High accuracy of recognition of

common forms of folliculitis by

dermoscopy: An observational study
Murat Durdu, MD,a Enzo Errichetti, MD, MSc, DVD,b Ali Haydar Eskiocak, MD,c and Macit Ilkit, MDd
Adana and Şırnak, Turkey, and Udine, Italy

Background: Clinical differentiation of folliculitis types is challenging. Dermoscopy supports the

recognition of folliculitis etiology, but its diagnostic accuracy is not known.

Objective: To assess the diagnostic accuracy of dermoscopy for folliculitis.

Methods: This observational study included patients (N = 240) with folliculitis determined on the basis of
clinical and dermoscopic assessments. A dermoscopic image of the most representative lesion was
acquired for each patient. Etiology was determined on the basis of cytologic examination, culture,
histologic examination, or manual hair removal (when ingrowing hair was detected) by dermatologist A.
Dermoscopic images were evaluated according to predefined diagnostic criteria by dermatologist B, who
was blinded to the clinical findings. Dermoscopic and definitive diagnoses were compared by
dermatologist C.

Results: Of the 240 folliculitis lesions examined, 90% were infections and 10% were noninfectious.
Infectious folliculitis was caused by parasites (n = 71), fungi (n = 81), bacteria (n = 57), or 7 viruses (n = 7).
Noninfectious folliculitis included pseudofolliculitis (n = 14), folliculitis decalvans (n = 7), and eosinophilic
folliculitis (n = 3). The overall accuracy of dermoscopy was 73.7%. Dermoscopy showed good diagnostic
accuracy for Demodex (88.1%), scabietic (89.7%), and dermatophytic folliculitis (100%), as well as for
pseudofolliculitis (92.8%).

Limitations: The diagnostic value of dermoscopy was calculated only for common folliculitis. Diagnostic
reliability could not be calculated.

Conclusion: Dermoscopy is a useful tool for assisting in the diagnosis of some forms of folliculitis. ( J Am
Acad Dermatol 2019;81:463-71.)

Key words: cytology; dermoscopy; diagnostic tests; differential diagnosis; folliculitis; pseudofolliculitis.

F olliculitis is an inflammatory skin disease shaft. Although any hair-bearing region may be
characterized by asymptomatic, itchy, or affected, folliculitis is usually localized to the face,
mildly painful, single or multiple, erythema- scalp, thigh, axilla, and inguinal area; individuals of
tous papules and pustules located around the hair all ages and races are affected by this condition.1

From the Department of Dermatology, Başkent University Medical Reprint requests: Reprints not available from the authors.
School, Adana Dr Turgut Noyan Application and Research Accepted for publication March 20, 2019.
Center, Adanaa; Department of Dermatology, University Hos- Correspondence to: Murat Durdu, MD, Department of
pital Santa Maria della Misericordia, Udineb; Şırnak State Hos- Dermatology, Başkent University Medical School, Adana Dr
pital Department of Dermatology, Şırnakc; and Division of Turgut Noyan Application and Research Center, Seyhan, 01130,
Mycology, Department of Microbiology, Faculty of Medicine, Adana, Turkey. E-mail: [email protected].
University of Çukurova, Adana.d Published online March 23, 2019.
Funding sources: None 0190-9622/$36.00
Conflicts of interest: None disclosed. Ó 2019 by the American Academy of Dermatology, Inc.
IRB approval status: This study was reviewed and approved by the https://doi.org/10.1016/j.jaad.2019.03.054
institutional review board at the University of Başkent, Ankara,
Turkey (KA12/226).

