EGFR inhibitor-induced folliculitis decalvans: a case series and management guidelines

Abstract

Epidermal growth factor receptor (EGFR) is one of therapeutic targets in oncology for solid tumors originating from epithelial tissue, such as non-small-cell lung carcinoma (NSCLC) and breast cancer. EGFR inhibitors used in cancer treatment may cause a broad spectrum of dose-dependent cutaneous adverse events, including acneiform papulopustular rash, nail and hair disturbances, xerosis, and mucositis. The pathogenesis of the EGFR inhibitor-induced adverse reactions originates from disturbances in keratinocyte differentiation, cytokine secretion, and neutrophil chemotaxis. One of the rare, yet distressing adverse events may be folliculitis decalvans, a progressive neutrophil-driven scarring alopecia with hair tufts formation resembling doll's hair. Early diagnosis and introduction of treatment are crucial for disease prognosis since a long course of the disease leads to decreased quality of life. Here, we review the literature cases of EGFR inhibitor-induced folliculitis decalvans and provide guidance on management and prevention of this condition in oncologic patients. Furthermore, we report the first afatinib-associated folliculitis decalvans in three female patients with NSCLC.

Fig. 1

Common cutaneous adverse reactions of EGFR inhibitors. EGFR, epidermal growth factor receptor.

Fig. 2

Macroscopic image of the first (a), second (b and c), and third patient (d). (a) Yellow crusts, extravasations, erythema, and alopecia on the vertex of the scalp (first patient). (b) Pili torti and atrichous areas on the frontal area (second patient). (c) Tufted hair and alopecia on the parieto-occipital area (second patient). (d) Yellow crusts, extravasations, erythema, and alopecia on the vertex of the scalp (third patient).

Fig. 3

Trichoscopy of the first (a), second (b and c), and third patient (d). (a) Yellow crusts, whitish purulent discharge, extravasations, and pili torti (first patient). (b) Erythematous base and pili torti (second patient). (c) Hair tufts with polytrichia, tubular scaling formation, and crusts (second patient). (d) Hair tufts with polytrichia, erythematous base, and follicular pustules (third patient).

Fig. 4

Clinical and trichoscopic improvement of the third patient. (a) Complete resolution of the scalp lesions (compare to Fig. 2d). (b) Trichoscopic findings characteristic for folliculitis decalvans are not present (compare to Fig. 3d).