Disseminate and Recurrent Infundibular Folliculitis

Updated: Jun 14, 2022
Author: Christopher R Gorman, MD; Chief Editor: William D James, MD 

Overview

Practice Essentials

Disseminate and recurrent infundibular folliculitis (DRIF) was first described in 1968 by Hitch and Lund.[1] The clinical presentation is much like miliaria or keratosis pilaris. It is mostly seen in young healthy people, and most patients have a dark skin color. It consists of generalized flesh-colored papules. Therapy has generally been unsuccessful.

Courtesy of San Antonio Uniformed Services Health Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.

The validity of disseminate and recurrent infundibular folliculitis as a separate entity has been questioned. However, it does have such a characteristic clinical picture that for the present it is accepted as an entity.

Etiology

The etiology of disseminate and recurrent infundibular folliculitis is not established. The history often suggests a hot, humid environment as a precipitating cause. Once established, disseminate and recurrent infundibular folliculitis tends to persist or recur over a prolonged period.

Prognosis

Disseminate and recurrent infundibular folliculitis may last for years. Pruritus is the troublesome symptom of disseminate and recurrent infundibular folliculitis. In the past, this was difficult to relieve. Disseminate and recurrent infundibular folliculitis may make it uncomfortable for the patient to work in a hot, humid environment. Complications of disseminate and recurrent infundibular folliculitis can be due to excoriations and possible impetiginous infection.

Diagnostics

In the workup of suspected disseminate and recurrent infundibular folliculitis (DRIF), patch testing or a potassium hydroxide wet mount may be performed to investigate possible allergic contact dermatitis or Pityrosporum folliculitis.

A biopsy is not diagnostic in disseminate and recurrent infundibular folliculitis.

Histologic findings

Histologic examination reveals superficial spongiotic dermatitis associated with a hair follicle and the adjacent epidermis superficially; this finding is not specific. Exocytosis is noted into the spongiotic area. The subadjacent dermis has inflammatory cells, and the deeper dermis is uninvolved.

In 3 patients with DRIF in India, clinicians noted mononuclear cell infiltrate concentrated around the hair follicle infundibulum, also with scant spongiosis around the follicle. A few scattered melanophages were also observed in the dermis.[2]  

Treatment

Although unfamiliar to generalists, dermatologists should recognize disseminate and recurrent infundibular folliculitis.

Limiting activity under hot, moist conditions may be necessary to prevent or relieve symptoms of disseminate and recurrent infundibular folliculitis.

Cooling, soothing emollients have been used for 30 years, with variable success, in disseminate and recurrent infundibular folliculitis (DRIF).

Corticosteroids have not been demonstrated effective, with the exception of a single case report by Hinds and Heald using potent topical corticosteroids.[3]

In 1999, Ruvikumar et al reported that psoralen plus ultraviolet light A (PUVA) therapy was successful in disseminate and recurrent infundibular folliculitis.[4]

In 1998 and again in 2004, Aroni et al reported successful treatment of disseminate and recurrent infundibular folliculitis with isotretinoin.[5]

Keeping a patient in a cool, dry environment has been successful in relieving symptoms of disseminate and recurrent infundibular folliculitis.

Also see Medication.

Epidemiology

Frequency

United States

Although the first case of disseminate and recurrent infundibular folliculitis was not reported until 1968, other more recent reports indicate that it is a fairly common occurrence. Clinics that see a large number of young dark-skinned patients report that disseminate and recurrent infundibular folliculitis is a common condition. Indeed, it may occur in large numbers in hot, humid weather.

International

Cases of disseminate and recurrent infundibular folliculitis have been reported from Europe and India.[6] Limited cases have also been reported from Mexico.[7]

Disseminate and recurrent infundibular folliculitis has been reported primarily in people of African American origin in the United States.[8] Why a number of dermatoses tend to be papular and follicular in dark-skinned people is not known. This phenomenon is well documented in atopic dermatitis.

Although most of the patients are men, disseminate and recurrent infundibular folliculitis has been reported in women.

Most of the reported disseminate and recurrent infundibular folliculitis patients have been healthy, young adults.

 

Presentation

History

Most patients report a sudden onset of a widespread pruritic papular eruption. Disseminate and recurrent infundibular folliculitis has been reported to be exacerbated by hot showers and relieved by anything that cools (eg, cool showers, lotions, swimming). Occasionally, a patient may report that a number of peers have been affected at the same time. Often, disseminate and recurrent infundibular folliculitis patients have a personal or family history of atopy.

Physical Examination

Physical examination in disseminate and recurrent infundibular folliculitis reveals a papular eruption that has a follicular location. In a given area, all the follicles are involved, with no skipping of any follicles in the area involved. The usual sites are the chest and mantle and the upper arms. Infundibular folliculitis is rather monomorphic without noted rubor, calor, and dolor.

See the images below.

Courtesy of San Antonio Uniformed Services Health Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.
Courtesy of San Antonio Uniformed Services Health Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.
 

DDx

Diagnostic Considerations

Also consider the following:

  • Miliaria rubra pilaris
  • Papular contact dermatitis notably to homomenthyl salicylate found in sunscreens
  • Phrynoderma
  • Various folliculitises, including the one associated with AIDS
  • Vitamin A deficiency
  • Juxtaclavicular beaded lines
  • Apocrine miliaria
  • Patchy pityriasiform lichenoid eczema (Kitamura-Takahashi-Sasagawa disease)

Differential Diagnoses

Medication
 

Medication

Medication Summary

Emollients have been used for decades in disseminate and recurrent infundibular folliculitis, with variable success. Early reports indicated treatment with vitamin A.[9] Later, vitamin A therapy was reported to be ineffective. Several authors have reported success with isotretinoin systemic therapy. However, the standard dosing protocol has not been established.

Anti-inflammatory Agent

Clobetasol propionate (Temovate, Clobex, Cormax)

Clobetasol propionate is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Clobetasol propionate decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.