Medication Summary
The goals of pharmacotherapy are to reduce inflammation, eliminate infection if present, reduce morbidity, and prevent complications.
Treatment varies with the particular disease suspected and consists of a wide range of methods, including excision, laser ablation, topical/oral antibiotics, topical/oral retinoids, and drug withdrawal. Please review individual topics in Physical Examination for greater detail.
Antifungals, Other
Class Summary
Antifungals are used in the first-line therapy of Pityrosporum folliculitis. The use of topical agents has few adverse effects besides an allergic reaction to the active agent or inactive component. The mechanism of action usually involves the inhibition of pathways (eg, enzyme, substrate, transport) that are necessary for sterol and/or cell membrane synthesis, or the permeability of the cell membrane (polyenes) of the fungal cell is altered.
Ciclopirox (Loprox)
Ciclopirox interferes with DNA, RNA, and protein synthesis by inhibiting the transport of essential elements in fungal cells.
Econazole (Spectazole)
Econazole is effective in cutaneous infections. Ii interferes with RNA and protein synthesis and metabolism. Econazole disrupts fungal cell wall permeability, causing fungal cell death.
Ketoconazole (Extina, Xolegel)
Ketoconazole is an imidazole broad-spectrum antifungal agent; it inhibits the synthesis of ergosterol, causing cellular components to leak and resulting in fungal cell death.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
Because the etiology and the pathogenesis of eosinophilic pustular folliculitis have not been fully elucidated, no established treatment schemes exist. 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.
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).
Antihistamines, First Generation
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
Cyproheptadine is used for the symptomatic relief of allergic symptoms caused by histamine released in response to allergens and skin manifestations.
Hydroxyzine (Vistaril)
Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in the subcortical region of the CNS.
Immunosuppressants
Class Summary
Treatment with oral cyclosporine might successfully control eosinophilic pustular folliculitis refractory to indomethacin.
Cyclosporine (Gengraf, Neoral, Sandimmune)
Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions. It suppresses mRNA expression of Th2 cytokines (interleukins 4 and 13) in peripheral blood mononuclear cells.
Pimecrolimus cream (Elidel)
Pimecrolimus cream is used for short-term treatment or for intermittent, long-term treatment in unresponsive or intolerant cases. It is available in a 1% cream.
This was the first nonsteroid cream approved in the United States for mild to moderate atopic dermatitis. It is derived from ascomycin, a natural substance produced by the fungus Streptomyces hygroscopicus var. ascomyceticus. Pimecrolimus cream selectively inhibits the production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids. Pimecrolimus cream is indicated only after other treatment options have failed.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting. Antibiotic treatments for rosacea include tetracyclines and metronidazole. Dapsone is used in the treatment of eosinophilic pustular folliculitis.
Dapsone (Aczone)
Dapsone prevents bacterial use of para-aminobenzoic acid (PABA) for folic acid synthesis by acting as a competitive inhibitor.
Tetracycline
Tetracycline inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Tetracycline has anti-inflammatory activity. It can be administered at 250-500 mg orally twice daily.
Doxycycline (Doryx, Adoxa, Monodox, Vibramycin)
Doxycycline is a broad-spectrum antibiotic with excellent gram positive cover, including most resistant staph organisms. It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline may block the dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Metronidazole (MetroCream, MetroGel)
Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into the cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
Retinoid-Like Agents
Class Summary
These agents stimulate cellular retinoid receptors and help normalize keratinocyte differentiation and are comedolytic. In addition, they have anti-inflammatory properties. Oral isotretinoin also reduces sebum production in the skin. Retinoids are classified into 3 generations. The first comprises topical tretinoin and systemic isotretinoin. Acitretin is a second-generation retinoid used to treat psoriasis. The third-generation retinoids include topical adapalene and tazarotene.
Topical tretinoin (Retin-A Micro, Atralin, Tretin-X Avita)
Topical tretinoin inhibits microcomedo formation. It decreases the cohesiveness of keratinocyesin sebaceous follicles, which allows for easy removal. It has anti-inflammatory properties. Topical tretinoin is available as creams and gels.
Adapalene (Differin)
Adapalene inhibits microcomedo formation. It decreases the cohesiveness of keratinocyesin sebaceous follicles, which allows for easy removal. It has anti-inflammatory properties and is available as creams and gels.
Tazarotene (Tazorac)
Tazarotene inhibits microcomedo formation. It decreases the cohesiveness of keratinocyesin sebaceous follicles, which allows for easy removal. It has anti-inflammatory properties and is available as creams and gels.
Isotretinoin (Claravis, Amnesteem, Sotret, Myorisan)
Isotretinoin is an oral retinoid indicated for recalcitrant, nodulocystic acne. It addresses all four pathogenic factors involved the development of acne: follicular hyperkeratinization, inflammation, sebum production, and Cutibacterium acnes (formerly Propionibacterium acnes)growth. Treatment is weight-based, usually dosed initially 0.5 mg/kg and increased to 1 mg/kg in 2 divided doses for 15-20 weeks. Once-daily dosing is not recommended. One may adjust the dose to administer up to 2 mg/kg/day. Patients must be registered into government regulated iPledge program in order to receive the medication.
Acne Agents, Topical
Class Summary
Acne products are used for the treatment of mild to moderate acne vulgaris. These agents may have antibacterial and comedolytic properties. In severe cases, the agents may be used as an adjunct in therapeutic regimens.
Salicylic acid acne (Benzac Blemish Clearing Hydrator 0.5%, Benzac Intensive Spot Treatment 2%, Benzac Skin Balancing Foaming Cleanser 0.5%)
Salicylic acid is a comedolytic agent. It inhibits the formation of comedones resulting from oil and skin cells that become trapped in the pore. Its lipophilic characteristics facilitate the peeling of the exterior layer of the dermis and opens follicles that are plugged. This leads skin cells to renew their cell cycle of proliferation and differentiation. Salicylic acid can interfere with the arachidonic acid cascade of the inflammatory process. This action results in the reduction of inflammatory acne lesions.
Benzoyl peroxide (BenzEFoam, PanOxyl, Neutrogena On The Spot, Invisible Acne Treatment)
Benzoyl peroxide is an oxidizing agent that possesses antibacterial properties and is comedolytic. The antibacterial activity results from the release of active or free-radical oxygen that can oxidize bacterial proteins. Benzoyl peroxide is oxidized into benzoic acid with contact to the skin. It is available OTC and by prescription.
Azelaic acid (Azelex, Finacea)
Azelaic acid has been shown to help reduce inflammation and may aid in treatment of postinflammatory hyperpigmentation. Apply it twice daily. Improvement may be seen within 4 weeks.
Erythromycin and benzoyl peroxide (Benzamycin)
This agent contains erythromycin, which is a macrolide antibiotic, as well as benzoyl peroxide. Benzoyl peroxide, in addition to being an antibacterial agent, is a keratolytic and desquamative agent. With benzoyl peroxide, free-radical oxygen is released upon administration, oxidizing bacterial proteins in sebaceous follicles and decreasing the number of anaerobic, bacterial, and irritating free fatty acids. It has keratolytic and comedolytic effects.
Erythromycin is indicated for infections caused by susceptible strains of microorganisms.
The combination drug may be applied topically twice daily.
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Acneiform eruption. Courtesy of DermNet New Zealand (http://www.dermnetnz.org/assets/Uploads/doctors/quizzes/48/case6.jpg).
