Eosinophilic Folliculitis Treatment & Management

Updated: Apr 07, 2017
  • Author: Camila K Janniger, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Treatment

Medical Care

Numerous topical and systemic therapies are available for eosinophilic folliculitis. Treatment modalities are chosen based on disease severity, patient preference (including cost and convenience), and response. Highly active antiretroviral therapy along with isotretinoin therapy is beneficial for eosinophilic folliculitis in the setting of HIV disease. [35] A new isotretinoin-loaded invasomal gel may be particularly effective. [36]  Eosinophilic folliculitis may also respond well to systemic indomethacin, [37] which is considered first-line therapy in Japanese patients, in whom it has been found to be particularly effective among women. [4] A number of therapeutic options are delineated below. There are no generally accepted treatment protocols. [38, 39]

Topical corticosteroids are the mainstay of treatment for eosinophilic folliculitis. The mechanism of action of corticosteroids in eosinophilic folliculitis is not fully understood; the anti-inflammatory and immunosuppressive properties of these agents may contribute to their effect.

The potency of the steroid prescribed depends on the location of the skin lesions. In the scalp, potent steroids in alcohol solution, such as fluocinonide 0.05%, are frequently indicated. On the face and other sensitive body sites, a low-potency cream, such as hydrocortisone 1%, may suffice.

The typical regimen consists of twice-daily application of topical corticosteroids. This decreases the inflammation and plaques in most patients. Skin atrophy due to topical corticosteroid use is usually not a problem unless the medication is continuously applied after the skin has normalized. Severe flares may be treated with short courses of oral prednisone.

Fukamachi et al evaluated the therapeutic effectiveness of various treatments for eosinophilic pustular folliculitis in 20 patients. [40] Oral cyclosporine was markedly effective in all 11 patients treated with the drug, and topical tacrolimus ointment alleviated eosinophilic pustular folliculitis in 3 of 7 of the study participants. In addition to indomethacin or other oral nonsteroidal anti-inflammatory drugs (NSAIDs), oral cyclosporine and topical tacrolimus appeared to be beneficial in patients resistant to previous treatments. Others also recommend cyclosporine. [41]

Topical tacrolimus is a good option for both eosinophilic pustulosis of infancy and adult cases. [42, 43] Topical tacrolimus ointment 0.03% may produce rapid clearance in infants. Indomethacin is another option for refractory infantile eosinophilic pustular folliculitis. [44]

Retinoids, such as isotretinoin, inhibit sebaceous gland function and keratinization. Clinical improvement occurs in association with a reduction in sebum secretion. This effect is temporary and is related to the dose and duration of treatment. Monitoring for hypertriglyceridemia and hepatotoxicity is required. Common adverse effects include cheilitis and alopecia. Systemic retinoid therapy is teratogenic; it is indicated only in patients who have no reproductive potential. Alternatives include indomethacin and dapsone.

Ishiguro reported treatment outcomes of 20 patients with Ofuji disease, or classic eosinophilic pustular folliculitis. Eleven of the 20 patients were treated with oral indomethacin, with 8 and 3 of those patients showing complete and partial responses, respectively. In contrast, 12 of the 20 patients had previously been treated with topical steroids. Seven, 2, and 3 of the patients showed partial response, no response, and unknown responses, respectively; no complete responses were seen. In disease unresponsive to topical steroids and other treatments, oral indomethacin at doses of 50-75 mg/day in adults, if tolerated, may yield the highest complete response rate. [45]

In patients infected with HIV, treat mild eosinophilic folliculitis with topical steroids and oral antihistaminics. Treat moderate disease with oral itraconazole, isotretinoin, or phototherapy. Treat severe eosinophilic folliculitis with isotretinoin therapy for several months.

Potential treatments include oxyphenbutazone, colchicine, minocycline, oral metronidazole, [46] acitretin, cyclosporine A, UV-B therapy, [47, 48] interferon alfa-2b, tacrolimus, [49, 50, 51] doxycycline, [52] and radiation therapy. [53]

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Consultations

Consider referral to a dermatologist in the following settings:

  • If the diagnosis of eosinophilic folliculitis needs to be confirmed
  • If the response to treatment is inadequate
  • If the primary care physician is not familiar with the recommended treatment modality
  • If the patient has widespread or severe eosinophilic folliculitis
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