Persistent Chronic Folliculitis

[shaunmck]

Dear Dr.

I am a 33 year old white male and I have been battling with what a dermatologist diagnosed as chronic folliculitis for around 4 years.  The affected areas are limited to the crowns on my scalp.

The symptoms started with the scalp in these areas being sore, red and the skin would often bleed.  This changed about 2 years ago where the bleeding stopped and the hair started tufting and hair loss in affected areas occurred.  There also appears to be scarring / thickening of the scalp in the affected areas.

I have been to numerous dermatologists and I have been on a vast number of treatments, some of which appear to make the symptoms slightly better, but none have cured the problem.

Before this problem started I did get severe sunburn on my scalp which resulted in blisters,  however I am not sure if this is related.  I have also been on a few courses of Roaccutane for the past 6 to 8 years to treat mild acne.  The doses ranged from 20mg to 80mg per day and my body weight is around 86kg.

I have been for a scalp biopsy and the results are as follows:

Nature of Specimen
Skin Biopsy

Clinical History
The patient is a 33 year old male who has a 4 year history of a tender erythematous plaque present on the vertex of the scalp with scarring and alopecia.  Cicatricial alopecia.

Microscopic Examination
Examination of sections prepared from the tissue submitted confirms the presence of skin tissue in which hair follicular structures are identified.

The superficial epidermis shows some hyperkeratosis and underlying mild spongiosis is seen.  There is no evidence of interface dermatitis seen.

There is no dermal scarring, but there is perifollicular chronic inflammatory infiltration present.  Vacuolar alteration is not observed,  but occasional dyskeratotic cells are seen within hair follicular epithelium.  Hair shafts are identified.

There is no evidence of any fungal infection seen on special stains.

Multiple further levels have been examined.  These show acute inflammatory changes in one of the hair follicles in which aggregates of acute inflammatory cells are present.

There is no evidence histologically of scarring alopecia, but there are changes of an acute-on-chronic folliculitis.

Conclusion:
- No evidence of scarring alopecia seen
- Evidence of acute-on-chronic folliculitis present
- No fungal infection identified


These are the treatments I have been on:

15/08/2012 - Rimactane 450mg daily x 10
15/08/2012 - Purbac D5 x 20
09/2012 - Purbac D5 x 6/52
12/09/2013 - Cipla Azithromycin 500mg daily x 3 - Repeat x 4
28/11/2013 - Cyclimycin 100mg daily x 1/12 - Repeat x 2
17/02/2014 - Lennon Dapsone 100mg daily x 1/12
17/03/014 - Clindahexal 150mg - 2 per day - x 2/12
17/03/2014 - Rifampicin 150mg - 4 per day - x 2/12
17/03/2014 - Elidel 1% cream - Apply at night - x 2/12
05/06/2014 - Prednisone (High dose) - x 7 days
05/06/2014 - Advantan cream - x 1/52
05/06/2014 - Dermovate scalp lotion - x 1/52
12/06/2014 - Advantan cream - x 6/52
04/09/2014 - Cortisone injections into affected areas
13/11/2014 - Cortisone injections into affected areas

The Cortisone injections have reduced the swelling and redness a bit, but the problem is still there.

My acne flared up again last month so the dermatologist put me on 40mg of Roaccutane per day, and this has seemed to make the folliculitis more sore, swollen and red.

The Dermovate and Advantan creams which I am currently using seem to reduce the redness, swelling and pain somewhat.

Please help, the numerous dermatologists I have been to aren't sure what is causing the problem and I really want to find a cure before I lose even more hair. :(

Shaun.

[shaunmck]

Can you please give me a list of blood tests you think I should go for?

There are over 50 on the lab form. I was at the dermatologist today and mentioned blood tests to him and he said the only one he suggests is an ANA test.

[shaunmck]

The biopsy was done on one of the lesions and it included a few hair follicles. The lab results are included in my original post.

I will arrange for blood tests to be done and I will post the results here.

Thanks again for the reply.

[PMDER1]

looks pink and swollen. ask the dermatologist what the lab results were? they shouldnt be witholding info from you. also if theres nothing on the biopsy, tell them to do one on or near the lesion you are describing. if nothing comes through have them do blood test on everything. i suspect it could be a immune disordor instead of ainfections.

[shaunmck]

I'm not sure what they did at the lab.  The dermatologist took the biopsy and sent it to the lab.  I'm assuming he asked them to check for anything relating to folliculitis.

The list of treatments in my original post are what I have been on and some of them are antibiotics.

The 2 affected areas of my scalp look similar to this at the moment:

[url]http://api.ning.com/files/luW0f1HQFHh5s1ffpRGMfdLj2wJIcHNkeDmAd6*iYogVUPagnqF6PsVfwe-GMzKU00xQurG36o8x2HOB4PCCR17Hxos9Dnwr/100_4856.JPG[/url]

[PMDER1]

I just looked online, theres another microorganism that can folliculitis, called Malassezia folliculitis , It would be help if you had pictures.

[PMDER1]

the blood work is to rule out any blood disorders, like certain serious diseases.

[PMDER1]

did they try to culture the bacteria? did they give you antibiotics for it?
Tell them to do a biopsy again, and mention those other inflammatory diseases. Tell them to do a full panel bloodwork, to rule out something wrong with diabetes, or thyroid issues. Also suggest celiacs disease to them, because these also can cause skin rashes.

[shaunmck]

Thanks for the reply.

No I didn't mention any of those to them because I am not even sure what I have.  They didn't mentioned any of those either.

If there was bacteria in the follicles, surely the biopsy would have revealed that?  The dermatologist said to me that if there was bacteria it would be easier to treat because he would know what to give me.

How would you normally treat antibiotic resistant bacteria?

[PMDER1]

did you ever mention psoriasis,eczema or sebherroic dermatitis to your doctors.

[PMDER1]

it seems like folliculitis, since they determined that to be the caused. and you have acne treatment. you most likely have an antibiotic resistant bacteria.