eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Eosinophilic Folliculitis

Author: Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Coauthor(s): Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School; M Angelica Selim, MD, Associate Director of Dermatopathology, Departments of Pathology and Internal Medicine, Assistant Professor, Duke University Medical Center; Christopher R Shea, MD, Professor and Chief, Section of Dermatology, Department of Medicine, University of Chicago
Contributor Information and Disclosures

Updated: Jul 20, 2009

Introduction

Background

Eosinophilic folliculitis (EF) is a recurrent skin disorder of unknown etiology. In 1965, Ise and Ofuji reported a case of recurrent follicular pustules and eosinophilia in a Japanese woman.1 Five years later, and after 3 additional cases, Ofuji named this skin condition eosinophilic pustular folliculitis (EPF).2 Orfanos and Sterry argued that the name sterile eosinophilic pustulosis might be more appropriate because this lesion is not restricted to the hair follicle. Other names have also been proposed (eg, classic form of eosinophilic folliculitis, Ofuji disease, eosinophilic pustular dermatosis). Over the past 2 decades, the spectrum of eosinophilic folliculitis has expanded to pediatric populations, transplant recipients, and persons with HIV and hematopoietic disorders.

Eosinophilic folliculitis is a noninfectious eosinophilic infiltration of hair follicles. The 3 variants of eosinophilic folliculitis include classic eosinophilic pustular folliculitis, immunosuppression-associated eosinophilic folliculitis (mostly HIV-related), and infancy-associated eosinophilic folliculitis.3

Eosinophilic folliculitis has been classified as an AIDS-defining illness. In both children and adults, eosinophilic pustular folliculitis should be viewed as a possible cutaneous sign of immunosuppression. However, eosinophilic folliculitis may also develop in immunocompetent persons.

Pathophysiology

Although the exact etiology of eosinophilic folliculitis remains obscure, studies have favored an autoimmune process directed against sebocytes or some component of sebum. Markers of acute inflammatory activation of the epithelia, such as ICAM-1 and MAC 387, are strongly positive in sebocytes of eosinophilic folliculitis lesions but only weakly reactive in the follicular epithelium. Antibody formation and the creation of immune complexes are believed to directly or indirectly mediate clinical manifestations. Patients with eosinophilic folliculitis create antibodies to the intercellular substance of the lower epidermis and the outer root sheath of the hair follicle. An abnormal Th2-type immune response to a follicular antigen, such as caused by Demodex species, may be responsible for HIV-associated eosinophilic folliculitis.

Frequency

United States

The prevalence of eosinophilic folliculitis is unknown.

Mortality/Morbidity

Eosinophilic folliculitis is not disabling or life-threatening, but it may be intensely pruritic.

Race

Eosinophilic folliculitis is more common among Asian persons but also occurs among persons of Hispanic descent and in whites and blacks.

Sex

  • The male-to-female ratio of eosinophilic folliculitis is 5:1.
  • HIV-associated eosinophilic folliculitis is more common among homosexual or bisexual men.

Age

  • Eosinophilic folliculitis is most common among persons aged 20-40 years.
  • In the pediatric population, eosinophilic folliculitis typically affects patients aged 5-10 months, although neonatal cases have been reported.

Clinical

History

  • Patients with eosinophilic folliculitis develop recurrent crops of sterile pustules and papules.
  • Pruritus develops in half of the patients, in some cases with considerable intensity.4
  • The clinical course of eosinophilic folliculitis is characterized by multiple cycles of exacerbations and remissions.
  • The individual skin lesions usually heal spontaneously a few months to several years after onset.
  • Eosinophilic folliculitis can become severe and persistent in certain populations (eg, persons infected with HIV) and may develop after mini-allogeneic bone marrow transplantation.5

Physical

  • Eosinophilic folliculitis typically appears as an area of erythematous papules and pustules. These involve the face in most (85%) affected patients.

    Eosinophilic pustular folliculitis in a patient i...

    Eosinophilic pustular folliculitis in a patient infected with HIV. Note acneiform hyperpigmented papules. Photograph courtesy of Sarah A. Myers, MD.

