Therapeutic effect of botulinum toxin A on folliculitis dissecans of the scalp

Fonte de financiamento: Nenhuma.
Conflito de interesses: Nenhum.
Data de Submissão: 20/04/2023
Decisão final: 20/06/2023
How to cite this article: Neri SR, Franzolin MR, Kalil CLPV, Marques VD, Marques RM, Domingos MO. Therapeutic effect of botulinum toxin A on dissecting cellulitis of the scalp. Surg Cosmet Dermatol. 2024;16:e20240252.

Abstract

A patient with dissecting folliculitis of the scalp who did not respond to antibiotic therapy received four monthly sessions of intradermal administration of 100 IU of botulinum toxin A. Four months after treatment, a complete recovery of the affected area of the patient's scalp was observed. A biopsy taken from the affected area showed the presence of Staphylococcus lugdunensis and Staphylococcus aureus resistant to erythromycin. Botulinum toxin A had no effect on the viability or biofilm production of the Staphylococcus strains, indicating that the healing effect of the toxin was associated with the host response alone.

Keywords: Botulinum Toxins Type A; Folliculitis; Alopecia; Staphylococcus aureus; Staphylococcus lugdunensis.

INTRODUCTION

Dissecting folliculitis of the scalp (DFS) is a rare cause of scarring alopecia characterized by neutrophilic inflammation, hair loss, perifollicular pustules, nodules, and abscesses.¹ Although these abscesses are sterile, they are frequently associated with secondary bacterial infection, mainly by Staphylococcus aureus.² The conventional treatment for this disorder involves the use of topical and oral antibiotics, which may not be very effective in severe cases, for which surgical removal of the lesions needs to be considered.³ Therefore, there is an urgent need to find new treatments to control the development of DFS. Several studies have demonstrated the effectiveness of botulinum toxin A as an alternative treatment for nonscarring androgenetic alopecia, which is not associated with infection.^4,5 We report the case of a patient with DFS who showed complete resolution of the condition after treatment with botulin toxin A.

CASE REPORT

A 37-year-old man with clinical symptoms of DFS was admitted to our clinic. The patient did not have associated comorbidities such as high blood pressure, diabetes, or obesity. Clinical examination revealed the presence of nodules, abscesses, and a patch of hair loss (Figure 1).

At admission, the patient was treated with tetracycline antibiotics (100 mg/day for 12 weeks) and received intralesional administration of corticosteroids and antibiotics, but did not respond to these treatments. Botulinum toxin A was considered an alternative treatment option. The patient received intradermal administration of 100 IU of botulinum toxin A (Allergan) at days 0, 30, 60, and 90. A diagram of the scalp area to be treated was previously defined by outlining the infection sites. Each injection site received a dose of 2.5 IU/100 µL of botulinum toxin A in sterile saline 0.9%. The patient did not receive any other type of treatment during this period. After treatment, the patient reported resolution of pain within the first 2 weeks. Four months after the initial treatment, the abscesses and swelling subsided and a significant increase in hair density was observed (Figure 2).

For microbiological analysis of the affected area, a punch biopsy of approximately 3 mm in size of the patient's scalp was performed before treatment with botulinum toxin A.^6-8 The results showed the presence of S. aureus and S. lugdunensis resistant to erythromycin (Table 1).

The effect of botulinum toxin A on the growth (bacteriostatic effect) and killing (bactericidal effect) of S. aureus and S. lugdunensis was also investigated, by measuring the optical density of the bacterial culture and counting the number of colony-forming units, respectively.^9-11 In addition, the effect of botulinum toxin A on biofilm formation by the bacterial strains was determined by colorimetric assay, as described by Sheikl et al.¹² The results showed that botulinum toxin A had no effect on the viability of the Staphylococcus strains and did not influence their ability to form biofilm (Table 2).

DISCUSSION

DFS is a rare skin disorder that can cause significant emotional distress due to the appearance of the affected skin, as well as itching, pain, and permanent hair loss. It destroys hair follicles by causing deep follicular occlusion, followed by follicular rupture and deep inflammation of the hair bulb. Therefore, DFS is categorized as a type of cicatricial folliculitis.¹³ Although DCS is commonly associated with S. aureus, our report shows that S. lugdunensis can also be involved. In addition, our findings indicate that the healing effect of botulinum toxin A does not seem to be associated with the toxin's direct action on the pathogen, as it had no effect on the viability of the Staphylococcus strains found in the patient and on their ability to produce biofilm. In contrast, treatment with botulinum toxin A was highly successful, with the patient reporting resolution of pain within the first few days of treatment and full recovery after 4 months. Therefore, it seems that the healing effect of botulinum toxin A is associated with the host response. However, the mechanism of action of the botulinum toxin A remains unclear, as the toxin has the ability to interact with both neuronal and immune cells.⁴ Nevertheless, several studies have indicated that, under conditions of altered immune response induced by the cholinergic anti-inflammatory pathway and the release of calcitonin gene-related peptide, botulinum toxin A can act locally as an antagonist agent.^4,14-17 Therefore, it is possible that the intradermal administration of botulinum toxin A in patients with DCS can shift the patient's dysfunctional inflammatory reaction to a competent immune response and, as a consequence, restore the normal functioning of the affected area of the scalp. However, further research is needed to fully understand the mechanisms behind the healing effect of botulinum toxin A and to establish protocols to optimize its use as a therapeutic tool for DFS.

