HIV-associated eosinophilic folliculitis
- Priya Rajendran, MD
Priya Rajendran, MD
- Clinical Instructor
- University of California, San Francisco
- Whitney A High, MD
Whitney A High, MD
- Associate Professor of Dermatology and Dermatopathology
- University of Colorado School of Medicine
- Toby Maurer, MD
Toby Maurer, MD
- Professor of Dermatology
- University of California, San Francisco, School of Medicine
Eosinophilic folliculitis (EF) is a pruritic skin eruption consisting of follicular papules or pustules, predominantly located on the scalp, face, neck, and upper chest (picture 1A-B).
EF is a relatively common skin eruption in patients with advanced human immunodeficiency virus (HIV) disease [1,2]. A clinically distinct form of EF (Ofuji's disease) has also been described in otherwise healthy individuals, particularly in Japan . Other rare types of non-HIV-associated EF include infantile EF and EF associated with bone marrow transplantation [4,5]. Non-HIV-associated EF has also been described as a rare side effect of medication, including chemotherapy .
This topic reviews the presentation and management of HIV-associated EF. Bacterial folliculitis is discussed separately. (See "Infectious folliculitis".)
HIV-associated EF most commonly occurs in patients with late-stage disease or low CD4 counts . EF has been reported in HIV-infected men, women, and children [7-9]. The prevalence is uncertain, although one series of HIV patients reported folliculitis in 9 percent . In our experience, since the advent of antiretroviral therapy, EF has become less common.
The etiology of EF is unknown. Clinical characteristics of EF suggest that it may be an inflammatory disease related to immune dysregulation, perhaps in association with an underlying infection [11,12].
- Rosenthal D, LeBoit PE, Klumpp L, Berger TG. Human immunodeficiency virus-associated eosinophilic folliculitis. A unique dermatosis associated with advanced human immunodeficiency virus infection. Arch Dermatol 1991; 127:206.
- Majors MJ, Berger TG, Blauvelt A, et al. HIV-related eosinophilic folliculitis: a panel discussion. Semin Cutan Med Surg 1997; 16:219.
- Ofuji S, Ogino A, Horio T, et al. Eosinophilic pustular folliculitis. Acta Derm Venereol 1970; 50:195.
- Keida T, Hayashi N, Kawashima M. Eosinophilic pustular folliculitis following autologous peripheral blood stem-cell transplantation. J Dermatol 2004; 31:21.
- Fraser SJ, Benton EC, Roddie PH, et al. Eosinophilic folliculitis: an important differential diagnosis after allogeneic bone-marrow transplant. Clin Exp Dermatol 2009; 34:369.
- Laing ME, Laing TA, Mulligan NJ, Keane FM. Eosinophilic pustular folliculitis induced by chemotherapy. J Am Acad Dermatol 2006; 54:729.
- Basarab T, Russell Jones R. HIV-associated eosinophilic folliculitis: case report and review of the literature. Br J Dermatol 1996; 134:499.
- Ramdial PK, Morar N, Dlova NC, Aboobaker J. HIV-associated eosinophilic folliculitis in an infant. Am J Dermatopathol 1999; 21:241.
- Hayes BB, Hille RC, Goldberg LJ. Eosinophilic folliculitis in 2 HIV-positive women. Arch Dermatol 2004; 140:463.
- Uthayakumar S, Nandwani R, Drinkwater T, et al. The prevalence of skin disease in HIV infection and its relationship to the degree of immunosuppression. Br J Dermatol 1997; 137:595.
- Ellis E, Scheinfeld N. Eosinophilic pustular folliculitis: a comprehensive review of treatment options. Am J Clin Dermatol 2004; 5:189.
- Magro CM, Crowson AN. Eosinophilic pustular follicular reaction: a paradigm of immune dysregulation. Int J Dermatol 1994; 33:172.
- Bodokh I, Lacour JP, Perrin C, et al. Papular eruption in AIDS: role of demodectic mites? Acta Derm Venereol 1994; 74:320.
- Blauvelt A, Plott RT, Spooner K, et al. Eosinophilic folliculitis associated with the acquired immunodeficiency syndrome responds well to permethrin. Arch Dermatol 1995; 131:360.
- Fearfield LA, Rowe A, Francis N, et al. Itchy folliculitis and human immunodeficiency virus infection: clinicopathological and immunological features, pathogenesis and treatment. Br J Dermatol 1999; 141:3.
- McCalmont TH, Altemus D, Maurer T, Berger TG. Eosinophilic folliculitis. The histologic spectrum. Am J Dermatopathol 1995; 17:439.
- Smith KJ, Skelton HG, Yeager J, et al. Metronidazole for eosinophilic pustular folliculitis in human immunodeficiency virus type 1-positive patients. Arch Dermatol 1995; 131:1089.
- Soeprono FF, Schinella RA. Eosinophilic pustular folliculitis in patients with acquired immunodeficiency syndrome. Report of three cases. J Am Acad Dermatol 1986; 14:1020.
- Rajendran PM, Dolev JC, Heaphy MR Jr, Maurer T. Eosinophilic folliculitis: before and after the introduction of antiretroviral therapy. Arch Dermatol 2005; 141:1227.
- Parker SR, Parker DC, McCall CO. Eosinophilic folliculitis in HIV-infected women: case series and review. Am J Clin Dermatol 2006; 7:193.
- Odom RB, James WD, Berger TG. Andrews' diseases of the skin: Clinical dermatology, WB Saunders Company, Philadelphia 2000.
