Homoeopathic approach in folliculitis decalvans- a rare but challenging disease
Dr Arpita Mondal
Abstract: Folliculitis decalvans is a Latin name meaning inflammation of the hair root associated with hair loss. This is a commonly found primary scarring alopecia, with an incidence rate of 1.9-11.2% in those diagnosed with any form of scarring alopecia. The medical term for permanent hair-loss due to scarring is â€˜cicatricial (Latin for scarring) alopeciaâ€™. This article is an attempt to discuss the various aspects of Folliculitis decalvans (a type of alopecia) which shall help us in early diagnosis of the condition as well as in providing effective management.
Introduction: The word alopecia comes from the Greek ‘alopex’ which is literally translated as fox’s disease. Alopecia is defined as a hair loss disease that affects men, women and children. The one set of hair loss is often sudden, random and frequently recurrent. While the disease itself is not damaging to the person’s health, coping with hair loss can prove challenging. As per reports scalp may contain about 1,00,000 hairs and normally 100 hairs may fall out every day. Except lips, palms and soles entire body is covered by hair of varying thickness and colour. Good blood supply to the papilla and a healthy body and mind would lead to normal hair growth. Environment, life style and food habits also play a vital role. Folliculitis decalvans (FD) is a rare , chronic cicatricial (scarring ) alopecia that classically presents as an expanding patch of alopecia with peripheral pustules on the scalp .
The cause of FD is unknown ; it is speculated that the disease reflects an abnormal response to bacteria , particularly , Staphylococcus aureus. Although the term “folliculitis decalvans” was coined by Brocq in 1905, earlier report of what was likely FD date back to the late 1800s. FD usually occurs in adults. Folliculitis decalvans is not catching or contagious and is not cancerous. Folliculitis is not usually hereditary, although there are rare reports of it affecting members of the same family. Very rarely it can affect other hair bearing areas of the skin. Some other conditions with similar appearance as folliculitis decalvans are Seborrhoeic dermatitis, Lichen planopilaris, Acne keloidalis, Dissecting cellulitis of the scalp, Kerion, Hydraedenitis suppurativa, Discoid lupus erythematosus & Acne necrotica.
Classification: FD is classified as a primary cicatricial (scarring) alopecia, a group of disorders in which an inflammatory process targets the hair follicle, resulting in follicular destruction and permanent hair loss (Figure 1). This is in contrast to secondary cicatricial (scarring) alopecia, in which scarring processes in the skin incidentally destroy hair follicles. FD was further classified as a primary neutrophilic cicatricial alopecia in a classification scheme created by the participants of a 2001 workshop on cicatricial alopecia sponsored by the North American Hair Research Society. This classification system was based upon the type of inflammatory infiltrate associated with specific subtypes of cicatricial alopecia.
Clinical features: FD can cause an area of the scalp to become itchy, tight, sore or even painful. Sometimes no discomfort is felt at all. The affected area of the scalp becomes red and swollen and may scab nd crust over. Pus filled spots may develop, most commonly on the back of the head, but any other part of the scalp can be involved. Eventually, scarring develops, and several hairs (‘tufts’) come of the same opening of the skin. This is called ‘tufting’ and looks similar to dolls-hair or bristles of a tooth brush. Finally a bald patch is seen, which gradually gets bigger.
Pathology: Scarring directly succeeds follicular abscesses with a polymorphonuclear infiltrate, or there may be a prolonged intermediate stage of granulomatous folliculitis with numerous lymphocytes, some plasma cells and giant cells.
Diagnosis: Scalp folliculitis is generally diagnosed based on appearance. Laboratory testing may be performed to determine the causal organism and to rule out similar appearing conditions. A skin swab may be taken with a cotton wool bud and sent to the laboratory to check for a bacterial infection (germs). A bacterial infection with a germ called Staphylococcus aureus is often, but not always, found. Because a fungal infection (ringworm) can sometimes look similar to folliculitis decalvans, the laboratory can also test skin scrapings or plucked hairs for a fungus. Sometimes a small skin sample may be taken and checked under the microscope to confirm the diagnosis. This is called a skin biopsy and requires a local anaesthethic injection and stitches to close the wound, leading to a small scar.
Role of Diet in FD: Eating a balanced diet, including protein, complex carbohydrates, healthy fats, fresh fruits and vegetables, and drinking eight to ten glasses of water a day may stimulate the body’s immune system and shorten the course of the infection. Garlic (Allium sativum) and goldenseal (Hydrastis canadensis), both antiseptic agents against staph infections, may be taken. The daily dosage would vary from person to person and is based on the severity of the infection. Daily doses of 30-50 mg zinc, 1,000-5,000 mg Vitamin C and 300-2,000 mg bioflavinoids can also strengthen the body’s infection-fighting ability.