CONCLUSION

Our findings suggest that botulinum toxin A is an effective alternative for the treatment of DFS in patients who do not respond to conventional treatment with antibiotics.

AUTHOR'S CONTRIBUTION:

Simone Ramos Neri
ORCID: 0009-0004-7380-4795
Approval of the final version of the manuscript; study design and planning; collecting, analyzing, and interpreting data; effective participation in research guidance; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.
Marcia Regina Franzolin
ORCID: 0000-0003-0654-639X
Approval of the final version of the manuscript; collecting, analyzing, and interpreting data; effective participation in research guidance.
Célia Luiza Petersen Vitello Kalil
ORCID: 0000-0002-1294-547X
Approval of the final version of the manuscript, study design and planning; effective participation in research guidance; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.
Vaniky Duarte Marques
ORCID: 0009-0005-0307-6283
Approval of the final version of the manuscript; collecting, analyzing, and interpreting data; effective participation in research guidance.
Ronaldo Maciel Marques
ORCID: 0009-0006-8789-5936
Approval of the final version of the manuscript; collecting, analyzing, and interpreting data; critical review of the manuscript.
Marta Oliveira Domingos
ORCID: 0000-0003-4492-0709
Approval of the final version of the manuscript; preparation and writing of the manuscript; collecting, analyzing, and interpreting data; effective participation in research guidance; critical review of the literature; critical review of the manuscript.

REFERENCES:

1. Scheinfeld MS. A case of dissecting cellulitis and a review of the literature. Dermatol Online J. 2003;9(1):8.

2. Scheinfeld N. Dissecting cellulitis (perifolliculitis capitis abscedens et suffodiens): a comprehensive review focusing on new treatments and findings of the last decade with commentary comparing the therapies and causes of dissecting cellulitis to hidradenitis suppurativa. Dermatol Online J. 2014;20(5):22692.

3. Cuellar T, Roh DS, Sampson CE. Dissecting cellulitis of the scalp: a review and case studies of surgical reconstruction. Plast Reconstr Surg Glob Open. 2020;18(8):e3015.

4. Kim DW, Lee SK, Ahnn J. Botulinum toxin as a pain killer: players and actions in antinociception. Toxins (Basel). 2015;7(7):2435-53.

5. Zhou Y, Yu S, Zhao J, Xinyue Feng X, Zhang M, Zhao Z. Effectiveness and safety of Botulinum Toxin type A in the treatment of Androgenetic Alopecia. Biomed Res Int. 2020;2020:1501893.

6. Procop GW, Church DL, Hall GS, Janda WM, Koneman EW, Schreckenberger PC, et al. Diagnóstico microbiológico: texto e atlas colorido. 6th ed. Rio de Janeiro: Guanabara Koogan, 2008.

7. Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J of Clin Pathol.1966;45(4):493-6.

8. Clinical and Laboratory Standards Institute [CLSI]. M100-S27: performance standards for antimicrobial susceptibility testing. 27th ed. Wayne, Pennsylvania: Clinical and Laboratory Standards Institute, 2017.

9. Mira P, Yeh P, Hall BG. Estimating microbial population data from optical density. PLoS One. 2022;17(10):e0276040.

10. Baron F, Cochet MF, Ablain W, Grosset N, Madec MN, Gonnet F, et al. Rapid and cost-effective method for micro-organism enumeration based on miniaturization of conventional plate-couting technique. Lait. 2006:86(3):251-7.

11. Beck N, Callahan K, Nappier S, Kim H, Sobsey M, MeschkeJ. Development of a spot-titer culture assay for quantifying bacteria and viral indicators. J Rapid Meth Aut Mic. 2009;17(4):455-64.

12. Sheikh J, Hicks S, Agnol MD, Phillips AD, Nataro JP. Roles for Fis and YafK in biofilm formation by enteroaggregative Escherichia coli. Mol. Microbiol. 2001;41(5): 983-97.

13. Cardoso CO, Tolentino S, Gratieri T, Cunha-Filho M, Lopez RFU, Gelfuso GM. Topical treatment for Scarring and Non-Scarring Alopecia: an overview of the current evidence. Clinical Cosmet Investig Dermatol. 2021;14:485-99.

14. Pavlov VA, Tracey KJ. The cholinergic anti-inflammatory pathway. Brain, Behav Immun. 2005;19(6):493-9.

15. Assas BM, Pennock JL, Miyan JA. Calcitonin gene-related peptide is a key neurotransmitter in neuro-immune axis. Frontier Neurosci. 2014;8:23.

16. Pinho-Ribeiro FA, Baddal B, Haarsma R, O'Seaghdha M, Yang NJ, Blake K, et al. Blocking neuronal signaling to immune cells treats Streptococcal Invasive Infection. Cell. 2018;173(5):1093-7.

17. Mashimo M, Moriwaki Y, Misawa H, Kawashima K, Fujii T. Regulation of immune functions by non-neuronal Acetylcholine (Ach) via Muscarinic and Nicotinic Ach receptors. Int J Mol Sci. 2021;22(13):6818.