Track

Abstract

A 37-year-old female with frontal fibrosing alopecia (FFA) being treated with topical tofacitinib and oral hydroxychloroquine presented to the clinic with newly developed 1-3 mm hyperkeratotic atrophic round papules along her anterior hairline. Biopsy demonstrated subtle epidermal invagination adjacent to superficial deposits of birefringent crystalline material surrounded by a granulomatous inflammatory response. She was ultimately diagnosed with necrotizing infundibular crystalline folliculitis (NICF). She was treated with two weeks of ciprofloxacin with some clinical improvement, followed by three months of doxycycline and concurrent selenium sulfide shampoo. Topical tofacitinib was continued while hydroxychloroquine was held for two weeks, then restarted. At her last follow-up three months after initial presentation, the patient had significant improvement of her scalp involvement and was recommended to complete an additional three months of doxycycline given good treatment response. NICF is a rarely observed follicular entity of unknown etiology but is thought to favor sebaceous gland-rich areas such as the forehead and may be driven by resident skin yeasts and gram-positive bacteria, supported by its response to antibacterial and antifungal treatments. To our knowledge, this is the first reported case in a patient with scarring alopecia. Our patient was utilizing a topical JAK inhibitor in the same region of involvement, which is thought to alter the follicular microbiome and promote follicular hyper-keratinization. Although it is not clear if the JAK inhibitor contributed to the development of NICF in this patient, our case demonstrates that NICF can be successfully treated without needing to discontinue immunomodulating FFA treatment.