Eosinophilic pustular folliculitis: successful treatment with interferon-alpha

Adverse skin reactions due to pegylated interferon alpha 2b plus ribavirin combination therapy in a patient with chronic hepatitis C virus

Pegylated interferon (IFN)-alpha-2b with ribavirin has recently replaced "standard" IFN-alpha for the treatment of chronic hepatitis C. The most common side-effect of pegylated IFN-alpha-2b plus ribavirin combination therapy is localized inflammatory skin lesions at the site of injection. A 66-year-old female treated with once-weekly pegylated IFN-alpha-2b plus ribavirin for active chronic hepatitis C developed inflammatory skin lesions 2 months after starting antiviral treatment. The type of skin reactions observed were vesicle erythematous eruptions at the injection sites, and pruritic papular erythematous eruptions located on the face, neck, distal limbs, dorsa of the hands, trunk and buttocks away from the injection sites. Histological examination was performed on the pruritic papular erythematous eruption located on the left forearm, away from the injection sites. It showed epidermal spongiosis, a spongiotic microvesicle, and perivascular infiltration of the upper dermis with lymphocytes. The treatment was interrupted subsequently and the patient was rechallenged with pegylated IFN-alpha-2b plus ribavirin combination therapy, oral prednisolone with olopatadine hydrochloride and topical 0.1% diflucortolone valerate, which led to a significant improvement of skin lesions. Erythema with infiltration can occur at the injection sites of pegylated IFN-alpha-2b. However, the occurrence of vesicle erythematous eruptions away from the injection sites and autosensitization dermatitis apart from injection sites have not yet been frequently reported.

[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 (Ofuji's disease) in a patient with silicone tissue augmentation

Eosinophilic pustular folliculitis (EPF) (Ofuji's disease) is a rare dermatosis of unknown etiology. We describe a 45-year-old Chinese woman who developed EPF on her face seven years after having nose and chin augmentation with subcutaneous silicone injections.

Interferon treatment for hypereosinophilic syndromes and systemic mastocytosis

Hypereosinophilic syndromes (HES) and systemic mastocytosis (SMCD) are heterogeneous disorders with clinical symptoms from local and remote effects of excessive proliferation of eosinophils and mast cells, respectively. Interferon alpha (IFN-alpha), alone or in combination with other medications, can be a useful, and at times life-saving, treatment for patients with HES. Receptors for IFN-alpha are present on eosinophils, and clinical benefits are due to its effect on eosinophil proliferation, migration, activation, and survival. These effects are likely mediated through multiple pathways including, but not limited to, inhibition of eosinophil colony-forming cells, upregulation of IFN-gamma synthesis, and inhibition of production of eosinophil-active cytokines by T cells, mast cells, and mononuclear cells. IFN-alpha has been life-saving for patients with intractable HES that were resistant to prednisone, hydroxyurea, and other agents. Resistance to the eosinopenic effect of IFN-alpha does not develop and the dose of IFN-alpha necessary to maintain control of eosinophilia often decreases with time. The combination of IFN-alpha and hydroxyurea is very useful and allows dosage reduction of IFN-alpha and better control of hypereosinophilia than with either agent alone. The efficacy of IFN-alpha for treatment of SMCD has been more difficult to establish, with both favorable and unfavorable results reported. The disparate results may have resulted from the small number of patients with SMCD treated with IFN-alpha, the use of various criteria for a "successful" treatment outcome, short duration of treatment and follow-up, and the use of modest dosages. In reported series, side effects from IFN-alpha have frequently been dose-limiting. IFN-alpha improves many of the clinical symptoms of SMCD including dermatological, hematological, gastrointestinal, and systemic symptoms associated with histamine release. IFN-alpha has a beneficial effect on skeletal symptoms because of its ability to increase bone density and reduce painful episodes from vertebral fractures. No consistent improvement in bone marrow infiltration by mast cells has been demonstrated except in a recent study employing high dosages of IFN-alpha. A beneficial effect from the combination of IFN-alpha and prednisone has been reported for several patients, suggesting that combined use of these two medications may provide synergism in treatment outcomes.

Eosinophilic pustular folliculitis: a comprehensive review of treatment options

Eosinophilic pustular folliculitis (EPF), also known as Ofuji disease, is a disease that manifests with follicular papules or pustules. Its variants include a classic type that occurs most commonly in Japan, an HIV-associated type, an infantile type, a type that occurs on the palms and soles, a rare medication-associated variant, and a rare neoplasia-associated variant.A wide range of medications has been used to treat EPF. Topical corticosteroids are the first-line treatment option for EPF. Topical tacrolimus seems to be useful initial therapy as well. Oral indometacin (50-75 mg/day) is an effective treatment of classic EPF although it can induce peptic ulcers. For treatment of HIV-associated EPF when topical corticosteroids and indometacin do not work, various other treatments should be considered. These treatment options include cetirizine 20-40 mg/day, metronidazole 250 mg three times a day, itraconazole starting at a dosage of 200 mg/day and increasing to 300-400 mg/day, and topical permethrin. If these treatments do not work phototherapy with UVB is the 'gold standard' of treatment and is often curative. Treatments with less certain risk-benefit ratios but with some efficacy include PUVA (psoralen + UVA) photochemotherapy, oral corticosteroids, synthetic retinoids (i.e. isotretinoin 1 mg/kg/day), and acitretin (0.5 mg/kg/day), oral cyclosporine (ciclosporine) 5 mg/kg/day, interferon (IFN)-alpha-2b, and IFNgamma. Minocycline 100mg twice daily and dapsone 50-100mg twice daily have been used with some effect. The use of highly active antiretroviral therapy for HIV has resulted in the amelioration of EPF as CD4 cell counts rise above 250/mm(3). The diversity of clinical presentations and affected populations make it seem that EPF is a reaction pattern as much as a disease and that therapy should be tailored to the variant of EPF and the underlying etiology.

