Eosinophilic pustular folliculitis. Studies on possible chemotactic factors involved in the formation of pustules

Eosinophilic pustular folliculitis (Ofuji's disease) without macroscopic pustules

BACKGROUND

Eosinophilic pustular folliculitis (EPF), first described by Ofuji et al. in 1970, is a rare dermatosis characterized by pruritic papules and pustules on circinate erythematous plaques with eosinophilic infiltration in and around the hair follicle.

METHODS AND RESULTS

We report three cases of EPF that showed no macroscopic pustules during the total observation period. Histopathological examination revealed eosinophilic infiltration in and around the hair follicle in the lower dermis and subcutis.

CONCLUSIONS

EPF consists of clinical variants, one of which lacks obvious pustules.

Successful Treatment of Recalcitrant Primary Follicular Mucinosis with Indomethacin and Low-dose Intralesional Interferon Alpha

Follicular mucinosis (FM) is an epithelial reaction pattern that is characterized by the accumulation of mucinous material in the epithelial hair follicle sheath and the sebaceous glands. Although various pharmacological agents have been employed in an attempt to treat FM, effective therapeutic options have remained elusive. We experienced a recalcitrant form of primary FM that we successfully treated with indomethacin and low-dose intralesional interferon alpha (IFN alpha), respectively. To the best of our knowledge, the primary type of FM that responded to indomethacin and low-dose IFN alpha, respectively, in a single case has not been reported in the English medical literature.

Eosinophilic Pustular Folliculitis

Classical eosinophilic pustular folliculitis, or Ofuji's disease, is a chronic and relapsing dermatosis that is predominantly reported in East Asian populations. Clinically, the disease typically begins as small papules, which enlarge and coalesce into a large plaque, usually on the face. The histopathology is characterized by a prominent eosinophilic infiltrate in the dermis with concentration around pilosebaceous units, often with eosinophilic microabscess formation. The differentiation of eosinophilic pustular folliculitis from other eosinophilic dermatoses is practically challenging and requires close clinicopathologic correlation. Eosinophilic pustular folliculitis may also be associated with human immunodeficiency virus infection, various drugs, and some lymphomas and could also be thought of as a nonspecific dermatopathologic pattern in such settings. The cause of classical eosinophilic pustular folliculitis is unknown, although immune processes are almost certain to play a key role in its pathogenesis.

[Ofuji's disease: description of a case]

Eosinophilic pustular folliculitis (EPF) is a rare, chronic disease of unknown cause, characterized by itchy papules or pustules and an infiltration of eosinophiles in the biopsy. EPF occurs rarely outside Japan and very few cases have been described in non-Japanese race people. The causes of the disease and its definitive treatment have not yet been established. In our patient, the presence of subcorneal pustules in the biopsies initially favored a diagnosis of pustulosis and several biopsies were necessary before a diagnosis of EPF was reached. A new case of EPF recently presented at our clinic and we have carried out an extensive revision of the disease.

Eosinophilic pustular folliculitis: a 40 year retrospect

Eosinophilic pustular folliculitis (EPF) is a noninfectious eosinophilic infiltration of hair follicles first described 40 years ago. There are 3 variants: classic EPF, immunosuppression-associated (mostly HIV-related), and infancy-associated EPF. EPF has been classified as an AIDS-defining illness. In both children and adults EPF should be viewed as a possible cutaneous sign of immunosuppression. However, it may also be seen in persons with normal immune status. We review EPF on the 40th anniversary of its original description.

Neonatal eosinophilic pustulosis*

A pre-term, 7-week-old male infant presented with a recurrent pustular eruption involving his face and scalp with associated peripheral blood eosinophilia. Skin biopsy revealed spongiosis with numerous dermal and epidermal eosinophils without predominant follicular involvement. Immunohistology showed deposition of eosinophil granule major basic protein and eosinophil derived neurotoxin in the dermis and epidermis. He responded to conservative management. We discuss the differential diagnosis of neonatal eosinophilic pustular eruptions and suggest the term 'neonatal eosinophilic pustulosis' to best describe our case.

Pustulosis eosinofílica infantil

Childhood eosinophilic pustulosis is a rare disease that is characterized by recurrent outbreaks of pruritic pustules and follicular papules. The lesions are sterile and contain masses of eosinophils related to the scalp hair follicle. Because of the good prognosis for these symptoms, conservative treatment with topical corticosteroids is recommended. We present two cases of this disease, describing its clinical course and development over two years.

