What are the other Names for this Condition? (Also known as/Synonyms)

• Complex of Hidradenitis Suppurativa, Acne Conglobata, and Dissecting Cellulitis of Scalp
• FOT (Follicular Occlusion Triad)

What is Follicular Occlusion Triad? (Definition/Background Information)

• Follicular occlusion syndrome (FOS) is an unusual disorder that comprises a group of conditions. In this disorder, the hair follicle gets plugged by excessive scaling. With time, these blocked hair follicles rupture/burst open, causing severe signs and symptoms
• When 3 skin conditions namely, hidradenitis suppurativa, acne conglobata, and dissecting cellulitis of scalp are associated with FOS, it is known as Follicular Occlusion Triad
• The cause of Follicular Occlusion Triad is generally unknown, but it is influenced by environmental and genetic factors that include a dysfunctional immune system, obesity, smoking, and a positive family history
• Follicular Occlusion Triad is characterized by the appearance of boils and lumps on any part of the body. Over time, the lumps can get infected, rupture, bleed, and ooze pus. The skin lesions can lead to severe scarring and disfigurement
• The condition may be treated according to its severity. This may include the use of topical applications, oral medications, antibiotics, laser therapy, and cosmetic surgery. The prognosis of Follicular Occlusion Triad depends upon several factors including the severity of its signs and symptoms

Who gets Follicular Occlusion Triad? (Age and Sex Distribution)

• Follicular Occlusion Triad is a rare condition that can occur at any age, but is usually found in older adults
• Both males and females may be affected
• Individuals of all racial and ethnic background may be affected

What are the Risk Factors for Follicular Occlusion Triad? (Predisposing Factors)

The risk factors for Follicular Occlusion Triad may include the following:

• Family history of the condition
• Smoking
• Obesity
• Increased humidity
• A diet high in carbohydrates
• Certain bacterial infections

In addition to the above, the following factors may be specifically involved:

The risk factors for hidradenitis suppurativa, one of the conditions forming Follicular Occlusion Triad, include:

• A dysfunctional immune system
• A lack of proper hygiene
• Hormonal influence

The risk factors for acne conglobata, one of the conditions forming Follicular Occlusion Triad, include:

• Use of performance-enhancing anabolic steroids
• Testosterone-secreting tumors

The risk factors for dissecting cellulitis of scalp, one of the conditions forming Follicular Occlusion Triad, include:

• Dissecting cellulitis of scalp is associated with spondyloarthropathy

In rare cases, the following conditions are known to be associated with Follicular Occlusion Triad:

• A type of ectodermal dysplasia i.e., keratitis-ichthyosis-deafness syndrome
• Acanthosis nigricans due to metabolic syndrome and obesity
• Crohn’s disease
• Dowling-Degos disease
• Pyoderma gangrenosum
• Seronegative arthritis

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Follicular Occlusion Triad? (Etiology)

The cause of development of Follicular Occlusion Triad is unknown.

• This disorder develops when the hair follicle gets plugged by excessive scaling (keratin plug). With time, these blocked hair follicles rupture/burst open causing severe signs and symptoms
• All the 3 constituent disorders may be present in an individual; the disorders may appear one after the other
• It is thought that environmental and genetic factors may play a causative role in the development of hidradenitis suppurativa
• Acne conglobata may occur, in some cases, due to a sudden worsening of existing acne
• Research is currently being undertaken to identify the relevant causal factors

What are the Signs and Symptoms of Follicular Occlusion Triad?

In general, the signs and symptoms of Follicular Occlusion Triad may include the following:

• The presence of lumps or nodules that become inflamed and painful
• The lumps may appear at any location on the body - the head and neck region, chest and back, armpits and groin, scalp, etc.
• The lesions can break, form abscesses, which then drain pus and fluid
• On healing, it causes significant scarring of the skin
• Some cases are mild, while others are severe

The specific signs and symptoms of hidradenitis suppurativa may include:

• The onset of the condition is during teenage and early adulthood
• The common locations of the recurrent lesions are the armpits and groin region; other sites include the breasts, neck, and waist
• The boils or nodules, about 0.5-2.0 cm in size, become inflamed and painful
• The lumps can break and form abscesses, which then ooze foul-smelling pus
• When these ruptured boils heal, it causes scarring

The specific signs and symptoms of acne conglobata may include:

• Deterioration of existing acne that may take place due to a variety of factors
• The face, neck, and torso, are the usual sites of the highly-inflammatory skin lesions
• It then forms nodules in the body that gets infected and ruptures
• Ruptured lesions can bleed; formation of pockets of pus and abscesses may occur
• Formation of skin ulcers with the discharge of pus
• Permanent scarring of skin may ensue

The specific signs and symptoms of dissecting cellulitis of scalp may include:

• Formation of small/large nodules on the scalp, due to inflammation of the hair-follicles
• The nodules may be painful and can rupture to discharge pus
• Some lesions are longstanding; fresh nodules may form regularly
• There may be hair loss around the affected area, which is usually temporary

How is Follicular Occlusion Triad Diagnosed?

