Eosinophilic Pustular Folliculitis Medication

Updated: Apr 05, 2023
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Medication Summary

Because the etiology and the pathogenesis of eosinophilic pustular folliculitis have not been fully elucidated, no established treatment schemes exist. [44, 45]  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. [46] One study showed topical steroids effective in 90% of 61 affected infants. Another option for carefully selected patients may be low-dose isotretinoin. [47]

An alternative therapeutic option in patients with a long-term history of unsuccessful response to conservative therapy is ionizing radiation. [48] Eosinophilic pustular folliculitis may respond to treatment with indomethacin, [49] topical tacrolimus, [50, 51] pimecrolimus, [52] or transdermal nicotine patches. [53] Indomethacin may exert its therapeutic effect via reducing CRTH2 (chemoattractant receptor homologous molecule expressed on Th2 cells) expression, as well as by inhibiting prostaglandin D2 synthesis. [54, 55]  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. [56] Treatment with oral cyclosporine might successfully control eosinophilic pustular folliculitis refractory to indomethacin by suppressing mRNA expression of Th2 cytokines (interleukins 4 and 13) in peripheral blood mononuclear cells. [57] An isotretinoin-loaded invasomal gel may beneficially target pilosebaceous follicular units in some patients to treat this disorder. [58]


Nonsteroidal anti-inflammatory drugs

Class Summary

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis. Indomethacin may exert its therapeutic effect via reducing CRTH2 (chemoattractant receptor homologous molecule expressed on Th2 cells) expression, as well as by inhibiting prostaglandin D2 synthesis.

Indomethacin (Indocin)

Indomethacin is 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).



Class Summary

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)

Permethrin 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.



Class Summary

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)

Cyproheptadine is used for the symptomatic relief of allergic symptoms caused by histamine released in response to allergens and skin manifestations.

Hydroxyzine (Atarax)

Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in subcortical region of the CNS.