Skin diseases described in Japan 2004. In Japan beschriebene Dermatosen 2004

During the last century of modern dermatology, more than 30 skin diseases have been described first by physicians from Japan. Many of those conditions were disorders of pigmentation and keratinization, which are quite common in Oriental patients. Since the late 1940s, a number of skin diseases first reported in Japan have gained attention internationally among them being Kimura disease, hypomelanosis of Ito, Kawasaki disease, adult T-cell leukemia/ lymphoma, eosinophilic pustular folliculitis, prurigo pigmentosa, and Ofuji's papuloerythroderma. In this article, we review skin diseases that were first established as distinct entities in Japan, in order to familiarize readers of the Western literature with these conditions.

HIV seronegative eosinophilic pustular folliculitis successfully treated with doxicycline

Eosinophilic pustular folliculitis (EPF) is an unusual disease, first described in adult East Asians in 1970 by Ofuji. It is characterized by follicular papules and pustules tending to coalesce and form plaques involving the trunk, face and extremities. In recent years, it has been often associated with human immunodeficiency virus (HIV) infection or with immunosuppressed and/or oncohaematological patients. EPF has been described in immunocompetent adult caucasian patients only occasionally. The diagnosis requires clinical and microbiological features such as sterile folliculitis and histopathological findings characterized by folliculitis and perifolliculitis with eosinophilic infiltrate. We describe an HIV seronegative caucasian male with EPF, allergic to non-steroidal anti-inflammatory drugs and indomethacin, treated with oral doxicycline. The treatment led to the complete remission of the lesions within 2 months.

Ofuji's disease with follicular mucinosis and its differential diagnosis from alopecia mucinosa

OBJECTIVES

Ofuji's disease (OD) or eosinophilic pustular folliculitis and human immunodeficiency virus-associated eosinophilic folliculitis (HIV-EF) both show eosinophil-rich folliculocentric infiltrates, and it is not clear whether they are distinguishable pathologically. Follicular mucinosis (FM) has been observed in lesions of EF; such cases need to be differentiated from alopecia mucinosa (AM).

METHODS

We compared various pathologic features in 13 cases of OD, 10 cases of non-OD-typed papular EF (seven HIV-positive and three HIV-negative), and five cases of AM.

RESULTS

All cases of EF showed eosinophilic infiltrates affecting mainly the isthmus or/and sebaceous gland. Eosinophil-rich pilosebaceous pustules or/and microabscesses were noted in 69% of the biopsy specimens of OD, 73% of papular EF, 71% of HIV-EF, and 0% of AM. Mucin deposits, often abundant, were found in sebaceous lobules or/and isthmus in 41% of OD and 100% of AM. Compared with AM, OD with FM tended to show more numerous eosinophils, less abundant mucin, and most significantly, eosinophilic infundibular pustule or sebaceous microabscess.

CONCLUSION

Our study suggests that OD and HIV-EF are indistinguishable pathologically and the diagnosis requires clinical correlation. FM was not uncommonly seen in lesions of OD. OD with FM may be difficult to differentiate from FM, especially in cases presenting with non-annular or non-pustular lesions, but the diagnosis might be facilitated by finding eosinophil-rich pustule, microabscess, or infiltrate in pilosebaceous units microscopically.

Eosinophilic pustular folliculitis (Ofuji's disease): indomethacin as a first choice of treatment

Eosinophilic pustular folliculitis (EPF) is characterized by erythematous patches of large follicular papules and pustules involving mainly the face. Although various treatments have been attempted for EPF, including systemic and topical steroid, diaphenylsulphone, colchicine, minocycline as well as UVB phototherapy, there is no consensus on the first choice of treatment. We report a typical case and summarize 25 patients with EPF treated in our hospital between 1978 and 1998. Indomethacin was most frequently used (12/25) and showed clinical improvement in the majority of the cases (11/12). The effect of indomethacin was usually observed within 1--2 weeks after initiation of treatment. Decrease of peripheral blood eosinophils accompanied the clinical improvement. Thus, indomethacin should be considered as a first choice of treatment for EPF.

