Perifolliculitis capitis abscedens et suffodiens treatment with tumor necrosis factor inhibitors and baricitinib: A case report and literature review

Abstract

RationalePerifolliculitis capitis abscedens et suffodiens (PCAS), also known as dissecting cellulitis of the scalp (DCS), is a part of the “follicular occlusion tetrad” that also includes acne conglobate (AC), hidradenitis suppurativa (HS), and pilonidal sinus, which share the same pathogenic mechanism, such as follicular occlusions, follicular ruptures, and follicular infections.Patient concernsA 15-year-old boy had multiple rashes on the scalp accompanied by pain.DiagnosisThe patient was diagnosed with PCAS or DCS based on the clinical manifestations and laboratory examinations.InterventionsThe patient was initially administered adalimumab 40 mg biweekly and oral isotretinoin 30 mg daily for 5 months. Because the initial results were insufficient, the interval between adalimumab injections was extended to 4 weeks, and isotretinoin was changed to baricitinib 4 mg daily for 2 months. When the condition became more stable, adalimumab 40 mg and baricitinib 4 mg were administered every 20 and 3 days, respectively, for two more months until now.OutcomesAfter 9 months of treatment and follow-up, the original skin lesions of the patient were almost cured, and most inflammatory alopecia patches disappeared.ConclusionOur literature review did not find any previous reports on treating PCAS with TNF-α inhibitors and baricitinib. Accordingly, we presented the first successful treatment of PCAS with this regimen.

Improvement of Recalcitrant Dissecting Cellulitis of the Scalp After a Trial of Upadacitinib

“…Features of DCS overlap with many core qualities of HS, such as the type of lesions present, recurrence of lesions, and its suppurative nature, with the main difference being the location of the disease. These two diseases often coexist [ 1 ]. Oral JAK1 inhibitors have shown preliminary efficacy in treating moderate-to-severe HS in two phase II studies, have demonstrated high clinical responses in cohort studies, and are currently undergoing a phase III trial for HS [ 3 , 6 ].…”

“…In recent case studies, tumor necrosis factor-alpha inhibitors have shown some promise in DCS refractory to conventional treatment, a therapy also indicated for moderate-to-severe HS [ 10 , 11 ]. One recent case of an adolescent with DCS demonstrated a successful response to treatment with adalimumab and baricitinib [ 1 ]. However, there is no literature detailing the use of JAK inhibitors as a potential therapy for DCS, and to our current knowledge, this is the first case of recalcitrant DCS successfully responding to a trial of upadacitinib.…”

“…Dissecting cellulitis of the scalp (DCS) is a rare condition that is a part of the follicular occlusion tetrad of hidradenitis suppurativa (HS), acne conglobata, and pilonidal disease [ 1 ]. It commonly occurs in 20-40-year-old African American males and presents as painful, inflammatory nodules or abscesses that can precipitate the development of sinus tracts, keloids, and scarring alopecia [ 2 ].…”

“…It commonly occurs in 20-40-year-old African American males and presents as painful, inflammatory nodules or abscesses that can precipitate the development of sinus tracts, keloids, and scarring alopecia [ 2 ]. Although the precise etiology and inflammatory cytokines involved in DCS are unclear, it is suspected that an error in follicular keratinization leads to the obstruction and rupture of hair follicles, resulting in a chronic inflammatory response [ 1 ]. HS is a condition closely linked with DCS and thus, one of the pathways that could possibly be involved in the chronic inflammatory response is the Janus kinase (JAK) signaling pathway [ 3 ].…”