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    Eosinophilic pustular folliculitis in a patient i...

    Eosinophilic pustular folliculitis in a patient infected with HIV. Note acneiform hyperpigmented papules. Photograph courtesy of Sarah A. Myers, MD.

  • Other locations include the back and the extensor surface of the upper extremities.

    Eosinophilic pustular folliculitis in a patient w...

    Eosinophilic pustular folliculitis in a patient who is HIV-positive (the same patient shown in picture 1). Note follicular-based excoriated papules and pustules on the trunk. Photograph courtesy of Sarah A. Myers, MD.

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    Eosinophilic pustular folliculitis in a patient w...

    Eosinophilic pustular folliculitis in a patient who is HIV-positive (the same patient shown in picture 1). Note follicular-based excoriated papules and pustules on the trunk. Photograph courtesy of Sarah A. Myers, MD.

  • The papules gradually become confluent, creating indurate polycyclic plaques with a healing center and spreading periphery. They ultimately fade away, leaving residual hyperpigmentation and scaling.
  • Atypical presentations or nonclassic forms of eosinophilic folliculitis occur in certain populations.
    • Infantile eosinophilic folliculitis is characterized by erythematous papulopustules on the scalp as the primary area of involvement.
    • Patients with HIV-associated eosinophilic folliculitis present with widespread urticarial lesions or large erythematous plaques with excoriations.
  • Involvement of mucosa and the palms and soles is rare.6

Causes

  • Although production of cytokines and chemotactic factors and expression of intercellular adhesion molecules are evidence of activation of the follicular sebaceous unit, the stimuli that provoke these changes are unknown. Eosinophilic folliculitis may be associated with HIV infection, various drugs, and some lymphomas; it may be considered a nonspecific dermatopathologic pattern in such settings.7 The cause of classic eosinophilic pustular folliculitis is unknown, although immune processes almost certainly play a key role in its pathogenesis.
    • Many observations suggest a role for immunologic, infectious, and environmental factors.
    • Brenner et al (1994) described 3 cases of eosinophilic folliculitis associated with Pseudomonas infection of the hair follicles; the lesions improved with antipseudomonal treatment but recurred upon cessation of therapy.8
    • Other investigators have reported infectious associations, including dermatophyte infection, larva migrans, Pityrosporum infection, retrovirus,9 and hepatitic C virus infection.10
    • In addition, eosinophilic folliculitis has been associated with various medical conditions, including lymphoma, leukemia,11 myelodysplastic syndrome, atopy, and polycythemia vera.12
    • Eosinophilic folliculitis may also develop following bone marrow transplantation.13 Eosinophilic folliculitis may be considered a reaction related to immune dysregulation.

More on Eosinophilic Folliculitis

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

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  2. Ofuji S, Ogino A, Horio T, et al. Eosinophilic pustular folliculitis. Acta Derm Venereol. 1970;50(3):195-203. [Medline].

  3. Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. Aug 2006;55(2):285-9. [Medline].

  4. Suresh MS, Arora S, Nair RR. Doctor I am on fire: eosinophilic folliculitis in HIV negative. Indian J Dermatol Venereol Leprol. Mar-Apr 2009;75(2):194-6. [Medline].

  5. Fraser SJ, Benton EC, Roddie PH, Krajewski AS, Goodlad JR. Eosinophilic folliculitis: an important differential diagnosis after allogeneic bone-marrow transplant. Clin Exp Dermatol. Apr 2009;34(3):369-71. [Medline].

  6. Tsuboi H, Niiyama S, Katsuoka K. Eosinophilic pustular folliculitis (Ofuji disease) manifested as pustules on the palms and soles. Cutis. Aug 2004;74(2):107-10. [Medline].

  7. Sufyan W, Tan KB, Wong ST, et al. Eosinophilic pustular folliculitis. Arch Pathol Lab Med. Oct 2007;131(10):1598-601. [Medline].

