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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Folliculitis decalvans &#40;FD&#41; is a type of neutrophilic primary cicatricial alopecia &#40;PCA&#41; whose pathogenic effect is associated with a scarring response to infection by <span class="elsevierStyleItalic">Staphylococcus aureus</span> in predisposed individuals&#46; It affects young adults&#44; mainly males&#44; and is characterized by the presence of pruriginous or painful plaques located mainly on the vertex&#44; with pustules&#44; crusting&#44; and tufting&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent years have seen growing interest in a type of FD with lichenoid characteristics that can appear simultaneously or during the course of the disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 32-year-old woman consulted for a pruriginous bald patch on her scalp&#46; The patch had been developing over the previous 12 years&#46; It first appeared as a scarring plaque of alopecia on the parietal region&#44; with irregular borders and accompanied by erythema&#44; crusting&#44; and perifollicular scaling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Histology revealed lymphocytic scarring alopecia with scant focal neutrophils&#46; A blood workup including a study of autoimmunity was unremarkable&#46; With a clinical diagnosis of FD&#44; the patient underwent treatment with various regimens of topical antibiotics and corticosteroids&#44; intralesional corticosteroids&#44; doxycycline&#44; rifampicin&#47;clindamycin&#44; oral corticosteroids&#44; and hydroxychloroquine&#46; The flares initially stabilized&#44; although the disease progressed toward the posterior region &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; During follow-up&#44; the patient experienced flares of solitary pustules at the edge of the patch&#44; as well as follicular tufting&#46; Given the absence of a response to therapy and the clinical-pathological correlation &#40;symptoms suggestive of FD&#44; but histology showing lymphocytic PCA&#41;&#44; a second biopsy specimen was taken of the active lesions&#46; This again revealed lymphocytic cicatricial alopecia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The North American Hair Research Society classification of PCA according to the predominant cell in the inflammatory infiltrate<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> has led lichen planopilaris &#40;LPP&#41; and FD to be considered prototypes of lymphocytic and neutrophilic PCA&#44; respectively&#46; However&#44; co-occurrence of characteristics of FD and LPP points to an FD-LPP phenotypic spectrum&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2017&#44; Morais et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> reported a series of 13 patients with what they termed &#8220;lichen planopilaris with pustules&#8221;&#44; based on the clinical presentation of erythema and perifollicular scaling&#44; together with crusts&#44; follicular tufts&#44; and pustules&#46; However&#44; histopathology revealed that only 54&#37; of patients had lichenoid perifolliculitis&#44; whereas 77&#37; had neutrophilic folliculitis and 62&#37; tufts&#46; More recently&#44; Yip et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> reported 13 patients with characteristics of FD &#40;tufts&#44; pustules&#41; and of LPP &#40;erythema and perifollicular scaling&#41;&#44; that occurred sequentially or simultaneously&#46; Analysis of biopsy specimens of FD revealed a perifollicular infiltrate with neutrophils&#44; lymphocytes&#44; and plasma cells&#44; whereas lymphocytic inflammation was observed in the lichenoid areas&#46; Furthermore&#44; Egger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> reported on 7 patients&#44; with clinical and trichoscopy findings of LPP&#44; together with typical features of FD&#44; such as follicular tufts&#44; isolation of <span class="elsevierStyleItalic">S&#46; aureus</span> in culture&#44; and histologic characteristics such as compound follicular structures&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Various hypotheses have been put forward to explain the overlap between these 2 entities&#46; Yip et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> pointed to the dysbiosis of the microbiome in FD as the trigger of collapse of the immune privilege of the hair follicle through autoantigens that could induce a lichenoid immune response&#46; In addition&#44; it has been proposed that signs classified as LPP could be a manifestation of a common final pathway&#44; that the image is of an attenuated or forme frustre of FD modified by treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> or that the fugacity of the pustules and&#44; therefore&#44; of the neutrophils in the inflammatory infiltrate could lead them to be missing in histology&#44; thus paving the way for an erroneous diagnosis of LPP&#46; In this sense&#44; crusts are more constant&#44; and their presence&#44; together with follicular tufts&#44; reinforces the diagnosis of FD as opposed to LPP&#46; When the neutrophils disappear&#44; the presence of plasma cells in the inflammatory infiltrate would support the diagnosis of FD&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a> as well as the absence of interface dermatitis and epidermal hyperplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case we report&#44; the patient&#39;s condition had lichenoid characteristics such as perifollicular scaling and erythema&#44; as well as a lymphocytic infiltrate in the histology workup&#46; However&#44; the presence of crusts&#44; follicular tufts&#44; and the appearance of pustules during the course of the disease support a diagnosis of FD&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In practice&#44; it can prove impossible to distinguish between LPP and a lichenoid form of FD in PCA with only erythema and perifollicular hyperkeratosis&#46; Biopsy of an area with a lichenoid appearance can reveal a lymphocytic infiltrate&#46; However&#44; other histology data&#44; together with the clinical signs suggestive of FD described above&#44; enable the diagnosis to be corrected&#46; Recognizing this lichenoid type of FD has important implications for therapy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report the case of a patient with FD characterized clinically and histologically by lichenoid traits&#46; The case illustrates the difficulty in diagnosing this condition and the need to know the type of presentation in order to avoid a mistaken diagnosis of LPP and select appropriate therapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letter
Chronic Lichenoid Folliculitis Decalvans
Foliculitis decalvante liquenoide crónica
A. López Mateosa,
Autor para correspondencia
analopezmateos92@gmail.com

Corresponding author.
