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]

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)

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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)

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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)

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

Hydroxyzine (Atarax)

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

Questions

Theiler M, Oza VS, Mathes EF, Dvorak CC, McCalmont TH, Yeh I, et al. Eosinophilic Pustular Folliculitis in Children after Stem Cell Transplantation: An Eruption Distinct from Graft-Versus-Host Disease. Pediatr Dermatol. 2017 Mar 20. [QxMD MEDLINE Link].
Kostler E, Gossrau G, Kuster P, Bergner V, Seebacher C. [Sterile eosinophilic pustulosis (Ofuji). A rare entity in Europe]. Hautarzt. 1995 Sep. 46(9):643-6. [QxMD MEDLINE Link].
Weber L, Hochsattel R, Hesse G, Klein CE. [Sterile eosinophilic pustulosis (Ofuji)]. Hautarzt. 1988 Aug. 39(8):527-30. [QxMD MEDLINE Link].
Kinoshita Y, Kono T, Ansai SI, Saeki H. An aggressive case of granulomatous eosinophilic pustular folliculitis on the face. JAAD Case Rep. 2019 Mar. 5 (3):237-239. [QxMD MEDLINE Link].
Damiani G, Pacifico A, Scarabello A, Iacovelli P, Conic RRZ, Morrone A. Suspected eosinophilic pustular folliculitis presenting as rapidly evolving acneiform eruption. J Eur Acad Dermatol Venereol. 2020 Jan. 34 (1):e43-e44. [QxMD MEDLINE Link].
Kudejko J, Jablonska S, Chorzelski T. [Cutaneous changes combining features of Kimura's disease and Ofuji's disease (folliculitis pustulosa eosinophilica). A new disease entity?]. Przegl Dermatol. 1981 Jul-Aug. 68(4):487-95. [QxMD MEDLINE Link].
Takamura S, Teraki Y. Eosinophilic pustular folliculitis associated with hematological disorders: A report of two cases and review of Japanese literature. J Dermatol. 2016 Apr. 43 (4):432-5. [QxMD MEDLINE Link].
Lee ML, Tham SN, Ng SK. Eosinophilic pustular folliculitis (Ofuji's disease) with response to indomethacin. Dermatology. 1993. 186(3):210-2. [QxMD MEDLINE Link].
Miyauchi T, Fujigaki T, Uehara M, et al. Successful treatment of eosinophilic pustular folliculitis with indomethacin. Acta Dermatol Kyoto. 1985. 80:9-13.
Nishijima S, Sugiyama T, Nakagawa M, Odaka T, Takaishi K. Two cases of eosinophilic pustular folliculitis treated by acemetacin. J Dermatol. 1994 Oct. 21(10):779-82. [QxMD MEDLINE Link].
Brazzelli V, Barbagallo T, Prestinari F, Ciocca O, Vassallo C, Borroni G. HIV seronegative eosinophilic pustular folliculitis successfully treated with doxicycline. J Eur Acad Dermatol Venereol. 2004 Jul. 18(4):467-70. [QxMD MEDLINE Link].
Hashizume S, Ansai S, Kosaka M, Kawana S. Infantile case of eosinophilic pustular folliculitis successfully treated with topical indomethacin. J Dermatol. 2014 Feb. 41(2):196-7. [QxMD MEDLINE Link].
Yamamoto Y, Nomura T, Kabashima K, Miyachi Y. Clinical epidemiology of eosinophilic pustular folliculitis: results from a nationwide survey in Japan. Dermatology. 2015. 230(1):87-92. [QxMD MEDLINE Link].
