Refractory Folliculitis Decalvans Treatment Success with a Novel Surgical Excision Approach Using Guarded High-Tension Sutures

Introduction

Folliculitis decalvans (FD) is a debilitating condition that causes chronic inflammation and primary scarring alopecia. FD mainly affects middle-aged men and results in cicatricial alopecia and pustular plaques or masses. FD accounts for 10.5% of cicatricial alopecia cases and 2.8% of all alopecia cases.¹ While the etiology of FD has not been fully elucidated, Staphylococcus aureus has been reported to play a role in the disease.² Currently, there is no standard treatment for FD. Moreover, treatment options are suboptimal, often resulting in only temporary remission.^2–7 These therapeutic options include systemic antibiotics,^1–6 topical and intralesional corticosteroids,^1,3–6 isotretinoin,^6,7 tumor necrosis factor-alpha inhibitors,⁸ and photodynamic therapy,¹ with the most promising of these treatments (isotretinoin) showing a high relapse rate (>50%) within 2.5–3 months of stopping treatment.⁷ While the continuation of low-dose isotretinoin may control the disease in up to 33% of cases,⁷ it is not a viable path for many patients given isotretinoin’s poor toxicity profile.⁹

Longer-term remission has been reported, mainly in small, uncontrolled studies, after permanent hair elimination via laser hair removal^10,11 or radiation,¹² emphasizing the disease’s folliculocentric nature. However, the dynamics of laser functions suggest that their application may be limited to thin or atrophic lesions with follicular presence.^10,11,13 Furthermore, radiation is inapplicable in most instances because of its higher potential for adverse effects (including skin cancer). Although both lesions and hair can be removed using surgical methods, there have been no reports on surgical therapies for FD. Here, we describe surgical excision and closure by second intention healing (SIH) aided by guarded high-tension sutures, which were used to resolve FD in five patients in whom years of various conventional treatments had failed.

Methods

All patients provided written informed consent for surgical excision. All procedures were conducted per the Declaration of Helsinki (revised in 2013) Institutional Review Board approval was not required or sought as this study was not a prospective or systematic investigation of FD treatment but described the general principles for surgical excision of scalp lesions.

All patients in this retrospective study who underwent surgical excision for FD lesions had failed prior therapies, rejected the continuation of drug treatments, failed, declined, or were poor candidates for laser or radiation therapy.

Patients with thick mass lesions devoid of follicles were also considered poor candidates for laser hair removal treatment.

The surgeries were performed in a single Los Angeles clinic between March 2021 and June 2022. The diagnosis of FD was based on clinical examination and histologic findings (Figure 1).

Figure 1 Hematoxylin and eosin-stained biopsy lesion taken from FD-diseased areas of the scalp showing follicular obliteration by acute and chronic inflammatory cell infiltrate (blue arrow) with dermal scarring (red arrows) magnification x2 (A) and inflammatory cell infiltrate composed of mature lymphocytes and neutrophils (green arrow) magnification x10 (B). Abbreviation: FD, folliculitis decalvans.

Local anesthesia was achieved by injecting 1% lidocaine and a 1:200,000 epinephrine solution into the lesion margins. This was then further diluted with Ringer’s lactate at a 10:1 ratio and injected into the supragaleal plane of the entire lesion to achieve tumescent anesthesia and hydrodissection.

The lesions were excised using an electrosurgical tip with a 0.5–1 cm margin carried to the galeal plane (Figure 2A). Hemostasis was achieved using electrocoagulation and suturing. No undermining was performed. Hair follicles in the wound margins were deliberately destroyed by cautery to minimize the potential for isomorphic reactivation of FD from inflammation of entrapped hairs in the scar of the healing wound margins.¹⁴

Figure 2 Patient 1: Postoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp, immediately after excision (A); tension Suture guards to enable high-tension horizontal mattress suturing with less tissue tear-through or risk of tissue strangulation. Showing side (top) and top (bottom) views.(B), and postoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp immediately after applying high-tension sutures with guards in a horizontal mattress fashion and long suture tails to enable retightening as needed. The wound bed is filled with bacitracin antibiotic ointment (C). Abbreviation: FD, folliculitis decalvans.

The wound edges were pulled as close to each other as possible (but no less than 1 cm) under high tension. Finally, they were fixed in place using size 0 polydioxanone sutures placed in a horizontal mattress fashion, bolstered by a medical-grade plastic guard, which the lead author designed to minimize tissue tear (Athena Suture Guards^®; Dr. U Devices, Manhattan Beach, CA).¹⁵ (Figure 2B) Long suture tails were instituted to enable retightening as needed (Figures 2C and 3A).

Figure 3 Patient 3: Postoperative FD plaque involving the vertex, and mid-scalp, immediately after applying high-tension sutures with guards in a horizontal mattress fashion. The wound bed is filled with bacitracin antibiotic ointment. (A) At eight weeks postoperatively, a small STSG derived from the anterior thigh is used to close the residual open wound (red arrow). Tenting of skin from tension suture effect is visible (yellow arrows) (B). Abbreviations: FD, folliculitis decalvans; STSG, split-thickness skin graft.