Recent progress in the pharmacotherapy of Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a primary systemic vasculitis occurring primarily in patients with asthma. Unlike other small vessel vasculitides, CSS is characterised by blood and tissue eosinophilia. Corticosteroids are the therapy of first choice for all stages of the disease when active vasculitis needs to be treated rapidly. In patients with severe disease and organ- or life-threatening manifestation, the addition of cyclophosphamide appears to improve the outcome and reduces the incidence of relapses. In cases with an apparently better prognosis and less severe disease, methotrexate can be given as a corticosteroid-sparing agent in order to reduce the cumulative dose of corticosteroids, which is generally high in most cases as long-term administration of corticosteroids is often inevitable in order to control asthma, even if the vasculitis is inactive. In very severe cases of CSS, cyclophosphamide and corticosteroids may be insufficient to induce remission. In these cases, anti-TNF blocking agents such as infliximab or etanercept, may be added for a limited period of time. As this intense immunosuppression increases the risk for infections, a prophylaxis with sulfamethoxazole/trimethoprim is advised. Alternatively, the administration of recombinant IFN-alpha can be a effective when given on a short-term basis in otherwise refractory cases. Whether a continuous administration of immunosuppressive agents in addition to corticosteroids can reduce the frequency of relapses in CSS who are in remission is still unknown. As relapses occur in > 25% of all patients, studies addressing the prevention of relapses in CSS are highly desirable in the future.

Eosinophilic pustular folliculitis (Ofuji's disease) in Singapore: a review of 23 adult cases

The case records of 23 patients with classic eosinophilic pustular folliculitis (EPF), or Ofuji's disease, seen at the National Skin Centre in Singapore, from 1990 to 2001 were reviewed. All patients had clinical and histopathological findings consistent with EPF. There were eight men and 15 women (ratio 1:1.6). The mean age at presentation was 35 years. There was a marked predilection for Chinese patients (87%), with a racial distribution of 20:2:1 of Chinese, Malay and Indian patients, respectively. The most frequent site of occurrence was the face, particularly over both cheeks. The majority of patients (90%) treated with oral indomethacin had a good response within 2-4 weeks. Relapses were frequent in 82.6% of patients and maintenance with indomethacin or ketoprofen was beneficial. Eosinophilic pustular folliculitis is a rare but important disease entity presenting with recurrent indurated erythematous papulopustules and plaques on the face. Increased awareness of this condition is important as it can mimic many other conditions presenting as red plaques on the face.

Eosinophilic pustular folliculitis

Eosinophilic pustular folliculitis is a rase dermatosis and the treatment is difficult because the underlying pathogenic mechanism is unknown. The authors report a case of eosinophilic pustular folliculitis (Ofuji's disease) in a 50-year-old man who died 9 years after onset of the disease.

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.

Ofuji's disease: diagnostic and therapeutic problems. A report of three cases

BACKGROUND

Ofuji's disease is an eosinophilic dermatosis affecting mostly male subjects. It is characterized by the appearance of follicular papulopustules, at times on an erytemathous base, which tend to form an annular configuration. The evolution is relapsing remitting. The histopathological examination demonstrates a dense dermal infiltrate with a prevalence of perifollicular and perivascular eosinophilia. Peripheral blood eosinophilia is observed in a high percentage of cases. The pathogenesis is unclear.

METHODS

We report three cases of patients affected by Ofuji's disease with presentation on different sites. Our case reports concern three male subjects otherwise in good health and whose hematologic results were normal. Before they came to our observation, an erroneous diagnosis had been made and they had been subjected to improper treatment.

RESULTS

To make a definite diagnosis it was necessary to evaluate the following features as a whole: the clinical aspect, the evolution, the result of the histological examination, the negativity of cutaneous cultures and the lack of response to previous treatments. All three patients were treated with dapsone 100 mg/day with regression of the clinical manifestations. In one case there was a relapse which was treated with isotretinoin 0.5 mg/kg/day.

CONCLUSIONS

From our experience we can deduce that in cases of follicular pathologies which do not respond to conventional therapies, it is necessary to take into consideration the possibility of Ofuji's disease and, in that case, patients should be monitored because of the frequent relapses.

Complete remission of hypereosinophilic syndrome after interferon-alpha therapy: report of a case and literature review

Hypereosinophilic syndrome (HES) is a multisystem disease with a significant mortality rate. It is characterized by peripheral blood eosinophilia and infiltration of eosinophils into many organs including skin. We describe a patient with cutaneous, pulmonary, and gastric symptoms of HES. He was first treated with systemic and topical corticosteroids, antihistamines, and photochemotherapy. Therapy was switched to interferon-alpha, because we had to consider side effects of corticosteroids and no significant improvement had been achieved. During the period of usage of interferon-alpha for 50 weeks, his symptoms of HES nearly cleared. There has been no recurrence in the eight months since the discontinuation of interferon-alpha therapy.

HIV-related eosinophilic folliculitis: a panel discussion

Eosinophilic folliculitis is a common cause of morbidity in patients infected with the human immunodeficiency virus (HIV) and a marker of the acquired immunodeficiency syndrome (AIDS). No causative organism has yet been identified, although an aberrant Th2-type immune response to a follicular antigen appears relevant to pathogenesis. A variety of treatments have been reported to minimize the inflammatory component, relieve the concomitant pruritus, and/or favorably alter the cutaneous microenvironment.