folliculitis decalvans (FD) is a cicatricial alopecia characterized by the presence of intrafollicular and perifollicular neutrophilic infiltrates.1Miguel-Gómez L. Rodrigues-Barata A.R. Molina-Ruiz A. et al.Folliculitis decalvans: effectiveness of therapies and prognostic factors in a multicenter series of 60 patients with long-term follow-up.J Am Acad Dermatol. 2018; 79: 878-883https://doi.org/10.1016/j.jaad.2018.05.1240Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Dapsone has shown to be effective in treating diseases characterized by abnormal neutrophil recruitment. Its topical formulation minimizes the risk of hematologic adverse effects.2Al-Salama Z.T. Deeks E.D. Dapsone 7.5% gel: a review in acne vulgaris.Am J Clin Dermatol. 2017; 18: 139-145https://doi.org/10.1007/s40257-016-0242-0Crossref PubMed Scopus (20) Google Scholar Herein, we describe the therapeutic response to topical dapsone in patients with FD. We designed a retrospective study including patients with FD treated with topical dapsone, with a minimum follow-up period of 12 months. The clinical diagnosis was confirmed by biopsy. All patients were prescribed topical dapsone gel 5% 3 times a week. To assess the effect of the treatment, we recorded the number of flareups and the total number of months with an oral antibiotic before and after introducing the drug. A flareup was defined as the clinical worsening of the condition, which led to a need for an oral antibiotic. The student t test and Wilcoxon test were used to analyze statistically significant differences between both the periods for parametric and nonparametric variables, respectively. All tests were 2-sided, and statistical significance was considered with P < .05. The study was approved by the local institutional review board. A total of 14 patients (8 female and 6 male patients) with a mean age of 42 years (range 32-62 years) were included. The mean time from diagnosis to starting dapsone was 15 months (range 0-38 months). The patients received topical dapsone for a mean time of 30 months (range 7-54 months). Overall, a median of 0.13 flareups per month took place before drug administration, whereas the frequency after its introduction was 0.03 flareups per month (Table I). This reduction was statistically significant.Table IClinical course and treatment of FD patients before and after the introduction of topical dapsonePatients' dataBefore topical dapsoneAfter topical dapsoneP < .05Mo of follow-up (mean, range)14.7 (0-38)30.2 (9-54).28Number of visits (median, range)3.5 (1-9)5 (2-8).43Number of inflammatory flareups (median, range)2 (1-4)1 (0-3).012Number of flareups/mo (median, range)0.13 (0-0.7)0.03 (0-0.09).001Mo in remission (mean, range)9.7 (0-31)26.7 (6-54).08Concomitant treatments (n, %) Topical corticosteroids13 (93)10 (71)NA Topical antibiotic6 (43)1 (7) Ciclopirox shampoo4 (29)1 (7)Number of intralesional triamcinolone injections per visit (mean, range)0.66 (0-1)0.57 (0-1).53Total number of patients (N, %)14 (100)14 (100)FD, Folliculitis decalvans; NA, not applicable. Open table in a new tab FD, Folliculitis decalvans; NA, not applicable. No patient reported adverse effects. Three patients discontinued the treatment during the SARS-CoV-2 pandemic; 2 of them presented with a severe flareup a few weeks later. Interestingly, in 3 patients, there was a change over to the FD-lichen planopilaris phenotypic spectrum during the treatment. The aim of the treatment in patients with FD is to minimize the number of outbreaks and slow the progression. Oral antibiotics are administered in cycles of 2-3 months, but relapses are common. With the increase in antibiotic resistance, it is necessary to look for therapeutic alternatives that reduce the systemic use of antibiotics and extend the periods that are free of inflammation.3Asfour L. Harries M. Folliculitis decalvans in the era of antibiotic resistance: microbiology and antibiotic sensitivities in a tertiary hair clinic.Int J Trichology. 2020; 12: 193-194https://doi.org/10.4103/ijt.ijt_98_20Crossref PubMed Scopus (3) Google Scholar According to previous studies, the mean time of remission after the administration of systemic antibiotics is 4.6-7 months.4Vañó-Galván S. Molina-Ruiz A.M. Fernández-Crehuet P. et al.Folliculitis decalvans: a multicentre review of 82 patients.J Eur Acad Dermatol Venereol. 2015; 29: 1750-1757https://doi.org/10.1111/jdv.12993Crossref PubMed Scopus (55) Google Scholar In our study, the number of flareups decreased, and they took longer to appear. We believe that the inhibition of neutrophils by topical dapsone prevents new outbreaks. Moreover, topical dapsone has been proven to be a well-tolerated treatment, with adequate compliance by patients.2Al-Salama Z.T. Deeks E.D. Dapsone 7.5% gel: a review in acne vulgaris.Am J Clin Dermatol. 2017; 18: 139-145https://doi.org/10.1007/s40257-016-0242-0Crossref PubMed Scopus (20) Google Scholar Therefore, we consider the application of dapsone gel 5% 3 times a week to be a regimen with promising results in reducing the number of outbreaks. Limitations such as the small sample size, retrospective, uncontrolled nature of the study, and concomitant use of other treatments must be noted. In conclusion, our study describes the preliminary results of topical dapsone as a novel therapeutic option for FD. This therapy showed promising results in reducing the frequency of flareups, and it was well tolerated by the patients. None disclosed.