  8. Brenner S, Wolf R, Ophir J. Eosinophilic pustular folliculitis: a sterile folliculitis of unknown cause?. J Am Acad Dermatol. Aug 1994;31(2 Pt 1):210-2. [Medline].

  9. Veraldi S, Ferrante P, Mancuso R, et al. Evidence of retroviral involvement in an Italian patient with Ofuji's disease. Dermatology. 1999;198(1):86-9. [Medline].

  10. Gul U, Kilic A, Demiriz M. Eosinophilic pustular folliculitis: the first case associated with hepatitis C virus. J Dermatol. Jun 2007;34(6):397-9. [Medline].

  11. Patrizi A, Chieregato C, Visani G, et al. Leukaemia-associated eosinophilic folliculitis (Ofuji's disease). J Eur Acad Dermatol Venereol. Sep 2004;18(5):596-8. [Medline].

  12. Kimoto M, Ishihara S, Konohana A. Eosinophilic pustular folliculitis with polycythemia vera. Dermatology. 2005;210(3):239-40. [Medline].

  13. Goiriz R, Guhl-Millan G, Penas PF, et al. Eosinophilic folliculitis following allogeneic peripheral blood stem cell transplantation: case report and review. J Cutan Pathol. Dec 2007;34 Suppl 1:33-6. [Medline].

  14. Boone SL, Guitart J, Gerami P. Follicular mycosis fungoides: a histopathologic, immunohistochemical, and genotypic review. G Ital Dermatol Venereol. Dec 2008;143(6):409-14. [Medline].

  15. Fukamachi S, Kabashima K, Sugita K, Kobayashi M, Tokura Y. Therapeutic effectiveness of various treatments for eosinophilic pustular folliculitis. Acta Derm Venereol. 2009;89(2):155-9. [Medline].

  16. Lim HW, Vallurupalli S, Meola T, et al. UVB phototherapy is an effective treatment for pruritus in patients infected with HIV. J Am Acad Dermatol. Sep 1997;37(3 Pt 1):414-7. [Medline].

  17. Misago N, Narisawa Y, Matsubara S, et al. HIV-associated eosinophilic pustular folliculitis: successful treatment of a Japanese patient with UVB phototherapy. J Dermatol. Mar 1998;25(3):178-84. [Medline].

  18. Hara D, Kuroda K, Mieno H, et al. Treatment of eosinophilic pustular folliculitis with tacrolimus ointment. J Am Acad Dermatol. Nov 2004;51(5 Suppl):S143-5. [Medline].

  19. Kabashima K, Sakurai T, Miyachi Y. Treatment of eosinophilic pustular folliculitis (Ofuji's disease) with tacrolimus ointment. Br J Dermatol. Oct 2004;151(4):949-50. [Medline].

  20. Kawaguchi M, Mitsuhashi Y, Kondo S. Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus. Int J Dermatol. Aug 2004;43(8):608-10. [Medline].

  21. Brazzelli V, Barbagallo T, Prestinari F, et al. HIV seronegative eosinophilic pustular folliculitis successfully treated with doxicycline. J Eur Acad Dermatol Venereol. Jul 2004;18(4):467-70. [Medline].

  22. Wilson BD, Kucera JC, Shin PJ. The role of radiation treatment in the management of eosinophilic pustular folliculitis. J Med. 2002;33(1-4):111-3. [Medline].

  23. Basarab T. HIV-associated eosinophilic pustular folliculitis. J Am Acad Dermatol. Oct 1997;37(4):670-1. [Medline].

  24. Boudaya S, Turki H, Bouassida S, et al. [Eosinophilic pustular folliculitis in infancy: an unusual case]. Ann Dermatol Venereol. Apr 2003;130(4):451-4. [Medline].

  25. Buezo GF, Fraga J, Abajo P, et al. HIV-Associated eosinophilic folliculitis and follicular mucinosis. Dermatology. 1998;197(2):178-80. [Medline].

  26. Downs AM, Lear JT, Oxley JD, et al. AIDS associated eosinophilic folliculitis which responded to both high dose co-trimoxazole and low dose isotretinoin. Sex Transm Infect. Jun 1998;74(3):229-30. [Medline].

