Perforating Folliculitis Clinical Presentation

  • Author: Suguru Imaeda, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 17, 2012
 

History

In perforating folliculitis, papules typically are concentrated on hair-bearing portions of the extremities (arms, thighs) and buttocks. Often, lesions are asymptomatic, although pruritus may be a striking feature, especially in patients with renal insufficiency. Lesions may wax and wane and persist for months or years. Spontaneous remission can occur, and remission following renal transplantation has been documented in 1 patient who developed lesions secondary to renal failure.

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Physical

Typical primary lesions of perforating folliculitis consist of 2-8 mm diameter scaly folliculocentric papules with small central keratotic plugs and varying degrees of erythema (see the image below).

Typical appearance of lesions of perforating folliTypical appearance of lesions of perforating folliculitis consisting of keratotic follicular papules.

Compression of papules may yield keratin debris and a coiled hair or hair fragments. An initial eruption of follicular pustules, followed by typical plugged papules and subsequent development of prurigo-nodularis–like lesions was reported in 1 study. The Köebner phenomenon usually is not readily demonstrable, but a linear configuration occasionally can be observed. A case of progressive generalized perforating folliculitis has been reported to be associated with erythroderma, keratoderma of the palms and soles, alopecia of the scalp and eyebrows, and nail changes. Accompanying jaundice has been observed in patients with underlying liver disease.[6]

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Causes

A number of reported cases of perforating folliculitis appear to be idiopathic, but specific associations also have been observed. Although some associations could be coincidental, the association with chronic renal failure (including both dialysis-dependent and nondialysis patients) is relatively common, suggesting a pathogenetic link.[7, 8, 9, 10, 11, 12] Perforating folliculitis also is observed relatively commonly in association with diabetes mellitus.

Less common associations include sclerosing cholangitis,[13, 14] hypertension, atherosclerotic cardiovascular disease, acanthosis nigricans, psoriasis,[15] and phrynoderma.[16] A single case report described an association with Poland syndrome (unilateral absence of the pectoralis major muscle and ipsilateral symbrachydactyly), but this patient also had diabetes mellitus, hyperuricemia, and dilated cardiomyopathy.[17] A single case highlighted the presence of perforating folliculitis in a patient with human immunodeficiency virus infection.[18] Drug-induced cases include associations with infliximab and etanercept as possible inciting agents in a patient with rheumatoid arthritis[19] and dose-dependent association of sorafenib with skin lesions of perforating folliculitis.[20]

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Contributor Information and Disclosures
Author

Suguru Imaeda, MD  Chief of Dermatology, Yale University Health Services; Chief of Dermatology, West Haven Veterans Affairs Medical Center; Assistant Professor, Department of Dermatology, Yale University School of Medicine

Suguru Imaeda, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Connecticut State Medical Society, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Timothy McCalmont, MD  Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Apsara Consulting fee Independent contractor

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

Rosalie Elenitsas, MD  Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the significant contributions of previous author, James W. Patterson, MD, to the development and writing of this article which has been recently updated.

References

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  13. Kahana M, Trau H, Dolev E, Schewach-Millet M, Gilon E. Perforating folliculitis in association with primary sclerosing cholangitis. Am J Dermatopathol. Jun 1985;7(3):271-6. [Medline].

  14. Mahajan S, Koranne RV, Sardana K, Mendiratta V, Damani A. Perforating folliculitis with jaundice in an Indian male: a rare case with sclerosing cholangitis. Br J Dermatol. Mar 2004;150(3):614-6. [Medline].

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  16. Neill SM, Pembroke AC, du Vivier AW, Salisbury JR. Phrynoderma and perforating folliculitis due to vitamin A deficiency in a diabetic. J R Soc Med. Mar 1988;81(3):171-2. [Medline].

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  18. Rubio FA, Herranz P, Robayna G, Pena JM, Contreras F, Casado M. Perforating folliculitis: report of a case in an HIV-infected man. J Am Acad Dermatol. Feb 1999;40(2 Pt 2):300-2. [Medline].

  19. Gilaberte Y, Coscojuela C, Vazquez C, Rosello R, Vera J. Perforating folliculitis associated with tumour necrosis factor-alpha inhibitors administered for rheumatoid arthritis. Br J Dermatol. Feb 2007;156(2):368-71. [Medline].

  20. Wolber C, Udvardi A, Tatzreiter G, Schneeberger A, Volc-Platzer B. Perforating folliculitis, angioedema, hand-foot syndrome--multiple cutaneous side effects in a patient treated with sorafenib. J Dtsch Dermatol Ges. May 2009;7(5):449-52. [Medline].

  21. Ohe S, Danno K, Sasaki H, Isei T, Okamoto H, Horio T. Treatment of acquired perforating dermatosis with narrowband ultraviolet B. J Am Acad Dermatol. Jun 2004;50(6):892-4. [Medline].

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Typical appearance of lesions of perforating folliculitis consisting of keratotic follicular papules.
 
 
 
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