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Treatment of FD is challenging&#44; characterized by prolonged courses of medications and frequent relapse after suspension&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The therapeutic goals should be focused on controlling outbreaks and preventing the irreversible progression of alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Herein we report a case of FD with extensive involvement in the scalp whose disease control was only obtained with adalimumab&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 39-year-old-male with a personal history of bronchial asthma and ischemic transient stroke at 22 years of age as a complication of renovascular hypertension&#44; was previously followed in the Dermatology department of our hospital with a diagnosis of FD&#44; with a histopathological examination of a scalp biopsy compatible with the diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Back then&#44; in 2015&#44; in addition to topical and intralesional corticosteroids&#44; he was treated with various regimens of doxycycline&#44; and rifampicin&#47;clindamycin with initial clinical improvement&#44; but once the medication was stopped&#44; relapses were observed&#46; After one year&#44; he started missing appointments and lost follow-ups&#46; For about five years&#44; he had irregular appointments in private Dermatology and was treated with several cycles of doxycycline and clindamycin&#46; In November 2021&#44; he returned to our consultation&#44; with clinical worsening&#46; He was quite symptomatic&#44; with continuous pain that affected his quality of life&#46; He also mentioned that there had been a decreasing response to oral antibiotics in recent years&#46; Clinical observation revealed extensive involvement of the scalp&#44; with multiple-scarring alopecic patches with inflammatory active lesions in the borders&#44; characterized by follicular pustules&#44; tufting of hairs&#44; and hemorrhagic crusts &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#44; 2B&#44; and 2C&#41;&#46; On trichoscopy&#44; there was diffuse erythema&#44; alongside capillary tufts&#44; follicular pustules&#44; and perifollicular scale &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; Laboratory tests were found to be normal&#46; He started treatment with oral isotretinoin and azithromycin&#46; After six months&#44; given an absence of a response&#44; the medication was suspended and changed to adalimumab &#40;dosing regimen of 160<span class="elsevierStyleHsp" style=""></span>mg subcutaneously on day 1&#44; 80<span class="elsevierStyleHsp" style=""></span>mg starting on day 15&#44; and 40<span class="elsevierStyleHsp" style=""></span>mg weekly starting from day 29&#41;&#46; Disease control was achieved after three months of therapy&#46; The patient has been treated with adalimumab for the last 15 months with only one flare observed during this period&#44; which was successfully resolved with the addition of doxycycline &#40;already suspended&#41;&#46; In the last appointment&#44; he was asymptomatic with no active lesions at clinical and trichoscopy examinations &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tumor necrosis factor is a cytokine whose role as a mediator of inflammatory processes has been widely described&#44; and that is commonly encountered in neutrophilic dermatoses&#46; The inhibition of tumor necrosis factor-&#945; with biological treatment has been successfully used in many of these diseases&#44; with a positive outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> This case illustrates the difficulties faced when treating FD and supports existing evidence&#44; based on clinical case series&#44; regarding the efficacy of adalimumab in the treatment of refractory FD&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Jos&#233; Ramos&#58; Approval of the final version of the manuscript&#59; preparation and writing of the manuscript&#59; Manuscript critical review&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ant&#243;nio Magarreiro Silva&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Marta Ant&#243;nio&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Jo&#227;o Alves&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Therapy
Recalcitrant folliculitis decalvans successfully controlled with adalimumab
José Ramos
Corresponding author
jalramos@campus.ul.pt

Corresponding author.
, António Magarreiro Silva, Ana Marta António, João Alves
Dermatology and Venereology Department, Hospital Garcia de Orta EPE, Almada, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Folliculitis Decalvans &#40;FD&#41; is a primary cicatricial neutrophilic alopecia that affects young adults&#44; mainly men&#44; with a typically chronic and relapsing course&#46; The pathogenesis remains unclear&#44; current evidence suggests that in patients with genetic predisposition&#44; there is an altered interrelationship between local immunity and the microbiome &#40;mainly colonization by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#41; culminating in chronic stimulation of T-cell homing&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Clinically&#44; it starts with pruriginous or painful plaques in the vertex&#44; with tufts of hairs and perifollicular crusts&#44; which leads to the permanent destruction of hair follicular stem cell structure and subsequent replacement with fibrous tissue&#46; Treatment of FD is challenging&#44; characterized by prolonged courses of medications and frequent relapse after suspension&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The therapeutic goals should be focused on controlling outbreaks and preventing the irreversible progression of alopecia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Herein we report a case of FD with extensive involvement in the scalp whose disease control was only obtained with adalimumab&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 39-year-old-male with a personal history of bronchial asthma and ischemic transient stroke at 22 years of age as a complication of renovascular hypertension&#44; was previously followed in the Dermatology department of our hospital with a diagnosis of FD&#44; with a histopathological examination of a scalp biopsy compatible with the diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Back then&#44; in 2015&#44; in addition to topical and intralesional corticosteroids&#44; he was treated with various regimens of doxycycline&#44; and rifampicin&#47;clindamycin with initial clinical improvement&#44; but once the medication was stopped&#44; relapses were observed&#46; After one year&#44; he started missing appointments and lost follow-ups&#46; For about five years&#44; he had irregular appointments in private Dermatology and was treated with several cycles of doxycycline and clindamycin&#46; In November 2021&#44; he returned to our consultation&#44; with clinical worsening&#46; He was quite symptomatic&#44; with continuous pain that affected his quality of life&#46; He also mentioned that there had been a decreasing response to oral antibiotics in recent years&#46; Clinical observation revealed extensive involvement of the scalp&#44; with multiple-scarring alopecic patches with inflammatory active lesions in the borders&#44; characterized by follicular pustules&#44; tufting of hairs&#44; and hemorrhagic crusts &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#44; 2B&#44; and 2C&#41;&#46; On trichoscopy&#44; there was diffuse erythema&#44; alongside capillary tufts&#44; follicular pustules&#44; and perifollicular scale &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>D&#41;&#46; Laboratory tests were found to be normal&#46; He started treatment with oral isotretinoin and azithromycin&#46; After six months&#44; given an absence of a response&#44; the medication was suspended and changed to adalimumab &#40;dosing regimen of 160<span class="elsevierStyleHsp" style=""></span>mg subcutaneously on day 1&#44; 80<span class="elsevierStyleHsp" style=""></span>mg starting on day 15&#44; and 40<span class="elsevierStyleHsp" style=""></span>mg weekly starting from day 29&#41;&#46; Disease control was achieved after three months of therapy&#46; The patient has been treated with adalimumab for the last 15 months with only one flare observed during this period&#44; which was successfully resolved with the addition of doxycycline &#40;already suspended&#41;&#46; In the last appointment&#44; he was asymptomatic with no active lesions at clinical and trichoscopy examinations &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tumor necrosis factor is a cytokine whose role as a mediator of inflammatory processes has been widely described&#44; and that is commonly encountered in neutrophilic dermatoses&#46; The inhibition of tumor necrosis factor-&#945; with biological treatment has been successfully used in many of these diseases&#44; with a positive outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> This case illustrates the difficulties faced when treating FD and supports existing evidence&#44; based on clinical case series&#44; regarding the efficacy of adalimumab in the treatment of refractory FD&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Jos&#233; Ramos&#58; Approval of the final version of the manuscript&#59; preparation and writing of the manuscript&#59; Manuscript critical review&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ant&#243;nio Magarreiro Silva&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Marta Ant&#243;nio&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Jo&#227;o Alves&#58; Approval of the final version of the manuscript&#59; manuscript critical review&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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ISSN: 03650596
Original language: English
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