We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

EditorGranuloma annulare (GA) is a common non-infectious granulomatous didease. 1,2 Although no clear aetiology has been established, trauma, insect bite reactions, tuberculin skin testing, sun exposure, PUVA therapy, adverse reaction to drugs and viral infections have been proposed as inciting factors. 1 Its pathogenesis is probably immunologic. Evidence suggest that GA represents a cell-mediated immune response to an unknown antigen, in which granuloma formation by macrophage-histiocytes is mediated by interaction with T-helper lymphocytes. It is a Th1-driven inflammatory reaction, with interferon γ-producing lymphocytes eliciting matrix degradation. [3][4][5][6] Nearly 15% of patients with GA have the generalized subtype characterized by a later age of onset, increased prevalence of the HLA-Bw35 allele, protracted course, with only rare spontaneous resolution, and alterations in the lipid profile in about 45% of patients. 1,2,5 A 52-year-old Caucasian woman was observed for asymptomatic erythematous-violaceous annular plaques, with raised borders, symmetrically distributed over the neck and subsequently over the trunk and limbs, evolving for 6 months (Fig. 1). Besides rosacea, the patient was otherwise healthy. Laboratory findings, including autoimmune and hormonal screening, tumoral markers, viral, Borrelia burgdorferi and Treponema pallidum serologies and Mycobacterium polymerase chain reaction were all negative. Skin lesion biopsy showed a granulomatous dermatitis pattern with necrobiotic areas and lymphocytic infiltrate, supporting the diagnosis of GA (Fig. 2).

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