eMedicine Specialties > Dermatology > Diseases of the Adnexa

Eosinophilic Pustular Folliculitis: Treatment & Medication

Author: Marian Dmochowski, MD, Assistant Professor, Department of Dermatology, University School of Medicine at Poznan, Poland
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jan 14, 2009

Treatment

Medical Care

A variety of options have been described with variable results.

  • In classic cases, common options for treatment include indomethacin (orally or topically)15,16 and its newer derivative acemetacin,17 dapsone, topical and systemic steroids, isotretinoin, itraconazole, permethrin, interferon, and antibiotics.18 The experience of Japanese dermatologists is that indomethacin is by far the most effective in the classic form, although the mode of its action in this disease is still poorly understood.
  • Ultraviolet therapy with ultraviolet B or with ultraviolet A and psoralen plus ultraviolet A may be beneficial.19,20 The authors tend to try topical itraconazole cream first in patients with HIV-associated disease, adding an oral sedating antihistamine for bedtime use if pruritus is severe. Cetirizine seems to be a favorite because of its preferential effect on eosinophils, although these authors often prefer 4 mg of cyproheptadine at bedtime.
  • In patients with HIV-associated disease, antiretroviral therapy tends to greatly diminish or even eliminate the severity of this disorder.
  • Some patients with HIV-associated Ofuji disease may respond to oral metronidazole.

Medication

Because the etiology and the pathogenesis of eosinophilic pustular folliculitis have not been fully elucidated, no established treatment schemes exist. A number of options have been tried with various results; however, no controlled treatment trials have been performed for this condition. Oral indomethacin consistently appears to be most beneficial, at least in the classic form of the disease, whereas permethrin and cyproheptadine might alleviate the symptoms in some patients, especially in HIV-associated cases of the disease. The correction of immunodeficiency in HIV-related eosinophilic pustular folliculitis may clear the skin lesions. Systemic treatment modalities may not be needed for an infantile/childhood variant of eosinophilic pustular folliculitis because most cases respond to topical corticosteroids.

An alternative therapeutic option in patients with a long-term history of unsuccessful response to conservative therapy is ionizing radiation.21 Reports have suggested that eosinophilic pustular folliculitis may respond to treatment with topical tacrolimus,22 pimecrolimus,23 or transdermal nicotine patches.24 Additionally, one case report suggests that treatment with intravenous interferon gamma followed by oral ciclosporin may yield longer-lasting benefit by correcting an aberrant T-helper-2 – type immune response implicated in the pathogenesis of this dermatosis.25

Nonsteroidal anti-inflammatory drugs

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.


Indomethacin (Indocin)

A potent inhibitor of cyclooxygenase, which may decrease the local production of arachidonic acid derived chemotactic factors for eosinophils present in sebum (eg, 12-L-hydroxy-5,8,10-heptadecatrienoic acid and/or prostaglandin).

Adult

50 mg PO pc tid; taper as symptoms resolve

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, ACE inhibitors, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate and lithium toxicity; phenytoin levels may be increased when administered concurrently; concurrent administration with clopidogrel should be monitored closely for bleeding; coadministration with quinolones may increase risk of seizures

Documented hypersensitivity; GI bleeding or renal insufficiency; treatment of peri-operative pain in setting of coronary artery bypass graft; neonates with active bleeding, infection, necrotizing enterocolitis, severe renal failure, thrombocytopenia, or coagulation defects; patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Category D in third trimester of pregnancy (may cause closure of ductus arteriosus); acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if leukopenia, granulocytopenia, or thrombocytopenia persists)
Adverse effects include anemia, aplastic anemia, asthma , bronchospasm, blurred vision including corneal deposit and retinal disorder, inflammatory disorder of digestive tract including gastrointestinal perforation and ulcer, cardiac dysrhythmia, chest pain and myocardial infarction, congestive heart failure, cerebrovascular accident, epilepsy, hearing loss, hematuria, nephrotic syndrome, newborn renal dysfunction, dyspnea, edema, hypertension, and transitory neonatal hyperkalemia

Scabicides

These agents might be useful in some HIV-associated cases of eosinophilic pustular folliculitis in which the commensal hair follicle mite, Demodex, might be a triggering antigen; however, lesions reappear with discontinuation of treatment.


Permethrin (Elimite)

Acts on the nerve cell membrane to disrupt sodium channel current by which the polarization of the membrane is regulated. Delayed repolarization and paralysis of pests are the result.

Adult

Initial: Massage 5% cream or 1% liquid into affected skin qd
Maintenance: 1-2 applications/wk

Pediatric

<2 years: Not established
>2 years: Apply as in adults

Documented hypersensitivity to permethrin/chrysanthemums

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbate pruritus, erythema, and edema temporarily; use in pregnancy only if clearly needed

Antihistamines

These agents may alleviate itching in some HIV-associated cases of eosinophilic pustular folliculitis. Sedating forms may be more effective (especially for nocturnal pruritus).


Cyproheptadine (Periactin)

For the symptomatic relief of allergic symptoms caused by histamine released in response to allergens and skin manifestations.

Adult

4 mg PO hs; not to exceed 0.5 mg/kg/d

Pediatric

<2 years: Not established
2-6 years: 2 mg PO hs; not to exceed 12 mg/d
>6-14 years: 4 mg PO bid/tid; 16 mg/d maximum
>14 years: Administer as in adults

MAOIs prolong and intensify the anticholinergic effects; may have additive effects with alcohol and other CNS depressants; as a serotonin antagonist, may oppose effects of agents that inhibit serotonin reuptake; may blunt thyrotropin response

Documented hypersensitivity; newborn or premature infants; breastfeeding; during MAOI therapy; in cases of angle-closure glaucoma; stenosing peptic ulcer; symptomatic prostatic hypertrophy; bladder neck obstruction; pyloroduodenal obstruction; elderly and/or debilitated patients

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May diminish mental alertness; has an atropinelike action; caution in patients with a predisposition to urinary retention, history of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertension; may thicken bronchial secretions caused by anticholinergic properties, and may inhibit expectoration and sinus drainage


Hydroxyzine (Atarax)

Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS.

Adult

25-100 mg PO qd/qid

Pediatric

0.6 mg/kg/dose PO q6h

CNS depression may increase with alcohol or other CNS depressants

Documented hypersensitivity; early pregnancy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Associated with clinical exacerbations of porphyria (may not be safe for patients with porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness

More on Eosinophilic Pustular Folliculitis

Overview: Eosinophilic Pustular Folliculitis
Differential Diagnoses & Workup: Eosinophilic Pustular Folliculitis
Treatment & Medication: Eosinophilic Pustular Folliculitis
Follow-up: Eosinophilic Pustular Folliculitis
Multimedia: Eosinophilic Pustular Folliculitis
References
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References

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Further Reading

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Keywords

eosinophilic pustular folliculitis, EPF, Ofuji's disease, Ofuji disease, eosinophilic folliculitis, HIV-associated eosinophilic folliculitis, HIV-related eosinophilic folliculitis, infantile/childhood eosinophilic pustular folliculitis, sterile eosinophilic pustulosis, eosinophilic pustular dermatosis, infantile/childhood eosinophilic pustulosis of the scalp

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Contributor Information and Disclosures

Author

Marian Dmochowski, MD, Assistant Professor, Department of Dermatology, University School of Medicine at Poznan, Poland
Marian Dmochowski, MD is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Takeji Nishikawa, MD, Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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