Acquired scalp alopecia. Part II: A review

The neutrophil-associated and infiltrative scarring alopecias are reviewed including folliculitis decalvans, tufted folliculitis, dissecting cellulitis of the scalp, acne keloidalis and follicular degeneration syndrome. The management of acquired scalp alopecia is also reviewed including newer, promising therapies. More specific agents targeting components of the androgen system will make the treatment of androgenetic alopecia more rewarding. Similarly new immunomodulatory therapies show great promise for the lymphocyte-associated alopecias and include a new generation of macrolide immunosuppressives (tacrolimus, SDZ ASM 981, and SDZ 281-240), some of which appear to have good transcutaneous absorption.

Bacteriologic and immunologic aspects of gram-negative folliculitis: a study of 46 patients

BACKGROUND

Gram-negative folliculitis is an infection with gram-negative rods that most often occurs as a complication of prolonged broad-spectrum antibiotic therapy in patients suffering from acne and rosacea.

METHODS

The bacteriologic and immunologic findings are reported in 46 patients, 39 men and 7 women, aged 16-79 (median, 28) years, with gram-negative folliculitis. Hypersensitivity reactions to various microbial recall antigens as well as granulocyte functions were evaluated. Quantitative measurements of serum levels of immunoglobulin M, G, A, and E, total complement activity, complement factors C3 and C4, and alpha-1-antitrypsin were performed.

RESULTS

The gram-negative organisms most frequently cultivated from nares, facial skin, and pustules were Klebsiella spp., Escherichia coli, Enterobacter spp., and Proteus spp. In all patients, deviations of one or more immune parameters were detected, including lowered serum concentrations of immunoglobulin M and alpha-1-antitrypsin, and elevated levels of immunoglobulin E. The humoral and cellular parameters were not influenced by isotretinoin therapy of gram-negative folliculitis.

CONCLUSIONS

These findings suggest that gram-negative folliculitis is not only a complication of long-lasting antibiotic treatment of acne and rosacea, but might be an entity of its own. Immunologic factors may play a critical role in the pathogenesis of gram-negative folliculitis.

Diffuse alopecia with stem cell folliculitis: chronic diffuse alopecia areata or a distinct entity?

A 34-year-old woman presented with an 8-year history of slowly progressive diffuse nonscarring alopecia with loss of hair density. Scalp biopsy specimens showed increased miniaturized follicles and an asymmetric wedge-shaped lymphocytic infiltrate concentrated on the stem cell-rich region at the point of entry of sebaceous ducts and at bulge-like regions of multiple follicles. Several hair bulbs emerging at the stem cell compartment also were inflamed, but the hair bulbs in the deeper dermis and subcutis were spared. I speculate whether these findings may represent a stem cell folliculitis similar to the reaction pattern previously observed in graft versus host disease and in androgenetic alopecia. The additional presence of peribulbar lymphocytic inflammation could indicate that the patient had a variant of alopecia areata. The clinical presentation of a slowly progressive diffuse alopecia without progression to clinically recognizable alopecia areata and the prominent lymphocytic inflammation involving the stem cell compartment may prompt a reexamination of similar cases currently classified as chronic diffuse alopecia areata. The concept that lymphocytes can inhibit stem cell function without destroying the stem cells themselves needs consideration.

HIV-positive patients differ from HIV-negative patients in indications for and type of UV therapy used

BACKGROUND

Treatments using UV, UVB, or oral psoralen and UVA (PUVA) have been advocated for the care of HIV-infected persons with skin diseases. Concerns about the safety of these treatments exist.

OBJECTIVE

We attempted to determine the characteristics of HIV infected persons receiving UV therapy and establish the reasons for and type of treatment administered.

METHODS

During two 2-week periods, we prospectively ascertained basic information on all patients treated at 40 phototherapy clinics and detailed clinical information on patients known to be infected with HIV.

RESULTS

We identified 3716 persons receiving UV therapy, including 311 known to be infected with HIV. When compared with patients not known to be infected with HIV, HIV-positive patients were significantly more likely to be treated with UVB rather than PUVA and were more likely to be treated for pruritic conditions rather than psoriasis.