Treatment in modern medicine: Ointments are used & the patient is advised to do cautery & excision of the growths.
Homoeopathic approach: FD is a mixed miasmatic disease though predominantly syphilitic. Homoeopathy is based on nature’s law of cure and treatment is done on the basis of individualization of patients and holistic approach of cure. According to “$153”, more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case of disease are chiefly and most solely to be kept in view in the search of a Homoeopathic remedy. So any medicine from A to Z may be effective. Some of the most important homoeopathic medicines covering symptoms of Folliculitis decalvans are; Arundo, Calcarea silicata, Clematis erecta, Graphites, Hepar sulphuris calcareum, Hydrastis, Juglans cinerea, Lycopodium, Mercurious, Mezereum, Nitric acid, Oleander, Petroleum, Psorinum, Rhus toxicodendron, Syphilinum,, Ustilago & Vinca minor. Intercurrent & constitutional anti- miasmatic remedies would check the respective malady and also enhance the action of the specific remedy selected. Echinacea (Echinacea spp.) is helpful in modulating immune function. Selection of potency and dosages depend on the sensitivity, individual’s response to the remedy and chronicity of the condition. Selected rubrics corresponding to folliculitis decalvans from some repertories are as follows:-
Pustules – Arundo; Cic; Clem; Graph; Iris; Jugl, c.; Mez.
Boger Boenninghausen’s Repertory:
Painful to touch
At root: Aco., Chel., Chin., Colo., Sep.
Calvin B. Knerr’s Repertory:
Humid eruption like Tinea capitis, small, grain like pustules filled with pus, drying into honey like scales: Sulphur (second grade).
Glued together by exudation, crusts being entangled in hair and difficult to remove -Petroleum (second grade).
Matted by gluey discharge from humid eruption – Nat mur (Second grade).
Prognosis: If properly treated, the symptoms of bacterial folliculitis generally disappear in about two weeks. Fungal folliculitis should clear up within six weeks. But it can worsen if the condition is misdiagnosed and inappropriately treated with steroid creams. The folliculitis, if treated at the beginning stage with proper homeopathy, can prevent the follicles from fibrosis. But once the fibrosis develops, there is minimal chance of cure by any treatment. In the advanced cases, patients have to undergo hair transplantation surgery, either by strip harvesting or follicular unit extraction method.
Risks of hair transplantation surgery: Like good health and youth, most of us take a thick head of hair for granted – that is, until it is gone. For many people, hair transplant procedures can help bring back the appearance of a full – or, at least fuller- head of hair. As with any surgical procedure, hair transplantation carries risks, including bleeding and infection. Other risks that can occur with hair transplants include scarring and unnatural –looking new hair growth. Another potential risk is the sudden loss of transplanted hair, called shock loss. Fortunately, this hair loss is rarely permanent. To minimize the risks and improve the success of surgery, it is important to undergo hair transplantation only if one is healthy. One should always discuss the potential risks and benefits of the surgery with one’s doctor.
Research and future techniques: Stem cells and dermal papilla cells have been discovered in hair follicles. Research on these follicular cells may lead to success in treating baldness through hair multiplication (HM), also known as hair cloning. HM is being developed by Aderans Research Institute, a Japanese owned company in the USA.
Conclusion: Hair loss significantly impacts an individual’s self image, and studies indicate that patients with both clinically apparent and clinically imperceptible hair loss may have significantly decreased quality of life. Quality of life is defined as the subjective perception of the impact on the health status and on the physical, psychological, and social functioning and well-being of the patients. Although alopecia is a medically benign condition, it can affect patients’ quality of life. Indeed, it can have psychosocial complications, including depression, low self-esteem, altered self-image, and less frequent and enjoyable social engagements. To assess the severity of alopecia, quality of life seems to be a more relevant criterion than clinical evaluation such as alopecia extension because the perception of patients may differ significantly from those of their health-care providers.
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Dr Arpita Mondal
B.H.M.S. (Hons.), M.D. (Hom.); Ex-Housestaff, the Calcutta Homoeopathic Medical College and Hospital, Kolkata. Ex-P.G.T. (Dept. of Materia Medica), D.N.De Homoeopathic Medical College and Hospital, Kolkata. Consultant Homoeopathic Physician, Kolkata. E mail ID:firstname.lastname@example.org.