Case of syphilis with alopecia and folliculitis as manifestations

A 22-year-old homosexual man presented with increasing hair loss on the bitemporal scalp and scattered red follicular papules on his face over a period of 2 months. He claimed to have no previous history of genital ulcer or other skin lesions or application of medications/home remedies; however, dermatological examination revealed diffused red follicular papulopustules scattered on his face [Figure 1a]. The occipitotemporal scalp showed multiple irregular patches of nonscarring alopecia, with characteristic moth-eaten borders [Figure 1b]. Serological screening for syphilis further showed increased titers for rapid plasma reagin test (1:64), and Treponema pallidum hemagglutination assay and fluorescent treponemal antibody-absorption [Figure 2a] test were positive. serology for other sexually transmitted disorders were negative. Dermoscopy revealed black dots with diffuse telangiectasia in the alopecic patches, as well as brown rings around perifollicular areas [Figure 2b]. The patient denied biopsy on request. Alopecia is a rare clinical manifestation of secondary syphilis; however, with folliculitis it has seldom been mentioned in the literature.

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Figure 1a:

Diffuse red follicular pustules or papulopustules on the face

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Figure 1b:

Patches of irregular moth-eaten alopecia on the occipitotemporal scalp

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Figure 2a:

Fluorescent treponemal antibody-absorption test showed positive

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Figure 2b:

Dermatoscopy examination showed small patches of hair loss (blue arrow) with black dots (red arrow), brown rings around perifollicular areas (yellow arrow), and diffused telangiectasia (white arrow) (Dermoscopy-II, Dermat, China; polarized light mode, ×200)

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