Paradoxical reactions during treatment with a biologic agent are defined by the appearance or exacerbation of a pathological condition that usually responds to this drug while treating another condition. A 26-year-old woman presented with a 3-year history of Hurley Stage III hidradenitis suppurativa (HS) involving the groin, buttocks, and pubis, which had been refractory to topical antibiotics and corticosteroids, doxycycline, rifampicin, and clindamycin in combination. F I G U R E 1 Hurley stage III Hidradenitis suppurativa and paradoxical psoriasiform reaction to adalimumab. A,B, Inflammatory nodules and abscesses in the groin and pubis (Hurley Stage III, Physician's Global Assessment 4) together with erythemato-desquamative plaques on the legs and C, palms with pustules and D, extensive alopecia patches on the scalp secondary to desquamative plaques. Because of the severity of hair loss, the patient herself shaved the remaining hair and had to wear a wig.