463
464 Durdu et al J AM ACAD DERMATOL
AUGUST 2019

The treatment of folliculitis lesions varies accord- 2012 and November 2018 and in whom folliculitis
ing to the type of folliculitis. Even though folliculitis is had been diagnosed on the basis of clinical and
often caused by infectious agents, it may also be dermoscopic assessment (papules or pustules
associated with noninfectious causes. The latter cases centered around a hair) were considered eligible
are mainly pseudofolliculitis caused by ingrown hairs, for the study. The study was reviewed and approved
folliculitis decalvans, and eosinophilic folliculitis.2,3 by the institutional review board at the University of
Gram-positive bacteria, especially Staphylococcus Başkent, Ankara, Turkey. The Declaration of
aureus, are the main infec- Helsinki protocols were fol-
tious agents involved in follic- lowed, and the patients
ulitis, but gram-negative CAPSULE SUMMARY provided written informed
bacteria, fungi, viruses, and consent.
dThe diagnostic accuracy of dermoscopy
parasites may also cause this
for recognition of folliculitis etiology was
condition.4 Study design
not known; we determined the overall
Because of the common The study was designed as
accuracy of dermoscopy to be 73.7%.
assumption of a gram- an observational study. For
Dermoscopy showed good diagnostic
positive bacterial origin, each patient, a dermoscopic
value for Demodex (88.1%), scabietic
topical and/or systemic anti- image of the most represen-
(89.7%), and dermatophytic (100%)
biotic treatments are often tative lesion (the most in-
folliculitis, as well as for pseudofolliculitis
routinely recommended flamed papule or pustule)
(92.8%).
without establishing an etio- was acquired and recorded
logic diagnosis, with conse- dDermoscopic evaluation of folliculitis has with use of a digital dermo-
quent possible misdiagnosis the potential to prevent unnecessary scopy device (FotoFinder
and mistreatment. Indeed, diagnostic tests and unnecessary R2.200 [Teachscreen
clinical differentiation of the treatments. Software GmbH, Bad
various forms of folliculitis Birnbach, Germany]) by
may be challenging, and dermatologist A (M.D.).
additional tests are often required to reach a defin- When an ingrowing hair was detected by dermo-
itive diagnosis.5-7 scopy, it was removed with use of a needle to confirm
According to the available literature, cytologic the diagnosis of pseudofolliculitis (Fig 1) and no
examination is the first-line diagnostic test to estab- additional tests were performed. In other cases,
lish folliculitis etiology because of its reliability, cost- cytologic samples (4 per patient) were obtained
effectiveness, and rapidity. However, further tests from the lesions and evaluated under a microscope
and analyses are sometimes needed in cases of (see the section Cytologic assessment). When cyto-
inconclusive cytologic findings (eg, histopathologic logic assessment indicated the presence of bacteria or
examination and culture).4 fungi, culture was performed to isolate the etiologic
Although distinguishing follicular from nonfollic- agent. When cytologic findings were typical of viral or
ular papules and/or pustules in areas with terminal parasitic folliculitis, no additional tests were per-
hair is relatively easy, clinical differentiation of formed. When cytologic findings were negative, his-
pustules is challenging in areas with vellus hair.8 In topathologic examination was performed. Fig 2
the last few years, dermoscopy has also been shown summarizes the diagnostic algorithm used.
to be useful in assisting in the diagnosis of several Once etiologic diagnosis was reached, most char-
nontumoral skin conditions, including some forms acteristic dermoscopic images were sent electroni-
of folliculitis.8-14 However, the diagnostic accuracy of cally to dermatologist B (E.E.), who was blinded to
dermoscopy use for the recognition of various forms the clinical findings and final diagnosis, for dermo-
of folliculitis has not been determined. Here, we scopic assessment. Only common forms of folliculitis
have aimed to address this issue by evaluating for which reliable dermoscopic features were avail-
follicular lesions of various etiologies and calculating able from the literature data or personal observations
the accuracy parameters for each dermoscopic were considered (see the section Dermoscopic
finding. assessment), including Demodex-associated follicu-
litis, scabietic folliculitis, Malassezia folliculitis, der-
PATIENTS AND METHODS matophytic folliculitis, staphylococcal folliculitis,
Patients Pseudomonas aeruginosaeassociated folliculitis,
Consecutive patients who visited the pseudofolliculitis, and folliculitis decalvans.
Dermatology Department of Başkent University Finally, dermoscopic diagnosis was compared
Hospital in Adana, Turkey, between November with etiologic diagnosis by dermatologist C
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VOLUME 81, NUMBER 2