Eosinophilic pustular folliculitis: report of seven cases in Thailand

Seven cases of eosinophilic pustular folliculitis (EPF) were diagnosed at the Institute of Dermatology within the seven years from 1989-1996. There were 4 males and 3 females, age 24-44 years, with durations of the disease before diagnosis ranging from 3 months to 5 years. The face was the most commonly involved area. Lesions also occurred simultaneously on other sites including the chest, trunk, scalp, and palmoplantar areas. Diagnosis was made from clinical features, hematologic examinations, and histopathologic pictures. Topical piroxicam gel, 0.5%, and oral indomethacin gave good results; some lesions subsided within a few days, and the remissions lasted for four months to five years.

Itchy folliculitis and human immunodeficiency virus infection: clinicopathological and immunological features, pathogenesis and treatment

The predominant itchy folliculitis associated with human immunodeficiency virus (HIV) infection appears to be an eosinophilic folliculitis (EF). This is characterized by lytic degeneration of sebaceous glands and an inflammatory infiltrate in which eosinophils and CD8+ T lymphocytes predominate. All patients have low CD4 counts and present late on in their HIV disease. Lesional distribution is mainly truncal, with a significant proportion also having facial involvement. Our prospective survey has shown that it is impossible to differentiate clinically between infective folliculitis and EF, and we recommend therefore that all cases are biopsied. We review the clinicopathological and immunological aspects of HIV-associated itchy folliculitis, in particular HIV-associated EF as well as current theories on pathogenesis and treatment. We suggest that HIV-associated EF is an autoimmune disease with the sebocyte or some constituent of sebum acting as the autoantigen.

Eosinophilic pustular folliculitis in infancy: report of two new cases

Eosinophilic pustular folliculitis (EPF) is a cutaneous inflammatory follicular disorder of unknown etiology. The diagnosis is made on the basis of clinical and histopathologic features. We describe two patients who had recurrent episodes of pruritic follicular papular and pustular lesions on the face, extremities, and trunk. The eruptions lasted for 1 month with intermittent remissions. Laboratory tests disclosed no infectious or parasitic etiology in patient 2. In patient 1 we isolated methicillin-resistant Staphylococcus aureus in a blood culture. He had sepsis with lung and liver involvement. EPF is a self-limited dermatosis. On occasion, skin lesions may become superinfected, resulting in localized pyoderma or rarely systemic infection (sepsis). Histologically both of our patients showed a moderate mixed inflammatory infiltrate with numerous eosinophils centered around hair follicles. Their lesions responded well to topical corticosteroids.

Verrucous carcinoma of the face with a massive neutrophil infiltrate. Analysis of leucocyte chemotactic activity in the tumour extract

An unusual case of verrucous carcinoma of the face with a massive infiltration of neutrophils was found in a 60-year-old Japanese man who presented with a scaly, crusty tumour studded with pustules of 3 years duration on the left cheek. Histological examination showed a proliferation of deceptively benign-looking epidermal cells with an intact basement membrane, accompanied by a dermal infiltration of neutrophils and mononuclear cells and formation of microabscesses containing multinucleate giant cells, suggesting deep fungal infection or blastomycosis-like pyoderma. The lesion, however, was unresponsive to antifungal or antibacterial treatments and ultimately attained a considerable size in the following months. Based on the findings of repeat biopsy conducted 4 months later indicating further deeper invasion, a diagnosis of verrucous carcinoma of the face was made, and a total excision of the tumour and left cervical lymph node dissection were finally carried out. It can be speculated that aberrant production of leucocyte chemotactic cytokines such as interleukin-8 by dysplastic keratinocytes, subsequent neutrophil infiltration/serum permeation, generation of leucotactic anaphylatoxin C5a from serum through complement activation and of lipid chemotactic factors (leukotriene B4 and 12-hydroxy-eicosatetraenoic acid) by infiltrating leucocytes and/or dysplastic keratinocytes provoked the characteristic accumulation of neutrophils in the verrucous carcinoma of this case.