Jin SP, Park SY, Yeom KB, Kim YC, Cho KH. Eosinophilic pustular folliculitis involving labial mucosa, which improved with naproxen. Ann Dermatol. 2013 Feb. 25(1):120-2. [QxMD MEDLINE Link]. [Full Text].
Lim HL, Chong WS. Recalcitrant eosinophilic pustular folliculitis of Ofuji with palmoplantar pustulosis: dramatic response to narrowband UVB phototherapy. Photodermatol Photoimmunol Photomed. 2012 Aug. 28(4):219-21. [QxMD MEDLINE Link].
Buchness MR, Lim HW, Hatcher VA, Sanchez M, Soter NA. Eosinophilic pustular folliculitis in the acquired immunodeficiency syndrome. Treatment with ultraviolet B phototherapy. N Engl J Med. 1988 May 5. 318(18):1183-6. [QxMD MEDLINE Link].
Lim HW, Vallurupalli S, Meola T, Soter NA. UVB phototherapy is an effective treatment for pruritus in patients infected with HIV. J Am Acad Dermatol. 1997 Sep. 37(3 Pt 1):414-7. [QxMD MEDLINE Link].
Odyakmaz Demirsoy E, Demirsoy U, Ozod U, Kiran R. Eosinophilic pustular folliculitis of infancy suppressed with cetirizine. Pediatr Dermatol. 2019 Feb 21. [QxMD MEDLINE Link].
Ise S, Ofuji S. Subcorneal pustular dermatosis. A follicular variant?. Arch Dermatol. 1965 Aug. 92(2):169-71. [QxMD MEDLINE Link].
Ofuji S, Ogino A, Horio T, Oseko T, Uehara M. Eosinophilic pustular folliculitis. Acta Derm Venereol. 1970. 50(3):195-203. [QxMD MEDLINE Link].
Boone M, Dangoisse C, André J, Sass U, Song M, Ledoux M. Eosinophilic pustular folliculitis in three atopic children with hypersensitivity to Dermatophagoides pteronyssinus. Dermatology. 1995. 190(2):164-8. [QxMD MEDLINE Link].
Gul U, Kilic A, Demiriz M. Eosinophilic pustular folliculitis: the first case associated with hepatitis C virus. J Dermatol. 2007 Jun. 34(6):397-9. [QxMD MEDLINE Link].
Vakilzadeh F, Suter L, Knop J, Macher E. Eosinophilic pustulosis with pemphigus-like antibody. Dermatologica. 1981. 162(4):265-72. [QxMD MEDLINE Link].
Nunzi E, Parodi A, Rebora A. Ofuji's disease: high circulating titers of IgG and IgM directed to basal cell cytoplasm. J Am Acad Dermatol. 1985 Feb. 12(2 Pt 1):268-73. [QxMD MEDLINE Link].
Takematsu H, Tagami H. Eosinophilic pustular folliculitis. Studies on possible chemotactic factors involved in the formation of pustules. Br J Dermatol. 1986 Feb. 114(2):209-15. [QxMD MEDLINE Link].
Sato S, Chiba T, Nakahara T, Furue M. Upregulation of IL-36 cytokines in folliculitis and eosinophilic pustular folliculitis. Australas J Dermatol. 2020 Feb. 61 (1):e39-e45. [QxMD MEDLINE Link].
Maruo K, Kayashima KI, Ono T. Expression of neuronal nitric oxide synthase in dermal infiltrated eosinophils in eosinophilic pustular folliculitis. Br J Dermatol. 1999 Mar. 140(3):417-20. [QxMD MEDLINE Link].
Wong TW, Tsai YM, Lee JY, Hsu ST, Sheu HM. Eosinophilic pustular folliculitis (Ofuji's disease) in a patient with silicone tissue augmentation. J Dermatol. 2004 Sep. 31(9):727-30. [QxMD MEDLINE Link].
Keida T, Hayashi N, Kawashima M. Eosinophilic pustular folliculitis following autologous peripheral blood stem-cell transplantation. J Dermatol. 2004 Jan. 31(1):21-6. [QxMD MEDLINE Link].
Maejima H, Mukai H, Hikaru E. Eosinophilic pustular folliculitis induced by allopurinol and timepidium bromide. Acta Derm Venereol. 2002. 82(4):316-7. [QxMD MEDLINE Link].