  27. Ellis E, Scheinfeld N. Eosinophilic pustular folliculitis: a comprehensive review of treatment options. Am J Clin Dermatol. 2004;5(3):189-97. [Medline].

  28. Ho MH, Chong LY, Ho TT. HIV-associated eosinophilic folliculitis in a Chinese woman: a case report and a survey in Hong Kong. Int J STD AIDS. Aug 1998;9(8):489-93. [Medline].

  29. Jang KA, Chung ST, Choi JH, et al. Eosinophilic pustular folliculitis (Ofuji's disease) in myelodysplastic syndrome. J Dermatol. Nov 1998;25(11):742-6. [Medline].

  30. Keida T, Hayashi N, Kawashima M. Eosinophilic pustular folliculitis following autologous peripheral blood stem-cell transplantation. J Dermatol. Jan 2004;31(1):21-6. [Medline].

  31. Lee JY, Tsai YM, Sheu HM. Ofuji's disease with follicular mucinosis and its differential diagnosis from alopecia mucinosa. J Cutan Pathol. May 2003;30(5):307-13. [Medline].

  32. Lucky AW, Esterly NB, Heskel N, et al. Eosinophilic pustular folliculitis in infancy. Pediatr Dermatol. Jan 1984;1(3):202-6. [Medline].

  33. Majors MJ, Berger TG, Blauvelt A, et al. HIV-related eosinophilic folliculitis: a panel discussion. Semin Cutan Med Surg. Sep 1997;16(3):219-23. [Medline].

  34. Ota M, Shimizu T, Hashino S, et al. Eosinophilic folliculitis in a patient after allogeneic bone marrow transplantation: case report and review of the literature. Am J Hematol. Jul 2004;76(3):295-6. [Medline].

  35. Piantanida EW, Turiansky GW, Kenner JR, et al. HIV-associated eosinophilic folliculitis: diagnosis by transverse histologic sections. J Am Acad Dermatol. Jan 1998;38(1):124-6. [Medline].

  36. Ramdial PK, Morar N, Dlova NC, et al. HIV-associated eosinophilic folliculitis in an infant. Am J Dermatopathol. Jun 1999;21(3):241-6. [Medline].

  37. Shirafuji Y, Matsuura H, Sato A, et al. Hyperimmunoglobin E syndrome: a sign of TH1/TH2 imbalance?. Eur J Dermatol. Mar 1999;9(2):129-31. [Medline].

  38. Soeprono FF, Schinella RA. Eosinophilic pustular folliculitis in patients with acquired immunodeficiency syndrome. Report of three cases. J Am Acad Dermatol. Jun 1986;14(6):1020-2. [Medline].

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Further Reading

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Keywords

eosinophilic folliculitis, EF, eosinophilic pustular dermatosis, eosinophilic pustular folliculitis, EPF, Ofuji disease, Ofuji's disease, sterile eosinophilic pustulosis, immunosuppression-associated eosinophilic folliculitis, infancy-associated eosinophilic folliculitis, immunosuppression-associated EF, infancy-associated EF, pediatric eosinophilic folliculitis, infant eosinophilic folliculitis, pediatric EF, infant EF, neonatal eosinophilic folliculitis, neonatal EF, classic eosinophilic folliculitis, classic EF

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Contributor Information and Disclosures

Author

Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School
Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School
Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey
Disclosure: Nothing to disclose.

M Angelica Selim, MD, Associate Director of Dermatopathology, Departments of Pathology and Internal Medicine, Assistant Professor, Duke University Medical Center
Disclosure: Nothing to disclose.

Christopher R Shea, MD, Professor and Chief, Section of Dermatology, Department of Medicine, University of Chicago
Christopher R Shea, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society of Dermatopathology, Arthur Purdy Stout Society, Association of Professors of Dermatology, Chicago Dermatological Society, Dermatology Foundation, Illinois Dermatological Society, International Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Joseph Richard Masci, MD, Chief of Infectious Diseases, Associate Director, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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