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• W3204181722 abstract "Folliculitis decalvans (FD) is a rare condition that affects young people, with a slight predominance in males. The lesions start with follicular erythema that progresses to pustules. The pustules evolve into a crust, leading to hair loss and scarring alopecia. The etiology of FD is unknown but could involve an inadequate immune response to Staphylococcus aureus, resulting in a chronic inflammatory reaction of the affected area. Treatment of FD can be challenging. The aim of the treatment is to stop the development of pustules and the extension of irreversible alopecia. However, because the disease is rare, we lack sufficient evidence on the efficacy of therapy. In clinical practice, systemic and topical antibiotics, retinoids, dapsone, zinc, and/or topical tacrolimus are generally used.1Vañó-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: 1750-1757Crossref PubMed Scopus (50) Google Scholar Some reports of treatment of FD with photodynamic therapy (PDT) have been published, with encouraging results.2Castaño-Suárez E. Romero-Maté A. Arias-Palomo D. Borbujo J. Photodynamic therapy for the treatment of folliculitis decalvans.Photodermatol Photoimmunol Photomed. 2012; 28: 102-104Crossref PubMed Scopus (17) Google Scholar,3Miguel-Gomez L. Vano-Galvan S. Perez-Garcia B. Carrillo-Gijon R. Jaen-Olasolo P. Treatment of folliculitis decalvans with photodynamic therapy: results in 10 patients.J Am Acad Dermatol. 2015; 72: 1085-1087Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar These positive results may be due to the antibacterial and immunomodulation effects of PDT.4Castano A.P. Mroz P. Hamblin M.R. Photodynamic therapy and anti-tumour immunity.Nat Rev Cancer. 2006; 6: 535-545Crossref PubMed Scopus (1807) Google Scholar However, the use of this treatment is limited due to the variability of the illumination as well as the pain it causes, which is considered its main side effect. Moseley et al5Moseley H. Light distribution and calibration of commercial PDT LED arrays.Photochem Photobiol Sci. 2005; 4: 911-914Crossref PubMed Scopus (42) Google Scholar showed that 2 commercial light-emitting devices did not provide uniform light and demonstrated that the fluence rate could be 30% lower than that delivered to the central zone at a distance of only 2 cm from the central zone. To overcome this disadvantage, the development of a flexible light source appears to be an interesting solution for nonplanar surfaces such as the scalp. Recently, a textile PDT device incorporating light-emitting fabric was developed (Fig 1, A and B).6Cochrane C. Mordon S.R. Lesage J.C. Koncar V. New design of textile light diffusers for photodynamic therapy.Mater Sci Eng C Mater Biol Appl. 2013; 33: 1170-1175Crossref PubMed Scopus (46) Google Scholar The treatment of actinic keratosis with textile PDT showed promising results in terms of efficiency and tolerance (visual analog scale [VAS], 0.3/10).7Mordon S. Vignion-Dewalle A.S. Abi-Rached H. et al.The conventional protocol vs. a protocol including illumination with a fabric-based biophotonic device (the Phosistos protocol) in photodynamic therapy for actinic keratosis: a randomized, controlled, noninferiority clinical study.Br J Dermatol. 2020; 182: 76-84PubMed Google Scholar Moreover, the flexible nature of this device appears to be well suited for use on curved surfaces such as the scalp, resulting in uniform illumination.6Cochrane C. Mordon S.R. Lesage J.C. Koncar V. New design of textile light diffusers for photodynamic therapy.Mater Sci Eng C Mater Biol Appl. 2013; 33: 1170-1175Crossref PubMed Scopus (46) Google Scholar Here, we report a series of 4 patients with FD treated with textile PDT, showing excellent tolerance and good clinical outcomes. All 4 patients gave their informed consent. The affected area was delimited, and hair on the edge was cut or shaved to improve the precursor and light penetration. Methylaminolevulinate (Metvixia, Galderma) was applied on the affected area and 1 cm around. After 30 minutes under occlusion, a transparent plastic dressing and the light-emitting textile device were applied. Illumination was performed with red light (635 nm) for 2 hours and 30 minutes. The light irradiation was between 12 and 37 J/cm2, depending on the device. Patient 1 was a 24-year-old man with a 5-year history of FD that had been treated unsuccessfully with multiple antibiotics, dapsone, and systemic retinoids. The physical examination revealed a large area of cicatricial alopecia with numerous erosive lesions and some pustules (Fig 2, A). The symptoms (exudate and pain) caused severe functional impairment. Three sessions of textile PDT at 37 J/cm2 were performed at 1-week intervals. Systemic retinoids were