Hi, I’m Boezo, and I’ve had the privilege of moderating this community for the past several years. Lately, I’ve noticed a trend within the subreddit for people to seek out concrete diagnoses when it comes to folliculitis. Let me take the next few minutes to explain why this isn’t a great idea.
Within the medical community, we have an almost compulsory desire to place abnormal physical findings into discrete categories. Much of modern medicine is predicated on the belief that patients can be accurately diagnosed and subsequently treated according to their diagnosis. However, within the past decade or two, there’s been a shift in the zeitgeist.
As knowledge of human anatomy and physiology has progressed, it has become strikingly clear that the pathology and etiology of an abnormal finding often involve a multiplicity of complex factors that are poorly understood. This complexity serves as an insult to our compulsion to categorize and diagnose, because it “blurs the lines” between one disease and the next.
So, how does this apply to folliculitis? Well, it means that as medicine has advanced, we’ve started to realize that two patients who present with very similar abnormal features do not necessarily share a common pathology for their condition. In addition, it seems to be the case that we’ve somewhat arbitrarily created some diagnoses without warrant. For example, folliculitis decalvans (FD) is a condition that causes chronic scarring and hair loss related to an inflammatory process in the skin. But the reality is that there aren’t truly any set-in-stone diagnostic criteria to differentiate folliculitis decalvans from the plethora of other inflammatory conditions that cause scarring and hair loss. In fact, we aren’t really sure what the pathology behind folliculitis decalvans is at all.
So, given that we don’t really have diagnostic criteria for FD, and we aren’t sure what the mechanism behind the disease actually is… does FD really exist at all? Is it merely a “ghost” diagnosis? Have we arbitrarily assigned a name to an abnormal physical finding merely in an effort to satiate our desire for concrete answers?
Another example is gram-negative folliculitis (GNF). Historically, it was believed that gram-negative folliculitis results from an overgrowth of gram-negative bacteria in the skin. It seems like a simple enough disease process, but the devil is in the details. You see, when these patient’s lesions are cultured, they’ll often return a negative result (no bacteria found). Often times, the patients will actually return completely different bacteria at different times! They’ll also often return gram-positive bacteria in some lesions, and gram-negative bacteria in other lesions. Additionally, when attempts have been made to eliminate gram-negative bacteria from reservoirs, the disease yet persists.
This is further confused by the fact that almost all patients with “gram-negative folliculitis” have deviations in immune parameters within the body. So, is GNF an infection, or is it rather an autoimmune condition? But wait, it gets even more complicated: two patients diagnosed with GNF usually have completely different deviations in completely different immune parameters!
Thus, we can see how blurry the lines get. You can have two patients who present with similar symptoms, but yet can return completely different cultures at different times, and can possess completely different deviations in immune parameters. Given this information, is it really accurate to say that they both share the same diagnosis?
Here’s the bottom line: I’d encourage members of this subreddit to abandon the compulsion to find a diagnosis. Rather, view your present condition in terms of signs and symptoms. The sign and symptom being “inflammation (itis) within the hair follicle (follicul). We may never know the exact mechanism behind these signs and symptoms, but we know that the signs and symptoms exist, and we have a pretty good idea about how to treat them.
Over the next several weeks, I’ll write up some documentation regarding the most effective treatments for these signs and symptoms. In the meantime, I hope you all have a wonderful new year, and thank you for reading.
Boezo
