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.^[7]

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.^[8]

Physical

Eosinophilic folliculitis typically appears as an area of erythematous papules and pustules. These involve the face in most (85%) affected patients. Occasionally, the papules do not evolve into macroscopic pustules.^[9]

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

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

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

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The papules gradually become confluent, creating indurate polycyclic plaques with a healing center and spreading periphery. Sometimes the plaques may be studded with papules and sterile pustules.^[10]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.^[11]

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. The cause of classic eosinophilic pustular folliculitis is unknown, although immune processes almost certainly play a key role in its pathogenesis.

Eosinophilic folliculitis may be associated with HIV infection, various drugs, and some lymphomas; it may be considered a nonspecific dermatopathologic pattern in such settings.^[12]Drugs that have been associated with eosinophilic folliculitis are carbamazepine, allopurinol with or without timedium bromide, foscarnet, and various chemotherapeutic agents.^{[13, 14, 15, 16, 17, 18]}

Many observations suggest a role for immunologic, infectious, and environmental factors.

Brenner et al 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.^[19]

Other investigators have reported infectious associations, including dermatophyte infection, as well as infections due to larva migrans, Pityrosporum infection, retrovirus,^[20]and hepatitis C virus infection.^[21]

A linkage with pregnancy has been observed.^[22]

In addition, eosinophilic folliculitis has been associated with various medical conditions, including lymphoma, Sézary syndrome,^[23]leukemia,^[24] myelodysplastic syndrome, atopy, cutaneous angiosarcoma, and polycythemia vera.^{[25, 26, 27, 28, 29]}

Eosinophilic folliculitis may also develop following bone marrow and solid organ transplantation.^{[30, 31]}It may be considered a reaction related to immune dysregulation.

Eosinophilic folliculitis associated with wearing protective gear during the COVID-19 pandemic has been described^[32].

Complications

Eosinophilic folliculitis is a cutaneous disease without important sequelae. The only residual expression of the disease is cutaneous hyperpigmentation and scaling.