CONCLUSION

There were great variations in the relative reliance on UVB and PUVA among centers. There appears to be no agreement as to which type of UV therapy is optimal for patients infected with HIV. Most patients known to the treating clinician to be HIV positive are in the advanced stages of HIV disease. The number of persons with less advanced HIV disease receiving treatment remains unquantified but may be even more clinically important.

Sterile neutrophilic folliculitis with perifollicular vasculopathy: a distinctive cutaneous reaction pattern reflecting systemic disease

The authors prospectively encountered skin biopsies from 20 patients which demonstrated a neutrophilic or suppurative and granulomatous folliculitis accompanied by a folliculocentric neutrophilic vascular reaction of Sweet's-like or leukocytoclastic vasculitis subtypes. While in each case the histomorphology raised diagnostic consideration of bacterial folliculitis, patients frequently expressed systemic complaints such as arthritis, fever, and malaise, and special stains for micro-organisms were negative. Among the clinical presentations were folliculitis, vasculitis, acneiform eruptions, vesiculopustular lesions, and erythema nodosum-like lesions, with the legs, arms, and upper back being the most commonly involved sites. Nineteen patients were found to have specific underlying systemic diseases, namely, inflammatory bowel disease, Reiter's disease, Behçet's disease, hepatitis B, connective tissue disease including mixed connective tissue disease and rheumatoid arthritis, scrofuloderma, and hematologic dyscrasias. The other patient had antecedent bacterial sinusitis in the setting of atopy. The folliculocentric nature of these lesions may reflect preferential processing of antigens through the hair follicle and/or homology between bacterial and follicular heat shock proteins in the susceptible host, namely, one who responds excessively to exogenous antigenic triggers. Folliculitis with folliculocentric vasculopathy may be a clue to underlying systemic disease and/or an extracutaneous infection. Certain light microscopic features in concert with the clinical presentation may distinguish such cases from conventional infectious folliculitis.

HIV-associated eosinophilic pustular folliculitis: successful treatment of a Japanese patient with UVB phototherapy

We report the successful treatment with ultraviolet B phototherapy of a patient with HIV-associated eosinophilic pustular folliculitis. We were able to observe the clinical and therapeutic course for about one year and three months. This 35-year-old homosexual Japanese man presented with disseminated, discrete, follicular, erythematous papules with intense pruritus over his face, neck, chest wall, and upper back. Initially, the eruption responded to therapy with topical or oral indomethacin and oral H1 antihistamine. However, the eruption was highly prone to recurrence, and it gradually failed to respond to these therapies. The eruption became chronic and persistent and manifested the excoriated, prurigo-like nodules that are typical of reported pruritic papular eruption, suggesting that this skin disease and HIV-associated eosinophilic pustular folliculitis are two forms of the same disease entity. UVB phototherapy in small doses was very effective for the persistent eruption, and no recurrence of the eruption was noted during or since the six-month maintenance therapy (once a week at a dose equivalent to 0.75 of the minimal erythema dose) (9 months total). No unfavorable side effects have been observed during or after the UVB phototherapy (cumulative UVB doses of 2,320 mJ/cm2).

UVB phototherapy is an effective treatment for pruritus in patients infected with HIV

BACKGROUND

Pruritus in patients positive for HIV may be debilitating.

OBJECTIVE

Our purpose was to evaluate the efficacy of UVB therapy in the treatment of pruritus in patients positive for HIV.

METHODS

Twenty-one male HIV-positive patients with intractable pruritus (14 with eosinophilic folliculitis and 7 with primary pruritus) were treated three times weekly with UVB phototherapy. Pruritus was quantified with use of a subjective score of 0 (none) to 10 (severe).

RESULTS

Mean CD4 counts at the initiation of therapy were 91.0 +/- 31.9 cells/microliter. Pruritus scores before and after treatment were 8.6 +/- 0.4 and 2.2 +/- 0.5, respectively (p < 0.001). The mean number of treatments to achieve maximal improvement was 20.7 +/- 2.3, with a cumulative UVB dose of 3399.1 +/- 597.4 mJ/cm2. No significant difference was found between the group with eosinophilic folliculitis and the group with primary pruritus.

