(Acne decalvans; Folliculite epilante)
A number of cases have been repeated recently, especially by French authorities, of follicular or perifollicular inflammation resulting in cicatricial alopecia. But inasmuch as they may vary in degree from those presenting no positive inflammatory signs to those with pronounced pustulation, there are no exact clinical limits to this rare condition.
A mild form has been described which resembles alopecia areata and does not show much, if any, follicular inflammation. The lesions rarely exceed a silver quarter in size and are polished, smooth, ivory-like, with a central depression, and slightly elevated pale-red border. The patches spread in an irregular way, may be grouped or isolated and the border hairs are usually easily extracted. Some of the follicles in the affected area may entirely escape the process, leaving perfectly normal hairs.
Another form described by Quinquaud, in which a circumscribed loss of hair is the first noticeable symptom, presents on careful inspection small pustules perforated by hairs which are easily removed or fall out spontaneously. Pin- point- to pin-head-sized papules may be noted in place of the pustules but eventually crusts develop covering a secreting base. The lesions are usually few in number, isolated, appear in crops and are generally located on the scalp, although they have been observed in the beard or in the axillary and pubic regions. Scar-tissue formation eventually takes place producing a permanent alopecia in irregular, more or less depressed, circular spots averaging an inch in diameter.
Etiology and Pathology. This rare condition is found most commonly in males of the working class between the ages of thirty and forty. There is scarcely a doubt that the disease is parasitic although gastrointestinal and hepatic disorders may bear an etiological relation. Microscopically, a mild inflammatory process is first noted followed by atrophy involving all the dermal structures, including the sebaceous glands and hair-follicles.
Diagnosis. The mild form of this disease may be diagnosed from alopecia areata by the atrophic, smooth, ivory-like cicatrices with reddened borders and the absence of the short, club-shaped peripheral hairs found in the latter disease. The pustular form might be confused with sycosis or a pustular syphilid. Sycosis is known by its typical location, its larger pustules or nodules and signs of infiltration with little tendency to produce alopecia. Pustular syphilid would present other evidences of syphilis, with a pronounced ulcer beneath the crust containing a purulent secretion.
Prognosis and Treatment. While persistent and with little tendency to spontaneous disappearance, much benefit and possibly a cure may be expected from treatment. In a general way the means suggested for sycosis are here applied. The hair should be clipped short and in many instances extracted. Absolute cleanliness of the whole scalp, as well as the area involved, is essential. Painting the patches with tincture of iodin or salicylic acid (5 per cent. in collodion) may suffice, or ammoniated mercury, calomel, or sulphur ointments (15 to 60 grains to the ounce) may be more serviceable. Mercuric chlorid lotion (1:1000) benefitted the two cases under my observation, although they received Graphites and Kali brom. internally. The remedies mentioned under sycosis might be indicated.