Case of the Month
31-year-old woman developed a papular rash on the right side of her back 3 months after starting Remicade (Infliximab) for Crohn’s disease. The papules were almost conical with central crust-like umbilications . She is not diabetic and has no history of renal disease.
A biopsy was performed, and here are high and low power images of the dermatopathologic findings (courtesy of Erick Jacobson, M.D., dermatopathologist)
What's Your Diagnosis?
Acquired (Drug Induced) Perforating Folliculitis/Dermatosis from infliximab (Remicade)
The keratotic papules are a response to constant rubbing and scratching are commonly seen in patients with chronic renal disease. It has also been seen in patients with chronic eczema, HIV disease, liver disease, Hodgkin's disease and thyroid disorders.
Additionally, drug induced Acquired Perforating Folliculitis/Dermatosis after starting one of many biologic agents such as infliximab, etanercept, and others.
In this case, the offending biologic agent was infliximab (Remicade)
In my experience patients benefit from narrowband UVB phototherapy and a topical class 3 steroid like triamcinolone 0.1%, applied twice daily. I also recommend a topical anti-itch lotion such as Cerave anti-itch with pramoxine.
In extreme cases caused by a biologic agent, the systemic agent should be changed. If the systemic biologic agent is working well and the papules and pruritus can be managed well, the biologic treatment may be continued.
In extreme cases of Perforating Folliculitis, I have cautiously used thalidomide with significant success.
Taken from Andrews’ Diseases of the Skin Twelfth Edition p.770
For more dermatology cases-of-the-month visit Dr. Crutchfield's Case of the Month Archive
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