Navigating Treatments in Folliculitis Decalvans: A Comprehensive Systematic Review

Folliculitis decalvans (FD) is a chronic neutrophilic cicatricial alopecia characterized by recurrent scalp inflammation, pustules, tufted hairs, and progressive permanent hair loss. Owing to its relapsing course and the absence of standardized treatment guidelines, therapeutic management remains challenging. This systematic review summarizes available treatment approaches and reported outcomes in FD. A systematic literature search of PubMed, Web of Science, Embase, and Cochrane databases was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42023467796). Studies published between 1999 and December 2024 reporting treatment outcomes in at least one patient with FD were included. Full remission was defined as complete absence of inflammatory activity with stable disease, while partial remission indicated clinical improvement without relevant alopecia progression. Overall, 64 studies comprising 300 patients were included, mainly retrospective studies, case series, and case reports with low levels of evidence. Antibiotic-based therapies, particularly rifampicin-clindamycin combinations, showed favorable initial responses but frequent relapse after discontinuation. Isotretinoin demonstrated comparatively durable responses, with remission rates up to 82%. Biologic and targeted immunomodulatory therapies, including TNF-α inhibitors, apremilast, and various JAK inhibitors, showed promising outcomes in refractory cases. Current evidence supports individualized long-term treatment strategies focused on inflammation control and prevention of irreversible scarring.