Hair disorders: Cicatricial alopecias

Folliculitis decalvans (FD) is a chronic, neutrophilic cicatricial alopecia that can result in progressive, irreversible hair loss and considerable impairment of quality of life. Clinically, it presents with recurrent follicular pustules, perifollicular erythema and scaling, crusting, scalp discomfort, and progressive scarring alopecia, often with characteristic tufted hairs.

Despite its rarity, FD remains one of the most challenging inflammatory scalp disorders to diagnose and manage, owing to its relapsing course, heterogeneous clinical presentation, and limited evidence-based treatment options. Recent years have witnessed important advances in our understanding of disease pathogenesis, revealing a complex interplay between microbial dysbiosis, biofilm formation, innate immune activation, and collapse of follicular immune privilege.

This update session will revisit the essential clinical, trichoscopic, and histopathological features of FD and will explore the developments that are currently changing the way we understand and manage this challenging alopecia. Moreover, the session will also focus on recent advances in disease pathogenesis, practical treatment algorithms, and the latest consensus recommendations, highlighting how these insights can be integrated into everyday clinical practice and improve patient outcomes.

Particular attention will be given to the increasingly recognized FD–lichen planopilaris phenotypic spectrum, a concept that challenges the traditional distinction between neutrophilic and lymphocytic cicatricial alopecias and has important implications for diagnosis, monitoring, and therapeutic selection.

Learning objectives:

• Recognize clinical, trichoscopic, and histopathological findings that facilitate early diagnosis and assessment of disease activity in FD
• Discuss the evidence supporting the emerging FD–LPP phenotypic spectrum and its implications for the classification of cicatricial alopecias
• Apply contemporary treatment strategies, including conventional, combination, and emerging targeted therapies, to optimize long-term disease control and prevent irreversible scarring.