CONCLUSION

UVB phototherapy can produce significant relief of pruritus and improvement in the quality of life in patients positive for HIV.

Cicatricial alopecia

Scarring alopecias are of diverse etiology and pathogenesis. They may be histologically classified as primary or secondary, depending on involvement of reticular dermis. The most important primary scarring alopecias include pseudopelade, lichen planopilaris, and diffuse scarring of the vertex in African-Americans. The most important secondary scarring alopecias include folliculitis decalvans and late-stage lupus erythematosus.

[Follicular staphylococcal infections]

Staphylococcal folliculitis are a common disability in early adult life. Some patients suffer only one attack, while others continue to develop recurrences over months. In such a case, nasal carriage of staphylococcus aureus should be sought in the patients and family members. The lesions may often respond to topical antiseptics. Systemic antibiotics should only be started when furuncles are complicated. Topical antibiotics, applied to the anterior nares of patients and household carriers, seems to control recurrent infection more effectively than systemic antibiotics alone. Even so, few patients will experience recurrent lesions despite good initial response to treatment.

Eosinophilic pustular folliculitis (Ofuji disease) in a child

Eosinophilic pustular folliculitis (EPF) has been described mostly in adults from Japan. From the few reports of children with EPF it is clear that the disease displays the characteristic features, with some clinical differences compared to EPF in adults. We describe the case of an 8-year-old boy with multiple vesicles, pustules, and erythema multiforme-like lesions on the trunk and lower extremities. Results of histopathologic examination revealed subcorneal and intraepidermal pustules, and an inflammatory infiltrate consisting of lymphocytes and eosinophils mainly with a perifollicular distribution. The patient also had impaired chemotaxis, IgG3 subclass deficiency, and elevated IgE levels.

Common superficial fungal infections in patients with AIDS

Superficial mycotic infections such as seborrheic dermatitis, tinea pedis, tinea corporis, and onychomycosis are common in patients infected with human immunodeficiency virus (HIV). In communities where HIV infections are frequent, some of these clinical presentations serve as markers of the stage of HIV infection. The diagnosis of superficial fungal infection in HIV-positive patients may be difficult because of atypical clinical manifestations. Therefore, to ensure a correct diagnosis, skin scrapings should be collected for potassium hydroxide preparations and cultures. Most forms of dermatophytosis in HIV-positive patients respond well to many topical antifungal agents, such as azoles, terbinafine, and ciclopirox olamine. If the disease is chronic and extensive, then ketoconazole, fluconazole, and itraconazole are each effective.

HIV-associated eosinophilic folliculitis: case report and review of the literature

We report human immunodeficiency virus (HIV)-associated eosinophilic folliculitis in a previously well 40-year-old Portuguese lady. This condition, although similar to Ofuji's disease, has distinguishing features which allow the two to be differentiated. To the best of our knowledge, this is the first reported case of HIV-associated eosinophilic folliculitis in a female and in a patient in whom the HIV was heterosexually transmitted. Our patient is also unusual in being, we believe, only the second reported in whom this eruption was the presenting feature of HIV infection.

Ofuji's disease and cytokines: Remission of eosinophilic pustular folliculitis associated with increased serum concentrations of interferon gamma

BACKGROUND AND OBJECTIVE

Eosinophilic pustular folliculitis (EPF) is a distinct inflammatory dermatosis of unknown etiology. The aim of this study is to evaluate the serum levels of cytokines in 3 patients with EPF before and after treatment with indomethacin.

RESULTS

Serum levels of interleukin 4 (IL-4) were elevated in patients with EPF. The remission of EPF was associated with increased serum concentrations of interferon gamma with no essential change of serum levels of IL-4.

CONCLUSION

These results suggest that subtle changes in serum levels of cytokines are involved in the remission of EPF and that indomethacin may provide the remission of EPF by altering cytokine production in patients with EPF.