The patients were discharged on a 7-day course of oral cephalosporin with instructions to return the following day for wound inspection and hemostasis surveillance.

The wounds were left open to allow complete closure by SIH. Daily wound care was performed using a solution of diluted acetic acid in distilled water for cleaning and Aquaphor^® or bacitracin ointment (Figures 2C and 3A). Residual open wounds, often minor, if found at 8–12 weeks, were closed by applying a small split-thickness skin graft (STSG) (Figure 3B). High-tension sutures were removed once they became lax owing to wound contraction, typically between 4–6 weeks, with the option of retightening at 4 weeks. The remaining scalp was assessed for commonly associated conditions such as acne keloidalis nuchae (AKN)^16–18 and scalp-wide histologic evidence of perifollicular infundibulo-isthmic lymphocytic infiltrates and fibrosis, an lichen planopilaris (LPP)-like condition^19–21 These conditions were treated separately after completing FD treatment.

Results

Demographic and treatment detail are summarized in Table 1. Five patients (4 men and 1 woman) had their FD lesions excised using the described surgical method. The average age was 37 years (range 32–47). All achieved complete remission at 10–24 months of follow-up (Tables 1, 2 and Figures 4–8).

Table 1 Demographic and Pre-Surgical Data on Five Patients That Underwent Surgical Excision of FD Lesions with SIH Aided by Guarded High-Tension Suturing

Table 2 Surgical and Post-Surgical Data on Five Patients That Underwent Surgical Excision of FD Lesions with SIH Aided by Guarded High-Tension Suturing

Figure 4 Patient 1: Preoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp. (A) Thirteen months after complete excision of FD lesion and healing by second intention, aided by high-tension sutures with guards and a minor skin graft (B). Abbreviation: FD, folliculitis decalvans.

Figure 5 Patient 2: Preoperative FD plaque involving the vertex, mid-scalp extending to the frontal scalp, and acne keloidalis nuchae in the nape area (A) and nineteen months after complete excision of FD lesion and healing by second intention, aided by guarded high-tension sutures and a minor STSG (Green arrow). The tenting skin has flattened out (yellow arrows (B). Abbreviations: FD, folliculitis decalvans. AKN, acne keloidalis nuchae. STSG, split-thickness skin graft.

Figure 6 Patient 3: Preoperative FD plaque involving the entire vertex. (A) and eight months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures and a minor skin graft(B). Abbreviations: FD, folliculitis decalvans. AKN, acne keloidalis nuchae. STSG, split-thickness skin graft.

Figure 7 Patient 4 with FD plaque involving the right parietal prominence area before surgical excision and AKN lesions in the nape zone. (A) and four months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures and a minor skin graft (B). Abbreviations: FD, folliculitis decalvans; AKN, acne keloidalis nuchae.

Figure 8 Patient 5 with FD plaque involving the right parietal prominence area before surgical excision. (A) and nine months after complete excision of the FD lesion and healing by second-intention, aided by guarded high-tension sutures (B). Abbreviation: FD, folliculitis decalvans.

Two of the five patients with coronal wound diameters exceeding 10 cm required minor STSG for complete wound closure (Table 2 and Figure 3). The other three patients, with 10 cm or less coronal wound diameters, did not require skin grafting (Table 2, Figures 4, 7, and 8). In both cases requiring STSG, the skin grafts measured between 20–33% of the excision wound size (Table 1). A maximal wound diameter contraction of 47–83% was noted. All patients tolerated the procedure well without side effects, and remained in complete remission over a mean (SD) follow-up period of 17 months (6.1).

Discussion

Our case series demonstrates the successful treatment of refractory FD of various sizes by surgical excision and second-intention healing aided by high-tension suture guards with long-term remission. We are not aware of any reports of FD treatment by surgical excision.

Second-intention healing is an optimal surgical approach for addressing excised lesions located in relatively concave body surfaces.^22–24 However, FD, which typically occurs on the convex or flat surface of the vertex and mid-scalp, does not benefit from a concave surface. Despite the disadvantageous convex location, all five FD excision wounds showed significant wound contraction, suggesting a role for the guarded high-tension suturing technique.

