Facial Follicular Spicules: A Rare Cutaneous Presentation of Trichodysplasia Spinulosa

A 57-year-old man developed a disfiguring eruption of asymptomatic papules on his face, spreading to his ears, arms, and legs, 12 months after a heart transplant. This condition, identified as trichodysplasia spinulosa, was associated with immunosuppressive medications, including mycophenolic acid and tacrolimus ointment. The papules, resembling a nutmeg grater surface, were accompanied by eyebrow alopecia. A biopsy revealed dilated anagen hair follicles with proliferating inner root sheath cells, absence of hair shafts, and plugged infundibula. The inner root sheath keratinocytes were enlarged and dystrophic, while other skin structures were unaffected.