Eosinophilic pustular folliculitis (Ofuji disease) in childhood: a review of four cases

Four children under 2 years of age were treated at our hospital in the last three years with a recurrent vesiculopustular eruption of the scalp, variably extending to the face and limbs. All cases followed a cyclical pattern. Three of the children had a moderate response to topical steroids, and one went into remission after a two-month course of erythromycin. Ethnic origin may be an important predisposing factor. Histologically, all patients showed a moderate mixed inflammatory infiltrate with numerous eosinophils centered around hair follicles. Peripheral white blood cell count showing leukocytosis with eosinophilia was observed in those cases measured, but no consistent immunologic abnormalities could be identified.

Eosinophilic pustular folliculitis

Eosinophilic pustular folliculitis is characterized by the spontaneous development of recurrent, sterile papules, pustules, and plaques on the face, trunk, arms, and occasionally the palms and soles. Although the large majority of the reported cases have occurred in Eastern Asians, most patients in the United States have been infants or men seropositive for human immunodeficiency virus. We describe a North American woman with eosinophilic pustular folliculitis who was neither seropositive for human immunodeficiency virus nor of Asiatic descent.

Eosinophilic pustular folliculitis: fungal folliculitis?

Eosinophilic pustular folliculitis is a rare condition with no known cause. However, a fungal cause is suggested by (1) tinea-like annular lesions, (2) initial clinical consideration of fungal folliculitis in many reported cases, (3) an association with the acquired immunodeficiency syndrome, and (4) an association with scaly and vesiculopustular lesions of palms and soles. We report a case histologically identical to eosinophilic pustular folliculitis but in which hyphal fungal organisms were demonstrated in one of the involved hair follicles.

Eosinophil-infiltrating folliculitis in childhood--report of a case

A 5-year-old Japanese girl developed follicular pustules with erythematous plaques on the lower extremities. The histopathology was compatible with eosinophilic pustular folliculitis (EPF). However, the clinical findings were not typical of EPF; the pustules did not appear in crops, the pustules became ulcers, and the skin lesions appeared exclusively on non-seborrheic areas.

Psoriasis and leukocyte chemotaxis

Transepidermal migration of leukocytes, with resultant formation of microscopic or macroscopic sterile subcorneal pustules is a phenomenon characteristically noted in psoriasis and related sterile pustular dermatoses. It is natural to assume the presence of potent neutrophil chemotactic substances in the subcorneal portion of the lesional epidermis, because this location is the target of the in vivo leukocyte chemotaxis. In fact, crude psoriasis scale extracts show remarkably high neutrophil chemotactic and activating properties as compared with those of other non-psoriatic inflammatory dermatoses. We isolated a psoriatic leukotactic factor (PLF) having a molecular mass of around 12 kD, distinct from those common to other inflammatory changes involving the skin or those released by bacteria. Further analysis of PLF identified C5 cleavage fragments, together with other chemotactic peptides, such as those derived from monocytes. Likewise, potent low-molecular-mass chemotactic factors, including cell membrane lipid derived chemotactic factor, e.g. leukotriene B4, are also increased in psoriatic lesions, as in other nonpsoriatic inflammatory dermatoses. However, their activity to stimulate the generation of oxygen radicals in neutrophils was found to be much weaker than that of PLF. The peripheral blood leukocytes from active psoriatic patients show enhanced function in chemotaxis, phagocytosis, active oxygen production, and enzyme release; patients' sera contain substances such as anaphylatoxins that activate leukocyte function. Further research is required for clearer understanding of the series of events resulting in the leukocyte chemotaxis, as well as for the elucidation of the background immunoregulatory mechanisms.

Incontinentia pigmenti: eosinophil chemotactic activity of the crusted scales in the vesiculobullous stage

To investigate the mechanisms underlying eosinophil infiltration into the epidermis in incontinentia pigmenti (IP), we studied the eosinophil chemotactic activity in extracts of the crusted scales from three patients with IP in the vesiculobullous stage. Eosinophil chemotactic activity was detected in the eluates from a Sephadex G-75 chromatography column between the vitamin B12 and phenol red markers. The chemotactic activity was heat-stable and resistant to enzyme digestion, and recovered after ether extraction at low pH. Leukotriene B4 (LTB4) was demonstrated in the fractions with high eosinophil chemotactic activity. These findings suggest that LTB4 plays an important role in the accumulation of eosinophils within the epidermis in IP, in the vesiculobullous stage. Blood eosinophilia, however, may not be induced by the eosinophil chemotactic factors in the scales.