Manuscript:
A 37-year-old African American female, seven months post deceased donor
kidney transplant, presented with follicular papules on the face (Figure
1), arms (Figure 2), and upper back. An acneiform process was initially
suspected. Despite treatment with topical azelaic acid and triamcinolone
creams, her lesions progressed with extension to the lower extremities.
A biopsy (Figure 3) of the preauricular cheek lesion revealed marked
focal acute inflammation and necrosis around a hair follicle in the
dermis, with deeper sections showing a keratotic plug within a dilated
follicle, and the PAS stain was negative for fungal organisms. The
findings were consistent with trichodysplasia spinulosa. This rare skin
condition is linked to Trichodysplasia Spinulosa Polyomavirus (TSPyV)
and typically occurs in immunocompromised individuals. Viral replication
within keratinocytes and hyperproliferation in the inner root sheath
cell led to the development of keratin spines known as spicules [1].
These lesions can be pruritic. Areas commonly affected include the face,
particularly the nose, ears, and eyebrows, as well as the arms and upper
trunk. Trichodysplasia spinulosa is diagnosed based on clinical and
histologic features, immunostaining, and TSPyV PCR testing. Histological
findings include dilated hair follicles with keratin plugging, absent
hair shafts, and eosinophilic trichohyalin deposits in the inner root
sheath epithelium, accompanied by acanthosis and numerous apoptotic
cells. [1,2]. Treatment involves oral valganciclovir and topical
cidofovir 3% to reduce viral replication. Topical retinoids and
physical extraction of the spicules can be used to manage symptoms. The
persistence of this disease often warrants the reduction of
immunosuppressive regimens based on transplant nephrologist discretion
[3]. This highlights the importance of maintaining a balance between
preserving allograft function and managing complications of
immunosuppression, such as infections. The low index of suspicion for an
infectious cause of this patient’s symptoms allowed the disorder to
advance initially. This case underscores the need to raise awareness
among dermatologists, general practitioners, and the transplant
community about the importance of considering viral etiologies, such as
trichodysplasia spinulosa, in persistent dermatological conditions
following transplantation.