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56
Case Reports
Squamous cell carcinoma and folliculitis
decalvans: a case report on this uncommon association
Carcinoma espinocelular e foliculite decalvante: relato de caso
dessa rara associação
Authors:
Maria Lopes Lamenha Lins Cavalcante1
Ana Cecília Duarte Pinto1
Fernanda Freitas de Brito1
Gardênia Viana da Silva2
Sadamitsu Nakandakari3
Cleverson Teixeira Soares4
1
Dermatology Resident Physician, Instituto
Lauro de Souza Lima (ILSL) - Bauru (SP),
Brazil.
2
Dermatology Intern Physician, ILSL - Bauru
(SP), Brazil.
Preceptor, Medical Residency Program in
Dermatology, ILSL - Bauru (SP), Brazil.
3 DOI: http://dx.doi.org/10.5935/scd1984-8773.2015731656
ABSTRACT
Squamous cell carcinoma is related to exposure to UVB radiation and the presence of
chronic cutaneous lesions. Folliculitis decalvans is a cicatricial alopecia that develops
with the inflammation of the scalp. In the medical literature, the association between
folliculitis decalvans and squamous cell carcinoma is rare, a factor motivating this
report. A 66-year-old male patient, bearer of folliculitis decalvans since childhood,
complained of progressive growth of lesions in the alopecia area. The biopsy confirmed squamous cell carcinoma.This case report covers the concept of “Marjolin ulcer”
for including folliculitis decalvans as inflammatory lesion precursor of squamous cell
carcinoma.
Keywords: alopecia; carcinoma, squamous cell; folliculitis
Head of the Anatomic Pathology Department, ILSL - Bauru (SP), Brazil.
4 Correspondence:
Dra. Maria Lopes Lamenha Lins Cavalcante
Rodovia Comandante João Ribeiro de
Barros, km 225/226
17039-800 - Bauru - SP - Brazil
E-mail: [email protected]
This study was carried out at the Instituto
Lauro de Souza Lima (ILSL) - Bauru (SP), Brazil.
Received on: 01/06/2015
Approved on: 14/09/2015
Financial support: None
Conflict of interest: None
Surg Cosmet Dermatol 2015;7(3 Suppl 1):S56-8.
RESU­MO
O carcinoma espinocelular relaciona-se à exposição à radiação UVB e à presença de lesões cutâneas
crônicas. A foliculite decalvante é alopecia cicatricial que cursa com inflamação do couro cabeludo. Na
literatura médica, é rara a associação entre foliculite decalvante e carcinoma espinocelular, o que motivou o relato desse caso. Paciente do sexo masculino, 66 anos, portador de foliculite decalvante desde a
infância, queixava-se de lesões de crescimento progressivo sobre a área de alopecia. A biópsia realizada confirmou carcinoma espinocelular. O relato desse caso abrange o conceito de “úlcera de Marjolin”
ao incluir a foliculite decalvante como lesão inflamatória precursora de carcinoma espinocelular.
Palavras-chave: alopecia; carcinoma de células escamosas; foliculite
SCC and folliculitis decalvans 57
INTRODUCTION Non-melanoma skin cancer is the most frequent form
of cancer in humans – both in men and women. The estimated
incidence of non-melanoma cutaneous neoplasias in Brazil in
2014 was 98,420 new cases in men and 83,710 in women. 1
Squamous cell carcinoma (SCC) is the second most common
skin cancer and results from the malignant proliferation of keratinocytes. It has an incidence of 100 to 150 per 100,000 inhabitants, and is ten times more common in people over 75-yearsold. It is a multifactorial disease and is mainly related to exposure
to ultraviolet B radiation (UVB), sunburns in childhood, ionizing radiation, fair skin, genodermatoses, infection with oncogenic strains of human papilloma virus (HPV), immunosuppression,
chemical agents, and chronic skin lesions.2 Folliculitis decalvans
(FD) is a rare sub-group of cicatricial alopecias and presents as
a chronic and recurring course. Although the precise cause is
unknown, the association with Staphylococcus aureus and immune
mechanisms have been postulated in order to justify the related
follicular destruction.The classic clinical picture of FD, described
by Quinquaud in 1888, is characterized by follicular pustules associated with central cicatricial areas devoid of hair, secondary
to aggression by the etiologic agent and/or to pro-inflammatory
processes.3 In the literature, there are few cases of patients with
folliculitis decalvans who developed SCC. This rare association
motivated the report of the present case. Case report A 66-year-old white male patient bearing folliculitis
decalvans with histological diagnosis carried out 26 years before at a reference center, described having these lesions since
childhood. He had already made use of various treatments with
antibiotics, including tetracycline and dapsone, with partial improvement. The patient had not been followed up with for the
past 10 years, having returned in April 2014 complaining of lesions with progressive growth in the vertex, over the alopecia
area. He could not assert the duration of the development. The
dermatological examination revealed a plaque of alopecia in the
described region of the scalp, with polytrichia in the periphery. At the center of this area, two lesions could be observed: a
A
B
circumferential exulceration of about 4 cm with erythematous,
scaly edge topped by a hematic crust and nodules of approximately 3 cm with their surfaces covered with a cutaneous horn
(Figure 1). With these clinical findings, the diagnosis of SCC
over the folliculitis decalvans area was hypothesized.Three biopsies were then performed: one in each of the lesions and another
comprising the polytrichia area.The latter evidenced “scalp with
dense fibrosis, thinning of hair follicles and lymphocytic infiltrate with suppurative focuses compatible with decalvans folliculitis” (Figure 2), while the others showed SCC (Figure 3). The
patient was referred for surgical evaluation and is being followed
up with by the service. DISCUSSION Malignant transformation in burn scars was first described by Jean-Nicholas Marjolin, in 1828. The term “Marjolin
ulcer” is currently used when malignant neoplasms, especially
SCC, occur over chronic ulcers, fistulas, and scars of various eti-
Figure 1:
SCCs over folliculitis
decalvans area in the
scalp
Figure 2:
A. Histology of
the area of alopecia with polytrichia: skin with
dense
fibrosis,
thinning of hair
follicles and lymphocytic infiltrate
with suppurative
foci (HE – 20X);
B. Greater detail
of the inflammatory infiltrate (HE
– 200X)
Surg Cosmet Dermatol 2015;7(3 Suppl 1):S56-8.
58
Cavalcante MLLL, Pinto ACD, Brito FF, Silva GV, Nakandakari S, Soares CT
A
B
Figure 3: A. Histology of the lesions over the area of alopecia: well-differentiated SCC infiltrating the stroma, and chronic inflammatory process involving
the hair follicle (HE – 40X); B. Detail of SCC and chronic inflammatory process involving the hair follicle (HE – 400X)
ologies, including those of an infectious nature, such as leprosy,
tuberculosis and lobomycosis.5, 6 The literature describes a case of a patient with a case
of long course folliculitis decalvans who later developed SCC.
The constant production of pro-inflammatory cytokines and tissue remodeling in chronic inflammatory disorders provide a favorable environment for malignant transformation. The relative
contribution of ultraviolet radiation is difficult to assess. However, it is pertinent to advise the continuous use of photoprotection, as well as to maintain ambulatorial follow up with these
patients. Therefore, the emergence of a nodule or ulcer within
an area of folliculitis decalvans requires careful clinical evaluation
and biopsy when there is a suspicion of neoplasia.7 l REFERENCES
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