Differential Diagnoses

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, et al. Eosinophilic pustular folliculitis. Acta Derm Venereol. 1970. 50(3):195-203. [QxMD MEDLINE Link].
Nervi SJ, Schwartz RA, Dmochowski M. Eosinophilic pustular folliculitis: a 40 year retrospect. J Am Acad Dermatol. 2006 Aug. 55(2):285-9. [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].
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].
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].
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Fraser SJ, Benton EC, Roddie PH, Krajewski AS, Goodlad JR. Eosinophilic folliculitis: an important differential diagnosis after allogeneic bone-marrow transplant. Clin Exp Dermatol. 2009 Apr. 34(3):369-71. [QxMD MEDLINE Link].
Uchiyama M, Mitsuhashi Y, Okubo Y, Tsuboi R. Eosinophilic pustular folliculitis (Ofuji's disease) without macroscopic pustules. Int J Dermatol. 2012 Jan. 51(1):50-2. [QxMD MEDLINE Link].
Scavo S, Magro G, Caltabiano R. Erythematous and edematous eruption of the face. Eosinophilic pustular folliculitis. Int J Dermatol. 2010 Sep. 49(9):975-7. [QxMD MEDLINE Link].
Tsuboi H, Niiyama S, Katsuoka K. Eosinophilic pustular folliculitis (Ofuji disease) manifested as pustules on the palms and soles. Cutis. 2004 Aug. 74(2):107-10. [QxMD MEDLINE Link].
Sufyan W, Tan KB, Wong ST, et al. Eosinophilic pustular folliculitis. Arch Pathol Lab Med. 2007 Oct. 131(10):1598-601. [QxMD MEDLINE Link].
Mizoguchi S, Setoyama M, Higashi Y, Hozumi H, Kanzaki T. Eosinophilic pustular folliculitis induced by carbamazepine. J Am Acad Dermatol. 1988. 38:641-3.
Maejima H, Mukai H, Hikaru E. Eosinophilic pustular folliculitis induced by allopurinol and timedium bromide. Acta DermVenereol. 2002. 82:316-7.
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.
Roos TC, Albrecht H. Foscarnet-associated eosinophilic folliculitis in a patient with AIDS. J Am Acad Dermatol. 2001 Mar. 44(3):546-7.
Laing ME, Laing TA, Mulligan NJ, Keane FM. Eosinophilic pustular folliculitis induced by chemotherapy. J Am Acad Dermatol. 2006 Apr. 54(4):729-30.
Fujii M, Takahashi I, Kishiyama K, Honma M, Ishida-Yamamoto A. Case of generalized eosinophilic pustular folliculitis induced by allopurinol. J Dermatol. 2016 Apr. 43 (4):458-9. [QxMD MEDLINE Link].
Brenner S, Wolf R, Ophir J. Eosinophilic pustular folliculitis: a sterile folliculitis of unknown cause?. J Am Acad Dermatol. 1994 Aug. 31(2 Pt 1):210-2. [QxMD MEDLINE Link].
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. [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].
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].
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].
Patrizi A, Chieregato C, Visani G, et al. Leukaemia-associated eosinophilic folliculitis (Ofuji's disease). J Eur Acad Dermatol Venereol. 2004 Sep. 18(5):596-8. [QxMD MEDLINE Link].
Kimoto M, Ishihara S, Konohana A. Eosinophilic pustular folliculitis with polycythemia vera. Dermatology. 2005. 210(3):239-40. [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].
Cunningham F, Gupta P, Becher G, Magro CM. Necrotizing eosinophilic folliculitis: a new manifestation of the atopic diathesis?. Clin Exp Dermatol. 2017 Jan. 42 (1):100-101. [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].
Owen RL, Shah KK, Sosis AC, Purcell SM. Eosinophilic pustular folliculitis with underlying mantle cell lymphoma. Cutis. 2018 Jun. 101 (6):454-457. [QxMD MEDLINE Link].
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. 2007 Dec. 34 Suppl 1:33-6. [QxMD MEDLINE Link].
Kim BW, Lee JH, Won CH, Chang SE, Lee MW, Choi JH, et al. Eosinophilic pustular folliculitis: association with long-term immunosuppressant use in a solid organ transplant recipient. Ann Dermatol. 2014 Aug. 26(4):520-1. [QxMD MEDLINE Link]. [Full Text].
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].
Fujiyama T, Tokura Y. Clinical and histopathological differential diagnosis of eosinophilic pustular folliculitis. J Dermatol. 2013 Jun. 40(6):419-23. [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].
Chopra D, Kumari S, Kundal RK, Bahl RK, Aggarwal S, Singh H, et al. A study of clinicopathological correlation of pruritic papular eruptions in HIV patients. Indian J Sex Transm Dis AIDS. 2018 Jan-Jun. 39 (1):44-49. [QxMD MEDLINE Link].
Boone SL, Guitart J, Gerami P. Follicular mycosis fungoides: a histopathologic, immunohistochemical, and genotypic review. G Ital Dermatol Venereol. 2008 Dec. 143(6):409-14. [QxMD MEDLINE Link].
Schwartz RA, Janniger CK. Generalized pustular figurate erythema: A newly delineated severe cutaneous drug reaction linked with hydroxychloroquine. Dermatol Ther. 2020 May. 33 (3):e13380. [QxMD MEDLINE Link].
Fertitta, Laura; Bodemer, Christine; Molina, Thierry; Frassati-Biaggi, Annonciade; Fraitag, Sylvie; Leclerc-Mercier, et al. Eosinophilic Pustular Folliculitis of Infancy: A Histologic Assessment of 43 Cases. A J Derm. June 2022. 44(6):395-403(9). [Full Text].
Piantanida EW, Turiansky GW, Kenner JR, Mather MK, Sperling LC. HIV-associated eosinophilic folliculitis: Diagnosis by transverse histologic sections. J Am Acad Dermatol. 1998 Jan. 38(1):124-6.
Junqueira Magalhães Afonso JP, Tomimori J, Michalany NS, Nonogaki S, Porro AM. Pruritic papular eruption and eosinophilic folliculitis associated with human immunodeficiency virus (HIV) infection: A histopathological and immunohistochemical comparative study. J Am Acad Dermatol. 2012 Apr 19. [QxMD MEDLINE Link].
Satoh T, Ito Y, Miyagishi C, Yokozeki H. Basophils Infiltrate Skin Lesions of Eosinophilic Pustular Folliculitis (Ofuji's Disease). Acta Derm Venereol. 2011 Jan 31. [QxMD MEDLINE Link].
Annam V, Yelikar BR, Inamadar AC, Palit A, Arathi P. Clinicopathological study of itchy folliculitis in HIV-infected patients. Indian J Dermatol Venereol Leprol. 2010 May-Jun. 76(3):259-62. [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].
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].
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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].
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].
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].
Patel NP, Laguda B, Roberts NM, Francis ND, Agnew K. Treatment of Eosinophilic Pustulosis of Infancy with Topical Tacrolimus. Br J Dermatol. 2012 May 7. [QxMD MEDLINE Link].
Ng SS, Tay YK. Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus 0.1 percent ointment. Dermatol Online J. 2012 Feb 15. 18(2):10. [QxMD MEDLINE Link].
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Inaoka M, Hayakawa J, Shiohara T. HIV seronegative eosinophilic pustular folliculitis successfully treated with metronidazole. J Am Acad Dermatol. 2002 May. 46(5 Suppl):S153-5.
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Media Gallery

Eosinophilic pustular folliculitis in a patient infected with HIV. Note acneiform hyperpigmented papules. Photograph courtesy of Sarah A. Myers, MD.
Eosinophilic pustular folliculitis in a patient who is HIV-positive. Note follicular-based excoriated papules and pustules on the trunk. Photograph courtesy of Sarah A. Myers, MD.
Eosinophilic folliculitis (low-power). Note eosinophilic spongiosis, particularly involving the infundibular region of the hair follicle.
Eosinophilic folliculitis (high-power). In addition to the abundant eosinophils, note the variable numbers of neutrophils and mononuclear cells.

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Author

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers 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)

M Angelica Selim, MD, MD Director of Dermatopathology, Departments of Pathology and Internal Medicine, Associate Professor, Duke University Medical Center

Disclosure: Nothing to disclose.

Christopher R Shea, MD Eugene J Van Scott Professor in Dermatology, Chief, Section of Dermatology, Department of Medicine, University of Chicago, The Pritzker School of Medicine

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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Rajendra Kapila, MD, MBBS † Professor, Department of Medicine, Rutgers 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, Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Harry Dao, Jr, MD Assistant Professor, Department of Dermatology, Baylor College of Medicine

Harry Dao, Jr, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.