Eruptive Condyloma Accuminata after Initiation of Infliximab Treatment for Folliculitis Decalvans

We report a patient with recalcitrant folliculitis decalvans who was placed on infliximab due to failure to respond to numerous immunosuppressive drugs and antibiotics. After the second infusion of infliximab the patient reported a cutaneous eruption to the bilateral groin, penis, scrotum, perineum, and perianal region consistent with genital warts. The case highlights the need to inquire about a past or current history of genital or anal warts prior to the initiation of anti-TNF therapy, particularly with infliximab. If present, consideration should be given to concurrent antiwart therapy. 1. Introduction Folliculitis decalvans (FD) is classified as a neutrophilic primary cicatricial alopecia [1]. Clinically, FD usually affects the scalp and is characterized by erythematous follicular pustules and tufted folliculitis with multiple hairs emerging from a single dilated follicular ostia. Colonies of Staphylococcus aureus are often present [2]. FD is often recalcitrant to multimodal antimicrobial and anti-inflammatory therapy. Recently, Mihaljevic and Driesch reported the successful use of infliximab for the treatment of therapy-resistant FD [3]. Included in the potential risks of anti-TNF therapy is the increased susceptibility to de novo or reactivated infections. In this report, we detail the occurrence of eruptive condyloma accuminata after initiation of infliximab treatment for therapy-resistant folliculitis decalvans. This finding highlights the need to review with patients before initiating anti-TNF therapy the possibility of having warts of any kind and in particular genital warts. 2. Case Report The case concerns a 47-year-old man with a ten-year history of recalcitrant FD. He initially presented with erythematous follicular pustules and scarring alopecia to the scalp. Incidentally, he was also noted to have findings consistent with a mild hidradenitis suppurativa (HS) to the groin. A biopsy of the scalp revealed very dense collections of inflammatory cells noted in the superficial reticular dermis and papillary dermis with numerous bacterial colonies within dilated follicular ostia. He underwent extensive treatment including courses of oral minocycline, clindamycin, rifampin, and dapsone; topical clindamycin and antiseptic shampoos; clobetasol 0.05% lotion and intralesional triamcinolone injections; acitretin and isotretinoin; prednisone, methotrexate, and mycophenolate mofetil. Unfortunately, these treatments and combinations thereof failed to produce a consistent remission and the patient remained on 15–20？mg daily of prednisone to achieve