Ooi CG, Walker P, Sidhu SK, Gordon LA, Marshman G. Allopurinol induced generalized eosinophilic pustular folliculitis. Australas J Dermatol. 2006 Nov. 47(4):270-3. [QxMD MEDLINE Link].
Mabuchi T, Matsuyama T, Ozawa A. Case of eosinophilic pustular folliculitis associated with pregnancy. J Dermatol. 2011 May 4. [QxMD MEDLINE Link].
Matsudate Y, Miyaoka Y, Urano Y. Two cases of eosinophilic pustular folliculitis associated with pregnancy. J Dermatol. 2016 Feb. 43 (2):218-9. [QxMD MEDLINE Link].
Lo CS, Yang CY, Ko JH, Lee WY, Shih IH, Lin YC. Hyperimmunoglobulin E syndrome presenting as eosinophilic pustular folliculitis: a case report. Int J Dermatol. 2015 Feb. 54(2):211-4. [QxMD MEDLINE Link].
Jiang YY, Zeng YP, Jin HZ. Eosinophilic Pustular Folliculitis Associated with Cutaneous Angiosarcoma. Chin Med J (Engl). 2018 Jan 5. 131 (1):115-116. [QxMD MEDLINE Link].
Sugaya M, Suga H, Miyagaki T, Fujita H, Sato S. Eosinophilic pustular folliculitis associated with Sézary syndrome. Clin Exp Dermatol. 2014 Jun. 39(4):536-8. [QxMD MEDLINE Link].
Takashima S, Nishie W, Morita Y, Osawa R, Iwata H, Fujita Y, et al. Eosinophilic pustular folliculitis in a patient with mycosis fungoides. J Eur Acad Dermatol Venereol. 2015 Feb 11. [QxMD MEDLINE Link].
Takeuchi A, Nomura T, Kaku Y, Egawa G, Kabashima K. A case of atypical eosinophilic pustular folliculitis that emerged following the administration of capecitabine. J Eur Acad Dermatol Venereol. 2018 Feb 14. [QxMD MEDLINE Link].
Chuh A. Eosinophilic folliculitis due to wearing protective gear in citizens volunteering for sanitation services during the COVID-19 pandemic - an original epidemiological, clinical, dermoscopic, and laboratory-based study. Int J Dermatol. 2020 Dec. 59 (12):1468-1474. [QxMD MEDLINE Link].
Yoshida S, Yatsuzuka K, Chigyo K, Kuroo Y, Takemoto K, Sayama K. A Case of Eosinophilic Pustular Folliculitis since Birth. Children (Basel). 2021 Jan 7. 8 (1):[QxMD MEDLINE Link].
Nomura T, Katoh M, Yamamoto Y, Kabashima K, Miyachi Y. Eosinophilic pustular folliculitis: The transition in sex differences and interracial characteristics between 1965 and 2013. J Dermatol. 2015 Feb 10. [QxMD MEDLINE Link].
Lee WJ, Won KH, Won CH, Chang SE, Choi JH, Moon KC, et al. Facial and extrafacial eosinophilic pustular folliculitis: a clinical and histopathological comparative study. Br J Dermatol. 2014 May. 170(5):1173-6. [QxMD MEDLINE Link].
Holden KG, McCormick TG. A Dermatitis Mimicker: A Case of Infantile Eosinophilic Pustular Folliculitis. Dermatitis. 2022 Jan-Feb 01. 33 (1):e1. [QxMD MEDLINE Link].
Nomura T, Katoh M, Yamamoto Y, Miyachi Y, Kabashima K. Eosinophilic pustular folliculitis: Trends in therapeutic options. J Dermatol. 2016 Feb 15. [QxMD MEDLINE Link].
Nomura T, Katoh M, Yamamoto Y, Miyachi Y, Kabashima K. Eosinophilic pustular folliculitis: A proposal of diagnostic and therapeutic algorithms. J Dermatol. 2016 Mar 30. [QxMD MEDLINE Link].
Hernández-Martín Á, Nuño-González A, Colmenero I, Torrelo A. Eosinophilic pustular folliculitis of infancy: a series of 15 cases and review of the literature. J Am Acad Dermatol. 2013 Jan. 68(1):150-5. [QxMD MEDLINE Link].
