Tufted hair folliculitis: response to topical therapy with nadifloxacin

ARTICLE

Tufted hair folliculitis (THF) is a disease causing alopecia which is characterized clinically by the presence of a bundle of hair shafts emerging from single, dilated, follicular openings. It is a rare condition with only 32 reported cases, mostly from Europe and the United States [1-16]. Various treatments tried in the past have generally been unsuccessful. We report two characteristic cases of THF, which are the first cases from Japan to be reported in the international literature and we discuss a new effective treatment for this condition.

Case reports

Case 1

A 42-year old woman presented with a 20-year history of patchy hair loss on the scalp. She had been treated with topical steroid ointment mixed with antibiotics for 10 years. Physical examination showed a well-defined area of scarring alopecia on the parietal region. Within these areas were tufts of 7-10 normal-looking hairs arising out of dilated hair follicles (Fig. 1). A section of the affected area felt slightly edematous, and pus could be expressed from some follicular orifices. A sample of the pus was cultured and showed positive for staphylococcus aureus. Laboratory tests that were found to be normal or negative included a full blood count and liver and kidney function tests. We treated this patient with topical nadifloxacin ointment (NFO), a quinolone carboxylic acid antibacterial agent [10]. This ointment was applied 2 times per day. Although scarring alopecia persisted, this treatment stopped the expansion of alopecia.

Case 2

A 46-year old woman presented with a three-year history of erythematous pruritic plaque on the parietal region of the scalp. Physical examination revealed multiple bundles of hairs emerging from a single dilated follicular opening.

Histological examination of the tufted areas of the scalp showed scarring in the papillary to mid-dermis with perifollicular acute and chronic inflammation. There was a superficial perifollicular mixed inflammatory infiltrate composed of neutrophilis, lymphocytes and numerous plasma cells. The foci of fibrosis in the upper dermis and around grouped follicles were inconsistent findings. Multiple hair shafts, emerging from a single follicular opening, were observed. The structure of each hair papilla was normal, and none of the papilla appeared to fuse or subdivide to form multiple papilla (Fig. 2).

Several fungal cultures from the affected area were negative. However staphylococcus aureus was found to be present in the bacterial cultures. Laboratory tests, including full blood count, liver and kidney function tests, were within normal limits. The patient had been initially treated with topical steroid ointment mixed with antibiotics. This treatment produced some improvement with resolution of pruritus, however scarring alopecia persisted with gradual expansion. We subsequently treated this patient with NFO which stopped the expansion of alopecia.

Discussion

Smith first described this disorder in 1978 as "Tufted hair folliculitis of the scalp" [1]. Thereafter, we have been able to find only 32 reported cases [1-16] including the 2 cases reported here. Twenty-nine of these cases were reported from the United States and Europe [1-6, 8-16]. Three cases, including our two, were found in Japan [7]. All 32 patients were between the ages of 20 and 60 years old (10 patients in the twenties, 8 in the thirties, 6 in the forties, 5 in the fifties, and 3 in the sixties). There was a male preponderance with 20 out of these 32 patients being male. The sites of predilection were the occipital area (15 cases) and the parietal area (10 cases). Frequently reported symptoms were pruritus (11 cases) and pain (4 cases). Except for two cases, staphylococcus aureus infection was observed in all patients [9]. Good results have been reported after surgical excision of the involved areas [16]. However all reported topical treatments have been unsuccessful. Treatment with oral antibiotics have resulted in temporary cure in a few reported cases, however, long-term use of systemic antibiotics is best avoided to prevent possible hepatic or renal side effects. In our 2 patients, treatment with topical NFO resulted in the disappearance of pruritus and pustules, and expansion of the alopecia is not observed after 1 year. Nadifloxacin is a new quinolone antibiotic with a broad-spectrum antibacterial effect and little resistance. The topical preparation is much preferred for long-term use over systemic drugs. We believe that nadifloxacin ointment is an effective treament in patients for the prevention of the spread of lesions or recurrence.

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