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.^[42]A new isotretinoin-loaded invasomal gel may be particularly effective.^[43]Eosinophilic folliculitis may also respond well to systemic indomethacin,^[44]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.^{[45, 46]}

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.^[47]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.^[48]

Topical tacrolimus is a good option for both eosinophilic pustulosis of infancy and adult cases.^{[49, 50]}Topical tacrolimus ointment 0.03% may produce rapid clearance in infants. Indomethacin is another option for refractory infantile eosinophilic pustular folliculitis.^[51]

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.^[52]

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,^[53]acitretin, cyclosporine A, UV-B therapy,^{[54, 55]}interferon alfa-2b, tacrolimus,^{[56, 57, 58]}doxycycline,^[59]and radiation therapy.^[60]

Cetirizine has shown benefit in the treatment of infantile eosinophilic folliculitis, but the condition recurred after therapy was stopped.^[61]

Eosinophilic folliculitis associated with immune reconstitution inflammatory syndrome has been treated with thalidomide.^[62]

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

Medication

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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.

Sections Eosinophilic Folliculitis
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