, S. Plata Clementeb, C. Guerrero Ramírezb, J.M. Azaña Defezb
a Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
b Servicio de Dermatología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Patch of alopecia with irregular borders and inflammatory signs &#40;erythema and scaling&#41; on the periphery&#46; B&#44; Trichoscopy reveals perifollicular scaling and erythema&#44; with no pustules or crusts&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Folliculitis decalvans &#40;FD&#41; is a type of neutrophilic primary cicatricial alopecia &#40;PCA&#41; whose pathogenic effect is associated with a scarring response to infection by <span class="elsevierStyleItalic">Staphylococcus aureus</span> in predisposed individuals&#46; It affects young adults&#44; mainly males&#44; and is characterized by the presence of pruriginous or painful plaques located mainly on the vertex&#44; with pustules&#44; crusting&#44; and tufting&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent years have seen growing interest in a type of FD with lichenoid characteristics that can appear simultaneously or during the course of the disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 32-year-old woman consulted for a pruriginous bald patch on her scalp&#46; The patch had been developing over the previous 12 years&#46; It first appeared as a scarring plaque of alopecia on the parietal region&#44; with irregular borders and accompanied by erythema&#44; crusting&#44; and perifollicular scaling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Histology revealed lymphocytic scarring alopecia with scant focal neutrophils&#46; A blood workup including a study of autoimmunity was unremarkable&#46; With a clinical diagnosis of FD&#44; the patient underwent treatment with various regimens of topical antibiotics and corticosteroids&#44; intralesional corticosteroids&#44; doxycycline&#44; rifampicin&#47;clindamycin&#44; oral corticosteroids&#44; and hydroxychloroquine&#46; The flares initially stabilized&#44; although the disease progressed toward the posterior region &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; During follow-up&#44; the patient experienced flares of solitary pustules at the edge of the patch&#44; as well as follicular tufting&#46; Given the absence of a response to therapy and the clinical-pathological correlation &#40;symptoms suggestive of FD&#44; but histology showing lymphocytic PCA&#41;&#44; a second biopsy specimen was taken of the active lesions&#46; This again revealed lymphocytic cicatricial alopecia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The North American Hair Research Society classification of PCA according to the predominant cell in the inflammatory infiltrate<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> has led lichen planopilaris &#40;LPP&#41; and FD to be considered prototypes of lymphocytic and neutrophilic PCA&#44; respectively&#46; However&#44; co-occurrence of characteristics of FD and LPP points to an FD-LPP phenotypic spectrum&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2017&#44; Morais et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> reported a series of 13 patients with what they termed &#8220;lichen planopilaris with pustules&#8221;&#44; based on the clinical presentation of erythema and perifollicular scaling&#44; together with crusts&#44; follicular tufts&#44; and pustules&#46; However&#44; histopathology revealed that only 54&#37; of patients had lichenoid perifolliculitis&#44; whereas 77&#37; had neutrophilic folliculitis and 62&#37; tufts&#46; More recently&#44; Yip et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> reported 13 patients with characteristics of FD &#40;tufts&#44; pustules&#41; and of LPP &#40;erythema and perifollicular scaling&#41;&#44; that occurred sequentially or simultaneously&#46; Analysis of biopsy specimens of FD revealed a perifollicular infiltrate with neutrophils&#44; lymphocytes&#44; and plasma cells&#44; whereas lymphocytic inflammation was observed in the lichenoid areas&#46; Furthermore&#44; Egger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> reported on 7 patients&#44; with clinical and trichoscopy findings of LPP&#44; together with typical features of FD&#44; such as follicular tufts&#44; isolation of <span class="elsevierStyleItalic">S&#46; aureus</span> in culture&#44; and histologic characteristics such as compound follicular structures&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Various hypotheses have been put forward to explain the overlap between these 2 entities&#46; Yip et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> pointed to the dysbiosis of the microbiome in FD as the trigger of collapse of the immune privilege of the hair follicle through autoantigens that could induce a lichenoid immune response&#46; In addition&#44; it has been proposed that signs classified as LPP could be a manifestation of a common final pathway&#44; that the image is of an attenuated or forme frustre of FD modified by treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> or that the fugacity of the pustules and&#44; therefore&#44; of the neutrophils in the inflammatory infiltrate could lead them to be missing in histology&#44; thus paving the way for an erroneous diagnosis of LPP&#46; In this sense&#44; crusts are more constant&#44; and their presence&#44; together with follicular tufts&#44; reinforces the diagnosis of FD as opposed to LPP&#46; When the neutrophils disappear&#44; the presence of plasma cells in the inflammatory infiltrate would support the diagnosis of FD&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a> as well as the absence of interface dermatitis and epidermal hyperplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case we report&#44; the patient&#39;s condition had lichenoid characteristics such as perifollicular scaling and erythema&#44; as well as a lymphocytic infiltrate in the histology workup&#46; However&#44; the presence of crusts&#44; follicular tufts&#44; and the appearance of pustules during the course of the disease support a diagnosis of FD&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In practice&#44; it can prove impossible to distinguish between LPP and a lichenoid form of FD in PCA with only erythema and perifollicular hyperkeratosis&#46; Biopsy of an area with a lichenoid appearance can reveal a lymphocytic infiltrate&#46; However&#44; other histology data&#44; together with the clinical signs suggestive of FD described above&#44; enable the diagnosis to be corrected&#46; Recognizing this lichenoid type of FD has important implications for therapy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report the case of a patient with FD characterized clinically and histologically by lichenoid traits&#46; The case illustrates the difficulty in diagnosing this condition and the need to know the type of presentation in order to avoid a mistaken diagnosis of LPP and select appropriate therapy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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