Severe Treatment-Refractory Folliculitis Decalvans With Extensive Scalp Disfigurement. A Case Report and Review of Therapeutic Options.

Background: Folliculitis decalvans (FD) is a chronic, relapsing neutrophilic cicatricial alopecia characterized by recurrent follicular inflammation, pustules, crusting, tufted hair formation, and progressive destruction of hair follicles. Although conventional treatments may temporarily control inflammatory activity, some patients develop persistent, treatment-refractory disease with extensive scarring and severe scalp disfigurement. Case Presentation: We present the case of a 45-year-old man with long-standing folliculitis decalvans characterized by extensive cicatricial alopecia, inflammatory nodules, hypertrophic plaques, and marked distortion of scalp architecture. The patient had previously received prolonged courses of systemic antibiotics, oral isotretinoin, and intralesional corticosteroid injections. Despite temporary improvement in inflammatory activity, sustained clinical remission was not achieved. Progressive disease resulted in extensive scarring alopecia and substantial alteration of the scalp surface. Discussion: Treatment-refractory FD presents considerable therapeutic challenges because conventional treatments frequently provide incomplete or temporary disease control. Recent evidence supports individualized therapeutic strategies, including biologic agents, targeted immunomodulators, and selected procedural interventions. Surgical excision has emerged as a potential option for carefully selected patients with refractory disease, although the available evidence remains limited. Conclusion: This case illustrates the severe disfiguring potential of persistent follicular inflammation and highlights the importance of timely therapeutic reassessment in refractory FD. Multidisciplinary evaluation may be appropriate when conventional medical management fails, particularly when extensive scarring and scalp deformity have developed.