- Resneck JS Jr, Van Beek M, Furmanski L, et al. Etiology of pruritic papular eruption with HIV infection in Uganda. JAMA 2004; 292:2614.
- Eisman S. Pruritic papular eruption in HIV. Dermatol Clin 2006; 24:449.
- Afonso JP, Tomimori J, Michalany NS, et al. Pruritic papular eruption and eosinophilic folliculitis associated with human immunodeficiency virus (HIV) infection: a histopathological and immunohistochemical comparative study. J Am Acad Dermatol 2012; 67:269.
- Annam V, Yelikar BR, Inamadar AC, et al. Clinicopathological study of itchy folliculitis in HIV-infected patients. Indian J Dermatol Venereol Leprol 2010; 76:259.
- Handa S, Bingham JS. Dermatological immune restoration syndrome: does it exist? J Eur Acad Dermatol Venereol 2001; 15:430.
- Grange F, Schoenlaub P, Tortel MC, et al. [AIDS-related eosinophilic folliculitis. Efficacy of high dose topical corticotherapy]. Ann Dermatol Venereol 1996; 123:456.
- Harris DW, Ostlere L, Buckley C, et al. Eosinophilic pustular folliculitis in an HIV-positive man: response to cetirizine. Br J Dermatol 1992; 126:392.
- Buchness MR, Lim HW, Hatcher VA, et al. Eosinophilic pustular folliculitis in the acquired immunodeficiency syndrome. Treatment with ultraviolet B phototherapy. N Engl J Med 1988; 318:1183.
- Misago N, Narisawa Y, Matsubara S, Hayashi S. HIV-associated eosinophilic pustular folliculitis: successful treatment of a Japanese patient with UVB phototherapy. J Dermatol 1998; 25:178.
- Porneuf M, Guillot B, Barneon G, Guilhou JJ. Eosinophilic pustular folliculitis responding to UVB therapy. J Am Acad Dermatol 1993; 29:259.
- Lim HW, Vallurupalli S, Meola T, Soter NA. UVB phototherapy is an effective treatment for pruritus in patients infected with HIV. J Am Acad Dermatol 1997; 37:414.
- Kuwano Y, Watanabe R, Fujimoto M, et al. Treatment of HIV-associated eosinophilic pustular folliculitis with narrow-band UVB. Int J Dermatol 2006; 45:1265.
- Adams ML, Houpt KR, Cruz PD Jr. Is phototherapy safe for HIV-infected individuals? Photochem Photobiol 1996; 64:234.
- Meola T, Soter NA, Ostreicher R, et al. The safety of UVB phototherapy in patients with HIV infection. J Am Acad Dermatol 1993; 29:216.
- Akaraphanth R, Lim HW. HIV, UV and immunosuppression. Photodermatol Photoimmunol Photomed 1999; 15:28.
- Berger TG, Heon V, King C, et al. Itraconazole therapy for human immunodeficiency virus-associated eosinophilic folliculitis. Arch Dermatol 1995; 131:358.
- Otley CC, Avram MR, Johnson RA. Isotretinoin treatment of human immunodeficiency virus-associated eosinophilic folliculitis. Results of an open, pilot trial. Arch Dermatol 1995; 131:1047.
- Downs AM, Lear JT, Oxley JD, Kennedy CT. AIDS associated eosinophilic folliculitis which responded to both high dose co-trimoxazole and low dose isotretinoin. Sex Transm Infect 1998; 74:229.
- Kawaguchi M, Mitsuhashi Y, Kondo S. Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus. Int J Dermatol 2004; 43:608.
- Dale S, Shaw J. Clinical picture. Eosinophilic pustular folliculitis. Lancet 2000; 356:1235.
- Rho NK, Kim BJ. Eosinophilic pustular folliculitis: successful treatment with topical pimecrolimus. Clin Exp Dermatol 2007; 32:108.
- Toutous-Trellu L, Abraham S, Pechère M, et al. Topical tacrolimus for effective treatment of eosinophilic folliculitis associated with human immunodeficiency virus infection. Arch Dermatol 2005; 141:1203.
- Steffen C. Eosinophilic pustular folliculitis (Ofuji's disease) with response to dapsone therapy. Arch Dermatol 1985; 121:921.
- Malanin G, Helander I. Eosinophilic pustular folliculitis (Ofuji's disease): response to dapsone but not to isotretinoin therapy. J Am Acad Dermatol 1989; 20:1121.
- Bozeman PM, Learn DB, Thomas EL. Assay of the human leukocyte enzymes myeloperoxidase and eosinophil peroxidase. J Immunol Methods 1990; 126:125.
- Uihlein LC, Saavedra AP, Johnson RA. Cutaneous manifestations of human immunodeficiency virus disease. In: Fitzpatrick's Dermatology in General Medicine, Goldsmith LA, Katz SI, Gilchrest BA. (Eds), McGraw HIll, 2012. Vol 2, p.2439.
- RISK FACTORS
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- First-line therapy
- - Antiretroviral therapy
- - Topical corticosteroids
- - Antihistamines
- Second-line therapy
- - Phototherapy
- Third-line therapies
- - Itraconazole
- - Oral isotretinoin
- Other therapies
- - Topical permethrin
- - Topical calcineurin inhibitors
- - Oral metronidazole
- - Oral dapsone
- - Oral glucocorticoids
- - Other
- SUMMARY AND RECOMMENDATIONS