Eosinophilic pustular folliculitis in a patient with AIDS

Eosinophilic Pustular Folliculitis Following Autologous Peripheral Blood Stem-Cell Transplantation

We describe a case of eosinophilic pustular folliculitis (EPF) occurring after autologous peripheral blood stem-cell transplantation for non-Hodgkin's lymphoma and successfully treated with oral and topical indomethacin. Including ours, the reported cases of EPF with HIV-negative hematological disease have shown clinical features similar to those of HIV-associated EPF, however the prognosis is better than that for HIV-associated EPF, which usually shows a persistent course. EPF with HIV-negative hematological disease can be classified as a unique group in EPF.

Leukaemia-associated eosinophilic folliculitis (Ofuji's disease)

BACKGROUND

Ofuji's disease is an eosinophilic dermatosis mostly affecting male subjects. It is characterized by the appearance of follicular papulopustolosis, at times on an erythematous base, which tend to form an annular configuration.

PATIENTS AND METHODS

Two cases are described: the first is a 45-year-old man affected by acute myeloid leukaemia and Ofuji's disease; the second is a 61-year-old man affected by chronic lymphatic leukaemia and Ofuji's disease. Culture tests were negative in both cases. In both patients no hypereosinophilia was found.

CONCLUSIONS

The simultaneous presence of the two pathologies in these patients can only give rise to hypothesis. In the first case it could be attributed to interleukin (IL)-5, which causes both eosinophilic hyperproduction and blast differentiation. In the second case the hypersecretion of intercellular adhesion molecule type 1 (ICAM-1) in Ofuji's disease could be attributed to a modified transcriptional gene belonging to the class of immunoglobulin codifying genes located on the altered chromosomes in a certain percentage of leukaemic patients.

HIV-associated pruritus: etiology and management

With the advent of highly active antiretroviral therapy (HAART), life-threatening opportunistic infection has become less common in patients with HIV infection and longevity has increased dramatically. With increased longevity, the problems of living with a chronic disease have become more prominent in this patient population. Disorders such as fat redistribution and metabolic abnormalities can result from antiviral medications and from HIV disease itself. Pruritus is one of the most common symptoms encountered in patients with HIV. The spectrum of skin diseases in such patients encompasses dermatoses of diverse etiologies; a few are peculiar to patients with HIV while others are not. Some of these conditions may cause severe and sometimes intractable pruritus that provokes scratching, picking, disfigurement, sleep loss, and significant psychological stress. Moreover, the expense of ongoing medical treatments can be daunting. Skin rash can sometimes be the initial presentation of HIV infection or serve as a harbinger of disease progression. Causes of pruritus include skin infections, infestations, papulosquamous disorders, photodermatitis, xerosis, drug reactions, and occasionally lymphoproliferative disorders. Drug eruptions are particularly common in patients who are HIV positive, presumably as a result of immune dysregulation, altered drug metabolism, and polypharmacy. Itching can also result from systemic diseases such as chronic renal failure, liver disease, or systemic lymphoma. Workup of pruritus should include a careful examination of the skin, hair, nails, and mucous membranes to establish a primary dermatologic diagnosis. If no dermatologic cause is found, a systemic cause or medication-related etiology should be sought. Idiopathic HIV pruritus is a diagnosis of exclusion and should only be considered when a specific diagnosis cannot be established. The management of HIV-associated pruritus should be directed at the underlying condition. Phototherapy has been found to be useful in the treatment of several HIV-associated dermatoses and idiopathic pruritus as well. Unfortunately, some of the treatments that have been suggested for patients with HIV are anecdotal or based on small uncontrolled studies. The last decade has seen a surge in the utilization of HAART which, to some degree, reconstitutes the immune system and ameliorates some dermatologic diseases. On the other hand, some skin diseases flare temporarily when HAART is started. Unless frank drug allergy is suspected, HAART does not need to be stopped.

Ofuji's disease: a report on 20 patients with clinical and histopathologic analysis

BACKGROUND

Ofuji's disease, also referred to as classic eosinophilic pustular folliculitis, is a rare dermatosis of unknown origin for which there is no uniformly effective treatment.

OBJECTIVES AND METHODS

Twenty patients with Ofuji's disease (classic eosinophilic pustular folliculitis) evaluated in our department from January 1978 to June 1999 were studied clinically and histopathologically. Laboratory data, treatments, and clinical courses were evaluated in 12 of these individuals.

RESULTS

Nissl modified staining revealed moderate increases of mast cells around hair follicles and sebaceous glands in all 20 patients; the majority of the infiltrating mast cells were tryptase-positive and chymase-negative. Eight of 11 patients treated with oral indomethacin responded completely.

CONCLUSIONS

Indomethacin is an effective therapy for Ofuji's disease. Tryptase-positive and chymase-negative mast cells might play some role in the pathogenesis of Ofuji's disease.

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).

Eosinophils and AIDS

Since early descriptions of Acquired Immune Deficiency Syndrome (AIDS) in the 1980s most of our research effort has been focused on a singular population, the CD4 cell population. Numerous investigations have been done into why there is a gradual diminution in CD4 counts; therapeutic interventions have focused on raising abnormally low CD4 levels. I suggest that another cell line, the eosinophil cell line, may also be abnormal in AIDS and hypothesize that an increase in eosinophil cell count and activation of eosinophils may also be important to AIDS.

Eosinophilic pustular folliculitis: a sterile folliculitis of unknown cause?