Gallo G, Conti L, Quaglino P, Ribero S. Treatment of eosinophilic pustular folliculitis with low-dose isotretinoin. Int J Dermatol. 2022 Jul. 61 (7):e262-e264. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Toyonaga E, Abe R, Moriuchi R, Ito K, Abe Y, Shimizu H. Indomethacin for refractory infantile eosinophilic pustular folliculitis. JAMA Dermatol. 2013 Mar. 149(3):367-8. [QxMD MEDLINE Link].
Kawaguchi M, Mitsuhashi Y, Kondo S. Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus. Int J Dermatol. 2004 Aug. 43(8):608-10. [QxMD MEDLINE Link].
Patel NP, Laguda B, Roberts NM, Francis ND, Agnew K. Treatment of eosinophilic pustulosis of infancy with topical tacrolimus. Br J Dermatol. 2012 Nov. 167(5):1189-91. [QxMD MEDLINE Link].
Rho NK, Kim BJ. Eosinophilic pustular folliculitis: successful treatment with topical pimecrolimus. Clin Exp Dermatol. 2007 Jan. 32(1):108-9. [QxMD MEDLINE Link].
Kanekura T, Mera Y, Mera K, Saruwatari H, Kanzaki T. Efficacy of transdermal nicotine patches for eosinophilic pustular folliculitis. Br J Dermatol. 2005 May. 152(5):1074-5. [QxMD MEDLINE Link].
Satoh T, Shimura C, Miyagishi C, Yokozeki H. Indomethacin-induced reduction in CRTH2 in eosinophilic pustular folliculitis (Ofuji's disease): a proposed mechanism of action. Acta Derm Venereol. 2010. 90(1):18-22. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sugita K, Kabashima K, Koga C, Tokura Y. Eosinophilic pustular folliculitis successfully treated with sequential therapy of interferon-gamma and ciclosporin. Clin Exp Dermatol. 2006 Sep. 31(5):709-10. [QxMD MEDLINE Link].
Otsuka A, Doi H, Miyachi Y, Kabashima K. Treatment of eosinophilic pustular folliculitis with ciclosporin: suppression of mRNA expression of IL-4 and IL-13. J Eur Acad Dermatol Venereol. 2010 Dec. 24(12):1489-91. [QxMD MEDLINE Link].
Dwivedi M, Sharma V, Pathak K. Pilosebaceous targeting by isotretenoin-loaded invasomal gel for the treatment of eosinophilic pustular folliculitis: optimization, efficacy and cellular analysis. Drug Dev Ind Pharm. 2017 Feb. 43 (2):293-304. [QxMD MEDLINE Link].

Media Gallery

A patchy lesion on the cheek in a patient with eosinophilic pustular folliculitis. Courtesy of Professor T. Nishikawa, Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.
Widespread hyperpigmented patches on the back and the arms in a patient with eosinophilic pustular folliculitis. Courtesy of Professor T. Nishikawa, Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.
A 51-year-old Japanese man without a concomitant HIV infection with pustular eosinophilic folliculitis. Courtesy of Professor Akimichi Morita, Nagoya City University Medical School, Nagoya, Japan.
Transverse section from a 21-year-old man with eosinophilic pustular folliculitis. A perifollicular inflammatory infiltrate containing numerous eosinophils is present (hematoxylin and eosin, original magnification X400).
Vertical section from a 3-year-old girl with eosinophilic pustular folliculitis. A perifollicular inflammatory infiltrate containing eosinophils is present (hematoxylin and eosin, original magnification X200).