A diagnosis of Follicular Occlusion Triad may involve the following:

• A thorough medical history and physical examination
• Blood tests
• Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• Analysis of pus, culture of the fluid being drained
• Skin biopsy: A skin biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Follicular Occlusion Triad?

Follicular Occlusion Syndrome is an uncommon condition affecting the skin and the hair follicles. In general, it may result in the following complications:

• Secondary bacterial and fungal skin infections, which may result in fever and other associated signs and symptoms
• Permanent skin scars (fibrosis), leading to cosmetic issues requiring extensive surgical treatment
• Severe emotional and psychological stress

The complications of hidradenitis suppurativa may include:

• The presence of chronically-occurring nodules that can cause self-image issues and even severe depression
• Social ostracism and isolation
• Severe cosmetic concerns
• The chronic pain may be debilitating
• Longstanding or recurrent abscess can turn into squamous cell carcinoma

The complications of acne conglobata may include:

• Cosmetic disfigurement requiring extensive surgical treatment (restoration)
• Development of acne fulminans (a very severe form of acne conglobata)

The complications of dissecting cellulitis of scalp may include:

• Scarring of the affected scalp region leading to cosmetic issues
• Permanent loss of hair
• The condition is generally difficult to treat

How is Follicular Occlusion Triad Treated?

The treatment of Follicular Occlusion Triad may involve the following:

• For mild skin conditions, self-care measures are recommended, such as washing with mild soap (antibacterial) and applying warm compress
• For moderate skin conditions, topical applications and oral medications (such as retinoids, NSAIDs, corticosteroids, tumor inhibitors) are administered
• Medications, such as antibiotics, may be used for bacterial infection
• Under local anesthesia, a cosmetic procedure called dermabrasion is performed. In this procedure, the raised lumpy scars and skin dark spots are abraded (rubbed-off)
• Other cosmetic procedures, such as chemical peeling, minor skin surgery (punch excision), and microdermabrasion, may be used
• Laser excision therapy
• For severe skin conditions with superficial to deep lesions, surgical interventions may be necessary. This might involve surgical incision and drainage of the lesions, which can ensure quick healing process by removing skin and tissues that clog any tracts

Additionally, the following treatment measures may be noted:

• For hidradenitis suppurativa:
  • Chronic cases might require removal of skin and reconstruction of the area using of skin grafts
  • A complete removal of the affected skin does not prevent recurrence at other body locations. The recurrence may be aggravated by obesity and continuing skin infection
• For acne conglobata:
  • Immunomodulation therapy: Use of medications that alter the immune system
  • Cosmetic restorative surgery
• For dissecting cellulitis of scalp
  • The administration of systemic steroids
  • Laser epilation therapy (for hair follicles)

To reduce discomfort and prevent spread of infection, the following may be considered:

• Avoid tight restrictive clothing
• Keep the skin area clean
• Use warm compresses to reduce inflammation
• Avoid shaving of hair
• Avoid smoking

How can Follicular Occlusion Triad be Prevented?

Currently, there are no known methods to prevent Follicular Occlusion Triad occurrence.

What is the Prognosis of Follicular Occlusion Triad? (Outcomes/Resolutions)

• Follicular Occlusion Triad is a spontaneously developing and longstanding skin condition that may cause psychological and emotional trauma; particularly, if the signs and symptoms are severe
• The prognosis depends upon the severity of the signs and symptoms, response to treatment, and the severity of the underlying disorder/condition
• Both active and passive treatment measures are advocated to ensure an enhanced quality of life; however, it may not be completely cured

Additional and Relevant Useful Information for Follicular Occlusion Triad:

• Additionally, if there is the presence of a 4th condition called pilonidal sinus with follicular occlusion syndrome, then the disorder is termed as follicular occlusion tetrad
• There is no evidence to prove that oily foods and chocolate-based products have an influence on Follicular Occlusion Triad
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that could potentially worsen the condition
• The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help the condition from getting worse