By Gary M. White, MD
Eosinophilic folliculitis (EF) is a common itchy follicular disease that tends to present in HIV patients late in their disease and with low CD4 counts. It may also occur in patients being treated for hematologic malignancy including 2-3 months after bone marrow transplantation. The cause is not known, but it has been suggested that an autoimmune process against the sebocyte or a constituent of sebum is the cause [BJD 1999;141;3].
Chronic pruritic follicular papules of the trunk, neck, and arms in an HIV-positive patient is characteristic. Occasionally, one can see a few intact pustules. Almost all patients are men. Bacterial and fungal cultures should be obtained to exclude an infectious cause. Pseudomonal folliculitis may be found.
Distinguishing an infectious folliculitis from EF clinically is very difficult and therefore a biopsy is recommended [BJD 1999;141;3]. Biopsy is best performed on a nonexcoriated pustule. Find one and ask the patient if it itches. If it does, push on it to see if it is tender. If not tender, biopsy it. If tender, it may be an acne lesion. Biopsy shows a folliculitis with eosinophils. The disease is typically resistant to oral antibiotics and topical steroids but these may be tried in an effort to exclude other diagnoses, especially a course of antistaphylococcal antibiotics.
Therapy is often difficult.
Any therapy that improves the patient's immune status may improve the EF. Permethrin cream 5% QD initially then tapered is a good choice in therapy. It can very effectively smooth the skin and decrease pruritus. (Some feel its mode of action is by decreasing the population of demodex). The use of elimite may be combined with doxepin at night and the use of a class I topical steroid applied to new lesions. If this therapy fails after 2 weeks, one may add oral itraconazole e.g., 200 mg QD. It should be given for approximately 2 weeks and if no response is seen, then increase the dose to 300-400 mg/day. Often it is beneficial to combine its use with UVB phototherapy. (There is some evidence that KS can worsen with phototherapy so it should be avoided in EF patients who also have KS). Interestingly, fluconazole is reportedly not effective. As noted above, metronidazole 250 TID for 3 weeks can be dramatically effective. Some have suggested the addition of prednisone (e.g., 40 mg QOD) acutely for rapid initial control. Isotretinoin (1.0 mg/kg/day given for at least 2-3 months) can be dramatically effective.
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