stopped on the day of the first PDT session. Tolerance was excellent during the illumination (VAS, 0/10). A few crusts and light erythema spontaneously resolved within 2 days after the treatment. Favorable treatment outcomes were noticeable at 3-month follow-up. There were clear reductions in pain, burning, and oozing, and the pustules had resolved (Fig 2, B). The alopecia was relatively stable, with a slight progression at the center of the alopecic area. Control of the disease lasted for 4 months. Adalimumab 40 mg every 2 weeks was then prescribed, allowing stabilization of the disease. Patient 2 was a 37-year-old man who received a diagnosis of FD 10 years previously. He had been treated with systemic retinoids and topical and systemic antibiotics without any improvement. He had had no treatment in the past year. The physical examination showed a cicatricial alopecic area, with pustules and crusts on the periphery (Fig 3, A). Three sessions of textile PDT at 12 J/cm2 were performed at 1-month intervals. Tolerance was excellent (VAS, 0/10). Light erythema and edema were noted after each illumination. The evolution was favorable at 3 months, with a decrease of symptoms such as pain and burning and stability of the alopecic area (Fig 3, B). Systemic retinoids were then prescribed for a period of 6 months, allowing stabilization of the disease. At 2 years of follow-up, the disease was stable and the patient only applied topical moisturizers. Patient 3 was an 18-year-old man who received a diagnosis of FD 2 years previously. Systemic retinoids were contraindicated because of liver fibrosis. He had been treated with systemic and topical antibiotics, which improved symptoms but were stopped after 1 month because of noncompliance. The physical examination showed multiple nodules, pustules, and crusts of the occipital area and the temples, with a few alopecic areas. Three sessions of textile PDT at 12 J/cm2 were performed at 1-month intervals. Tolerance was excellent (VAS, 0/10). The evolution was favorable, with no sign of disease activity 6 months after treatment. Patient 4 was a 38-year-old man with scalp dermatosis that was initially diagnosed as psoriasis. He had undergone multiple treatments for psoriasis, including local corticosteroids and methotrexate, which were partially effective in reducing the FD symptoms. In addition, 40 mg of adalimumab every 2 weeks had been initiated 7 years previously, which reduced the flareups of FD. FD was diagnosed a few years later. Treatment with systemic antibiotics had a partial effect. Despite these multiple treatments, the disease was still active. The patient continued adalimumab throughout the PDT treatment course. The physical examination showed a large alopecic area 7 cm in diameter with erythema and pustules and symptoms such as itching, burning, and oozing. Three sessions of textile PDT at 12 J/cm2 were performed at 1-month intervals. Tolerance was excellent (VAS, 0-2/10). The evolution was favorable, with decreases in erythema, pruritus, and oozing and stability of the alopecia. There was no evidence of flareups in the 6 months following the last session. Our case studies show that PDT sessions resulted in stabilization of FD and a decrease in symptoms in all 4 patients, with excellent tolerance (VAS, 0-2/10). All patients indicated that the reduction of symptoms resulted in a significant improvement of their quality of life (not assessed with a standardized score). The PDT sessions of the first patient were performed at 37 J/cm2, and the PDT sessions of the next 3 patients were performed at 12 J/cm2, according to the device available at the time. There was no difference between light irradiation of 12 and 37 J/cm2 in the effectiveness of treating actinic keratosis.7Mordon S. Vignion-Dewalle A.S. Abi-Rached H. et al.The conventional protocol vs. a protocol including illumination with a fabric-based biophotonic device (the Phosistos protocol) in photodynamic therapy for actinic keratosis: a randomized, controlled, noninferiority clinical study.Br J Dermatol. 2020; 182: 76-84PubMed Google Scholar One patient was prescribed adalimumab during PDT sessions, which may have had a synergistic effect against FD. The reported clinical results of treatment of FD with PDT are variable.8Miguel-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: 878-883Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,9Rambhia P.H. Conic R.R.Z. Murad A. Atanaskova-Mesinkovska N. Piliang M. Bergfeld W. Updates in therapeutics for folliculitis decalvans: a systematic review with evidence-based analysis.J Am Acad Dermatol. 2019; 80: 794-801.e1Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Miguel-Gomez et al3Miguel-Gomez L. Vano-Galvan S. Perez-Garcia B. Carrillo-Gijon R. Jaen-Olasolo P. Treatment of folliculitis decalvans with photodynamic therapy: results in 10 patients.J Am Acad Dermatol. 