(A.H.E), who was blinded to the preceding analyses, noninfectious (Table I). The definitive diagnosis was
to assess the diagnostic accuracy of dermoscopy. made by cytologic analysis (n = 215), histopathologic
examination (n = 14), or ingrown hair removal
Cytologic assessment (n = 14).
Cytologic specimens were obtained from follic-
ulitis lesions by the skin scraping method. A total of Cytology
4 different cytologic samples were obtained from Cytologic examination was performed for 226
each patient. One sample was used for potassium patients (14 patients had pseudofolliculitis).
hydroxide examination, and the other 3 samples Cytologic examination led to the following diag-
were stained by using May-Gr€ unwald Giemsa stain, nostic findings in 215 cases (95.1%): Demodex
gram stain, or acid-fast stain.4 Cytologic evaluation parasites (n = 40), Sarcoptes scabiei (n = 28), hyphae
was performed according to the algorithm showed (n = 27), pseudohyphae (n = 2), bacteria (n = 57),
in Fig 2. budding spores (n = 52), acantholytic cells and
multinucleated giant cells (n = 3), molluscum bodies
Dermoscopic assessment (n = 3), and numerous eosinophils (n = 3) (Fig 2). No
Dermoscopic images (1920 3 1080 pixels) cytologic diagnosis was made for the remaining 11
were evaluated for the presence of diagnostic lesions.
criteria selected according to the available literature
data and preliminary observations (Table I and Histopathology and culture
Fig 3). Additional findings, characterized by low Histopathologic examination was performed for
sensitivity or low specificity (eg, pustules, unspe- 14 patients (5.8%), including 11 patients whose
cific vessels, crusting, scaling), were not considered condition could not be diagnosed by cytologic
in the analysis. examination and 3 patients characterized by
numerous eosinophils on cytologic examination.
Statistical analysis Histologic examination revealed perifollicular lym-
Diagnostic accuracy parameters for selected der- phocytic inflammation, tufting, and follicular hyper-
moscopic findings were calculated if observed in at keratosis in 7 patients, consistent with the diagnosis
least 10 patients to ensure statistically significant of folliculitis decalvans. Three patients showed mul-
numerosity. Specifically, for each feature the tiple eosinophils without bacteria, parasites, or
following were calculated: sensitivity (true fungal elements. Demodex parasites were detected
positives O [true positives 1 false negatives]); in 2 patients with Demodex folliculitis. Parasitic eggs
specificity (true negatives O [true negatives 1 false and fecal deposits within the stratum corneum were
positives]); positive predictive value (true detected in 1 patient with scabietic folliculitis.
positives O [true positives 1 false positives]); and Histopathologic examination revealed intracytoplas-
negative predictive value (true negatives O [true mic eosinophilic inclusion bodies in material from 1
negatives 1 false negatives]). The global diagnostic patient with molluscum folliculitis.
accuracy of dermoscopy was calculated as the per- Culture was performed for 57 lesions that were
centage of correct diagnoses. Possible comparative positive for bacteria by cytologic examination. S
analysis of accuracy parameters was performed by aureus (96.5%) was the most common cause of
using the Fisher exact test or chi-square test accord- bacterial folliculitis, with other lesions caused by P
ing to sample numerosity, with statistical significance aeruginosa (3.5%). Malassezia species were deter-
set at P \ .05 and without corrections for multiple mined in 32 of 52 patients (61.5%) with Malassezia
comparisons. All analyses were performed by using folliculitis. Specifically, Malassezia globosa was the
SPSS software (version 22, IBM, Armonk, NY). most frequently (37.5%) isolated species, followed
by Malassezia furfur (34.4%), Malassezia sympodia-
RESULTS lis (25%), and Malassezia arunalokei (3.1%). The
Patients most common isolated agent of tinea capitis was
A total of 240 folliculitis lesions from 240 patients Trichophyton violaceum (51.9%), followed by
(132 females and 108 males) were included in the Trichophyton mentagrophytes (33.3%) and
study. The mean age of the patients was 28 years Microsporum canis (14.8%).
(range, 2-76 years). The face was the most common
localization of lesions (35%). Other affected areas Dermoscopy
included the trunk (30.4%), scalp (21.3%), groin Correct etiologic diagnosis by dermoscopic ex-
(7.5%), and extremities (5.8%). Of the 240 lesions, amination was made in 177 out of 240 patients
216 (90%) lesions were infectious and 24 (10%) were (73.7%) with folliculitis (Table I). In general, the
466 Durdu et al J AM ACAD DERMATOL
AUGUST 2019