In second-intention healing, wound closure occurs through the combined processes of wound contraction (results in wound size reduction) and epithelization (results in no reduction in wound size). The lead author has shown in a previous publication that the application of tension tilts the process in favor of wound contraction, which has the effect of the wound edges closing in towards each other, reducing the final scar formed.²² The mechanism by which tension causes wound contraction is supported by studies that have shown that under tension, fibroblasts transform to proto-myofibroblasts and eventually myofibroblasts^25,26 which are crucial to the ability of the wound to contract.²⁷ Another benefit of using tension sutures, is that, it enables the surgeon to control the final shape of the wound by manipulating tension at various locations along tension sutures.²² This process is primarily mediated by contractile forces induced by the tension sutures, which prompt the deposition of collagen and fibronectin-rich extracellular matrix (ECM) by the resident fibroblasts. The newly synthesized collagen and ECM, together with the fibroblasts, exhibit distinctive alignment patterns parallel to the wound bed and in accordance with the anticipated lines of mechanical stress.^24,27

In all patients, the objective of permanently eliminating FD-diseased tissue was achieved. Wounds with coronal diameters ≤10 cm closed completely without skin grafting. In two patients where the coronal wound diameter exceeded 10 cm, a skin graft of a significantly smaller area, 20–33% of the original wound, was applied. Our 17-month follow-up without ancillary FD treatment suggests that the observed complete remission was long-lasting.

Other surgical approaches we considered and dismissed included tissue expansion to harness flaps for closing the excision wound. This is limited by high invasiveness, the requirement for general anesthesia, and a complication rate of over 27%.²⁸ In addition, the theoretical potential of the surgical trauma of such a procedure to cause an isomorphic activation of LPP disease²⁹ in the rest of the scalp already showing LPP-like histology was a deterring consideration. Another option was excision with skin grafting, which is a two-stage surgery that creates an uncontracted Alopecic plaque of the same or larger size than the original lesions, bearing a striking contrast with the surrounding skin in color, texture and lack of hair.^30,31 Both tissue expansion and extensive skin grafting procedures require a specialized skill set and a significant investment in equipment. The outpatient methodology described in this paper for excision followed by SIH aided by guarded high-tension sutures confers some benefits, including maintaining the wound margins under continuous high tension in the direction of closure. This latter feature encourages wound contraction and guides closure toward the desired scar esthetics.^26,32 Furthermore, suture guards minimize suture cut-through by redistributing and diffusing the high-tension vectors away from their natural tendencies of dragging the suture skin entry points toward the wound edges and cutting through. Traditional horizontal mattress sutures, with or without gauze-reinforced bolsters, if performed under considerably high tension for a sustainable amount of time, would drag suture entry points toward the wound edge, tearing through the tissue.

Apart from the unwelcome effect of the wound, suture tear-through neutralizes the high tension needed to keep the edges close to the desired proportions set by the surgeon. The result would be a diminution or even failure of the process, poor esthetics caused by new scars from the suture tears, and a final scar now off-kilter and wider due to failed or poorly controlled contraction. Another concern when using traditional horizontal vertical mattress suturing under very high tension with or without gauze bolsters is tissue strangulation due to strangulated vasculature; the plastic suture guard features foot pads (Figure 2) to minimize the pressure exerted on underlying tissue, thus canceling the risk of strangulation. Furthermore, the porous nature of gauze or cotton bolsters presents an added risk of infection if left in a wet wound environment for the 4-week period they are required to be in place. Lastly, current suture guards are often designed for short-term use in wounds that are closed primarily by stitching.³³ Also, the sutures on the bridging apparatus in current suture bridges would cross the wounds at their surfaces, thereby obstructing access to the wound bed and complicating wound care and hygiene necessary during the long SIH period.³⁴ A suture guard designed for use in a horizontal mattress fashion ensured unobstructed access to the open wound, allowing the daily wound care needed to maintain wound hygiene over the weeks required for its closure.

Wound undermining was avoided to provide the high-tension suture guards with a firm base to sit. Additionally, the risk of undermined wounds compromises the blood supply to the wound edges resulting in hematoma, hemorrhage, and possible necrosis.³⁵ All of these could be accentuated in a wound whose edges are subjected to considerable tension forces.

Our experience with Patient #1 suggests that the healing course can be prolonged in those with poor healing tendencies, evidenced by delayed or suboptimal granulation tissue formation. Using wound healing accelerators such as platelet-rich plasma³⁶ may be beneficial in such instances.

The association of FD with AKN is well established with studies, including two published by the lead author reporting a 7–24% association and suggesting a possible common pathoetiology.^16–18Three out of five patients in our cohort had separate AKN lesions in their nape zones that were treated by either an electrosurgical knife or punch excision (Table 1). Furthermore, the presence of an LPP-like disease in the remaining non-FD scalp is a recognized phenomenon^19–21 and may influence prognosis; this should be investigated in all FD patients using trichoscopy and histology and treated as a separate entity when found.³⁷ In our patients, LPP-like zones were treated with topical tacrolimus (1 week alternating with 2 weeks off) or a topical botanical (Gashee^®, FineTouch Laboratories. Manhattan Beach, CA) daily.³⁸

Limitations

The study was limited by the retrospective nature of this case series and the limited number of patients.

Conclusion

Surgical excision with second intention healing aided by the described guarded high-tension suture apparatus effectively treated small and extensive refractory FD lesions with long-term remission in our patient cohort. Further validation in larger controlled studies is warranted. To our knowledge, this is the first report of successful surgical treatment success of FD.