Diagnostic Challenges and Treatment Strategies in Neutrophilic Cicatricial Alopecias: A Narrative Review from Conventional Therapies to New Therapeutic Targets

Folliculitis decalvans (FD) and dissecting cellulitis of the scalp (DCS) are neutrophilic primary cicatricial alopecias characterized by chronic inflammation and irreversible hair loss, with distinct pathogenic mechanisms that make accurate diagnosis essential for appropriate management. This narrative review aims to provide a comprehensive overview of systemic therapeutic options for FD and DCS, to evaluate their efficacy in relation to underlying disease mechanisms, and to explore emerging targeted treatments. A literature search was conducted in PubMed/MEDLINE using relevant keywords related to neutrophilic cicatricial alopecias and therapeutic strategies, including studies reporting clinical outcomes in FD and DCS. Available evidence indicates that conventional therapies remain the cornerstone of management: antibiotics are typically first-line in FD, while isotretinoin represents the mainstay of treatment in DCS and a key option in refractory FD; however, these approaches are often associated with partial responses and frequent relapses. Biologic agents, particularly TNF-α inhibitors, have shown consistent benefit in refractory cases, while IL-17/23 and JAK inhibitors are supported by limited but emerging data. Overall, treatment response appears to reflect underlying pathogenic differences between FD and DCS, underscoring the importance of a tailored, mechanism-based approach. Further studies are needed to establish standardized treatment algorithms and confirm long-term efficacy and safety.