Fig 1. Pseudofolliculitis. A, Dermoscopy reveals erythema, white areas, and ingrown hair
(U-shaped). B, Ingrowing hair was removed by using a needle. C, Extracted hair.

diagnostic accuracy of dermoscopy was 72.7% and sensitivity of such a finding was 67.3%. Further,
83.3% in infectious and noninfectious folliculitis, although the specificity of all dermoscopic features
respectively. Specifically, in the infectious group, of dermatophytic folliculitis was 100.0%, only
the highest diagnostic value was obtained for broken hairs displayed acceptable sensitivity
parasitic folliculitis (88.7%), followed by fungal (74.1%) (Fig 4, G and H ).
folliculitis (76.5%). Although all patients with derma- Staphylococcal folliculitis displayed the lowest
tophytic folliculitis were able to have their diagnostic accuracy (50.9%), as only nonspecific
condition diagnosed by dermoscopic examination, findings were noted for all patients. The accuracy
only 62% of patients with Malassezia folliculitis for Pseudomonas-associated folliculitis was not
could have it diagnosed by dermoscopy. The diag- calculated because of the small sample size.
nostic accuracy of dermoscopic examination in bac- Although hair tufts were noted in all cases of
terial folliculitis was low. folliculitis decalvans, no accuracy parameters were
Regarding dermoscopic features of parasitic follic- calculated because of the small sample size (Fig 4, I
ulitis, both the specificity and sensitivity of Demodex and J ). Pseudofolliculitis showed a good diagnostic
tails were slightly higher (albeit not statistically accuracy, with 92.8% of cases correctly diagnosed by
significantly [P [ .05]) than those for Demodex highlighting of U-shaped ingrowing hairs on dermo-
follicular openings (100.0% vs 97.0% and 66.7% vs scopic assessment (Fig 4, K and L). The sensitivity
54.8%, respectively) in Demodex-associated follicu- and specificity of such a finding were 92.8% and
litis (Fig 4, A and B), whereas the hang glider sign 100%, respectively.
and burrow had equal sensitivity (82.8%) and
specificity (100%) for the diagnosis of S scabiei DISCUSSION
folliculitis (Fig 4, C and D). In the current study, we investigated the diag-
For fungal folliculitis, the specificity of dotted nostic value of dermoscopy in the differentiation of
vessels in the absence of other diagnostic criteria was folliculitis. We determined the diagnostic accuracy of
93.1% because it was rarely detected in other dermoscopy as 73.7%. The diagnostic accuracy was
folliculitis types (Fig 4, E and F ). However, the high in patients with Demodex folliculitis (88.1%),
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Fig 2. Diagnostic flowchart of the study patients.

468 Durdu et al J AM ACAD DERMATOL
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Table I. Diagnostic accuracy of dermoscopy for common forms of folliculitis

Form of folliculitis n Diagnostic accuracy* Sensitivity Specificity NPV PPV
Infectious folliculitis 216 72.7
Viral folliculitis 7
Herpetic 3
Molluscum contagiosum 4
Parasitic folliculitis 71 88.7
Demodex spp 42 88.1
Demodex tailsy 28 66.7 100 93.4 100
Demodex follicular openingsz 23 54.8 97 91 82.1
Sarcoptes scabiei 29 89.7
Hang glider sign 24 82.8 100 97.7 100
Burrow 24 82.8 100 97.7 100
Fungal folliculitis 81 76.5
Malassezia folliculitis 52 67.3
Dotted vessels 35 67.3 93.1 91.1 71.4
Candida spp. 2
Dermatophytes 27 100
Broken hairs 20 74.1 100 96.8 100
Corkscrew-like hairs 6 22.2 100 91 100
Black dots 2 7.4 100 89.5 100
Zigzag hairs 2 7.4 100 89.5 100
Morse code hairs 1 3.7 100 89.1 100
Bacterial folliculitis 57 49.1
Staphylococcus aureus 55 50.9
Central round pustule with periph- 28 50.9 96.2 86.9 82.4
eral sparse dotted vessels
Pseudomonas aeruginosa 2
Noninfectious folliculitis 24 83.3
Pseudofolliculitis 14 92.8
Ingrown hair 13 92.8 100 100 100
Eosinophilic folliculitis 3
Folliculitis decalvans 7
Hair tufts 7
Total 240 73.7