BACKGROUND

Eosinophilic pustular folliculitis (EPF) was initially defined as a sterile folliculitis of unknown cause. Because attempts to demonstrate bacterial organisms have been unsuccessful, and antibiotic therapy is usually ineffective, a bacterial infection is not considered a plausible causative factor for this disease.

OBJECTIVE

Our purpose was to describe five patients with the clinical and histologic characteristics of EPF and to report the results of bacterial cultures.

METHODS

Biopsy specimens were examined and pustules were cultured.

RESULTS

In three of the five patients, Pseudomonas infection of the hair follicle was the cause of the disease as proven by repeated cultures and the response to specific therapy. Three patients had a systemic disorder known to cause immunologic alteration: AIDS in one and a myeloproliferative disorder in two.

CONCLUSION

Although EPF was initially defined as a sterile folliculitis of unknown origin, three of our patients had an identifiable and treatable cause. We believe that these cases warrant the diagnosis of EPF.

Eosinophilic folliculitis occurring after bone marrow autograft in a patient with non-Hodgkin's lymphoma

Eosinophilic pustular folliculitis is a rare disorder previously reported predominantly in Japanese people who are otherwise healthy. Recently, the disorder has been noted in patients with acquired immune deficiency syndrome, as has eosinophilic folliculitis, a similar but distinct entity. The authors report a patient with eosinophilic folliculitis who was immunocompromised after high dose chemotherapy and bone marrow autograft for treatment of non-Hodgkin's lymphoma.

Eosinophilic folliculitis: a self-limiting illness in patients being treated for haematological malignancy

Eosinophilic folliculitis is a recognized skin manifestation of human immunodeficiency virus (HIV) disease. Five cases of eosinophilic folliculitis occurring in HIV-negative patients treated for haematological malignancy are reported. In four cases this self-limiting, pruritic eruption, affecting the head and upper trunk, occurred 3 months after bone marrow transplantation, and the fifth case was a patient undergoing chemotherapy for Waldenström's macroglobulinaemia. This suggests that eosinophilic folliculitis is a consequence of disturbances of immune function, and is not specific for HIV infection.

The ultrastructural histopathology of eosinophilic pustular folliculitis

The follicular skin lesions of a patient with eosinophilic pustular folliculitis were investigated by electron microscopy. Pustules in the outer root sheath contained acantholytic keratinocytes with numerous microvilli and features of desmosomal cleavage. The infiltrating eosinophils and neutrophils exhibited autolytic or degenerative changes rather than degranulation. The aggregated tubulo-vesicular structures were associated with the debris of autolytic eosinophils. Multiple, tiny, bubble-like structures enclosed within a membrane were frequently seen in the intercellular space. The intercellular space of the outer root sheath was widened with decreased desmosomal adhesion between the keratinocytes, but no intracellular edema was detectable. The infiltrating lymphocytes, predominantly T-cells with convoluted nuclei, extended cytoplasmic processes to adjacent keratinocytes. Apposition of T-lymphocytes and Langerhans cells was noted. Some keratinocytes in the outer root sheath contained large, sebaceous lipid droplets. No obvious virus particles or other pathogenic agents were detected. It is possible that T-lymphocytes and other immunosurveillance cells are involved in the pathomechanism of eosinophilic pustular folliculitis.

Eosinophilic pustular folliculitis in patients with acquired immunodeficiency syndrome

Three patients with AIDS had an intensely pruritic eosinophilic pustular folliculitis associated with abundant Pityrosporum yeasts in the follicles, demonstrated by direct microscopy. The excellent response to ketoconazole treatment suggests a possible pathogenic role for Pityrosporum.

UVB phototherapy of the pruritic papular eruption of the acquired immunodeficiency syndrome

BACKGROUND

Pruritic papular eruption (PPE) is a chronic dermatosis frequently seen in human immunodeficiency virus (HIV)-positive patients. UVB phototherapy has been successfully used to treat a similar inflammatory condition (Ofuji disease) as well as pruritus of systemic origin.

OBJECTIVE

We describe the successful treatment with UVB of seven of eight patients with PPE.

METHODS

Eight HIV-positive patients with PPE were treated. The number of papules in a specified area of skin and the intensity of pruritus were monitored before, during, and after UVB phototherapy given three times a week. Biopsy specimens were taken before and after therapy and systemic immune function was evaluated.

RESULTS

Both the number of papules as well as pruritus decreased after UVB treatment in all but one patient. Immunoperoxidase staining showed a relative decrease in CD4+, CD8+, and CD2+ cells in all samples studied except for the patient noted to be unresponsive to the therapy.

CONCLUSION

UVB phototherapy is effective in the treatment of patients with PPE. This is associated with a significant decrease in inflammation and number of T cells from various subsets within the dermis, thereby implicating these cells in the pathogenesis of this disorder.

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.

Pruritic papular eruption of the acquired immunodeficiency syndrome: a clinicopathologic study

The pruritic papular eruption of the acquired immunodeficiency syndrome is characterized by generalized, pruritic, skin-colored papules and nodules. Chronic lesions are excoriated and hyperpigmented. The eruption and pruritus typically wax and wane and are resistant to oral antihistamine and topical steroid therapy. The characteristic histologic features are (1) superficial and mid dermal perivascular and perifollicular mononuclear cell infiltrate with numerous eosinophils and (2) follicular damage of varying degrees. When compared with control subjects, these patients did not demonstrate any significant difference in laboratory or demographic data.

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.