2015; 72: 1085-1087Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar reported a prospective series of 10 patients treated by conventional PDT. Nine patients (90%) showed clinical improvement, and 6 patients (60%) had a persistent remission. The main side effect was pain. In contrast, in a study by Burillo-Martinez et al,10Burillo-Martinez S. Maroñas-Jimenez L. Palencia-Pérez S.I. Vanaclocha-Sebastián F. López-Gómez S. Failure of photodynamic therapy (PDT) in 3 patients with folliculitis decalvans.J Am Acad Dermatol. 2016; 74: e69-e70Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar PDT resulted in no improvement in all 3 patients and an overall worsening of the disease in 1 patient. All patients experienced discomfort that lasted from 1 to 3 days. Despite encouraging results in the treatment of FD, conventional PDT has 2 main disadvantages compared with textile PDT: variability of light delivery and pain. These 2 parameters are improved by using new light-emitting devices.7Mordon S. Vignion-Dewalle A.S. Abi-Rached H. et al.The conventional protocol vs. a protocol including illumination with a fabric-based biophotonic device (the Phosistos protocol) in photodynamic therapy for actinic keratosis: a randomized, controlled, noninferiority clinical study.Br J Dermatol. 2020; 182: 76-84PubMed Google Scholar,11Vicentini C. Vignion-Dewalle A.S. Thecua E. et al.Photodynamic therapy for actinic keratosis of the forehead and scalp: a randomized, controlled, phase II clinical study evaluating the noninferiority of a new protocol involving irradiation with a light-emitting, fabric-based device (the Flexitheralight protocol) compared with the conventional protocol involving irradiation with the Aktilite CL 128 lamp.Br J Dermatol. 2019; 180: 765-773PubMed Google Scholar,12Dubois M. Abi Rached H. Dezoteux F. et al.Real-life evaluation of the treatment of actinic keratoses by textile photodynamic therapy (FLUXMEDICARE® device).Photodiagnosis Photodyn Ther. 2021; 34: 102213Crossref PubMed Scopus (1) Google Scholar On the basis of our clinical experience, we believe that monthly to weekly sessions are required until the symptoms are controlled. The disease often recurs a few months after the sessions are stopped.1Vañó-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: 1750-1757Crossref PubMed Scopus (50) Google Scholar To avoid recurrence, regular sessions of PDT could be performed. Furthermore, a well-tolerated illumination device, such as textile PDT, facilitates multiple sessions. Systemic antibiotic therapy is currently the first-line treatment for FD, but it can increase bacterial resistance. Higher resistance rates of S aureus were shown in a cohort of patients with FD.13Asfour L. Trautt E. Harries M.J. Folliculitis decalvans in the era of antibiotic resistance: microbiology and antibiotic sensitivities in a tertiary hair clinic.Int J Trichology. 2020; 12: 193-194Crossref PubMed Scopus (3) Google Scholar Photodynamic therapy has antibacterial effects, with no resistance, and provides local immunomodulation,4Castano A.P. Mroz P. Hamblin M.R. Photodynamic therapy and anti-tumour immunity.Nat Rev Cancer. 2006; 6: 535-545Crossref PubMed Scopus (1807) Google Scholar,14Wan M.T. Lin J.Y. Current evidence and applications of photodynamic therapy in dermatology.Clin Cosmet Investig Dermatol. 2014; 7: 145-163PubMed Google Scholar which could help reduce the use of repeated antibiotic therapies and the risk of bacterial resistance. The bactericidal effect of PDT on S aureus biofilm has been shown in vitro, with more than 99% of bacteria killed after the treatment.15Zhang Q.Z. Zhao K.Q. Wu Y. et al.5-Aminolevulinic acid-mediated photodynamic therapy and its strain-dependent combined effect with antibiotics on Staphylococcus aureus biofilm.PLoS One. 2017; 12: e0174627Crossref PubMed Scopus (25) Google Scholar As with most other treatments used for FD, textile PDT may lead to transient results, but without any systemic side effects or development of bacterial resistance. It could potentially be synergic in combination with other treatments and thus serve as an alternative or combined treatment for FD. Photodynamic therapy using a new textile light-emitting device had a good outcome and excellent tolerance in 4 patients. This treatment could be an option in selected patients experiencing frequent flareups of FD and resistance to classical therapies. None disclosed." @default.
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• W3204181722 title "Treatment of folliculitis decalvans by photodynamic therapy using a new light-emitting device: A case series of 4 patients" @default.
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