NPV, Negative predictive value; PPV, positive predictive value.

*Stated if the total number exceeds 10.
y
Creamy or whitish gelatinous follicular plugs protruding from follicular openings.
z
Round creamy or whitish follicular plugs surrounded by an erythematous halo.

scabies folliculitis (89.7%), and dermatophytic follic- diagnose many nonpigmented diseases. Currently,
ulitis (100%). dermoscopy is also used in general dermatology. For
According to the available literature, bacterial pustular lesions, the first aim of dermoscopy is to
culture, fungal culture, and histopathologic exami- distinguish vellus-type hair.8 This inexpensive and
nation are the most common methods used to noninvasive diagnostic method is also used to
investigate the causes of folliculitis.4 Although poly- distinguish folliculitis from pseudofolliculitis.12
merase chain reaction is used for the diagnosis of In addition, dermoscopic findings of infectious
many infectious diseases, this molecular diagnostic folliculitis, such as Demodex folliculitis, scabies
method is not routinely used in the case of patients folliculitis, and dermatophytic folliculitis, have been
with folliculitis.4 Accordingly, the polymerase chain described.8,12,13,16 In the case of noninfectious follic-
reaction method is used in Western Europe and the ulitis, dermoscopic diagnostic findings of folliculitis
United States but gives positive identification of only decalvans have been reported. Here we have shown
27% of late-stage lesions.15 that multiple ([10) hairs emerging from a single
Dermoscopy, a noninvasive diagnostic method, is dilated follicular orifice (tufted hairs, polytrichia, or
mainly used to distinguish pigmented lesions and dolly hairs) are the most sensitive and specific
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VOLUME 81, NUMBER 2

Fig 3. Dermoscopic diagnostic algorithm for the analysis of folliculitis lesions.

dermoscopic finding of folliculitis decalvans. recommended.20,21 Recently, some dermatologic

However, tinea capitis with folliculitis decalvans- manifestations of Malassezia folliculi have been
like dermoscopic findings has also been reported.17 described. Jakhar et al9 reported that Malassezia
Other additional, nonspecific dermoscopic findings folliculitis presents as folliculocentric papule and
are perifollicular erythema arranged in a starburst pustules with surrounding erythema. Perilesional
pattern, yellowish tubular scaling, crusting, and hypopigmentation or brownish discoloration occurs
follicular pustules.11 when the lesion is regressing. However, preliminary
The development of multidrug-resistant bacteria observations of 52 cases in the current study indi-
creates significant health problems. One of the most cated that peripheral, regularly distributed dotted
important underlying reasons is the frequent and vessels in the absence of other diagnostic findings
unnecessary use of antibiotics.18 In patients with were the main dermoscopic clue of such a condition.
folliculitis, it is important to differentiate bacterial Nonetheless, we evaluated only active papular
etiology from other infectious causes to avoid un- pustules of patients and excluded postinflammatory
necessary use of antibiotics.4 Although bacterial lesions. Therefore, the frequency of postinflamma-
culture is usually sufficient in cases of bacterial tory changes, such as hypopigmentation or
folliculitis, additional tests, such as cytologic exam- brownish discoloration, was not obtained.
ination, fungal culture, and histopathologic exami- Although dermoscopy provides important find-
nation are required for other forms of folliculitis. We ings for the diagnosis of some types of infectious
have shown here that the diagnostic accuracy of folliculitis, there are no specific findings of herpetic
dermoscopy is 81.4% for folliculitis other than bac- folliculitis, eosinophilic folliculitis, and Candida
terial folliculitis. The diagnostic accuracy for folliculitis. However, it is possible to distinguish
Demodex folliculitis, scabies folliculitis, and pseudo- between these 3 types of folliculitis cytologically.
folliculitis was even higher. Hence, when performed Hence, if the cytologic examination shows only
before other diagnostic tests, dermoscopic examina- bacteria, diagnosis should be based on bacterial
tion could prevent unnecessary examinations, culture. Both herpes zoster folliculitis and herpes
reduce cost, and provide rapid diagnosis. simplex folliculitis are characterized by the presence
Malassezia folliculitis lesions are confused with of acantholytic cells and multinuclear giant cells.
bacterial folliculitis, candidiasis, and acne vulgaris. Hence, if immunofluorescence is performed, herpes
For the diagnosis of Malassezia folliculitis, Wood’s simplex folliculitis can be distinguished from herpes
lamp examination, cytologic examination, and his- zoster folliculitis.4,22
topathologic examination may be used.19 Because There are some limitations to the current study.
the diagnostic accuracy of cytologic examination is The diagnostic value of dermoscopy was not calcu-
higher than histopathologic examination, perform- lated for patients with molluscum folliculitis,
ing cytologic examination before taking a biopsy is herpetic folliculitis, or folliculitis decalvans because
470 Durdu et al J AM ACAD DERMATOL
AUGUST 2019

Fig 4. Dermoscopic findings of folliculitis. Demodex tails (arrows) in Demodex folliculitis (A

and B); burrow (arrow) in scabietic folliculitis (C and D); dotted vessels (arrows) in Malassezia
folliculitis (E and F); corkscrew-like hair (blue arrow), zigzag hair (black arrow), and black dot
(red arrow) in dermatophytic folliculitis (G and H); hair tuft (arrow) in folliculitis decalvans (I
and J); and ingrown hair (arrow) in pseudofolliculitis (K and L).
J AM ACAD DERMATOL Durdu et al 471
VOLUME 81, NUMBER 2

the sample size was too small. Further, the diagnostic 9. Jakhar D, Kaur I, Chaudhary R. Dermoscopy of Pityrosporum
reliability could not be calculated because only 1 folliculitis. J Am Acad Dermatol. 2019;80(2):e43-e44.
10. Errichetti E, Stinco G. Dermoscopy in general dermatology: a
dermatologist performed dermoscopic evaluation. practical overview. Dermatol Ther (Heidelb). 2016;6(4):471-507.
In conclusion, we have demonstrated that dermo- 11. Fabris MR, Melo CP, Melo DF. Folliculitis decalvans: the use of
scopy provides important findings for the diagnosis dermatoscopy as an auxiliary tool in clinical diagnosis. An Bras
of Demodex folliculitis, scabietic folliculitis, Dermatol. 2013;88(5):814-816.
Malassezia folliculitis, and dermatophytic folliculitis. 12. Chuh A, Zawar V. Epiluminescence dermatoscopy enhanced
patient compliance and achieved treatment success in pseu-
If the result of dermoscopy is negative, cytologic dofolliculitis barbae. Australas J Dermatol. 2006;47(1):60-62.
examinations, culture, and histopathologic exami- 13. Wang HH, Lin YT. Bar code-like hair: dermoscopic marker of
nations should be performed. tinea capitis and tinea of the eyebrow. J Am Acad Dermatol.
2015;72(1):S41-S42.
We acknowledge Dr Evrim Karaman and Associate 14. Tang J, Ran X, Ran Y. Ultraviolet dermoscopy for the diagnosis
Professor Aylin D€
ogen for the processing and identification of tinea capitis. J Am Acad Dermatol. 2017;76(2S1):S28-S30.
of patients with Malassezia folliculitis. 15. Domeika M, Bashmakova M, Savicheva A, et al, Eastern
European Network for Sexual and Reproductive Health (EESRH
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