A Case of Eosinophilic Pustular Folliculitis Associated With Herpes Zoster

ABSTRACT

Patients with eosinophilic pustular folliculitis (EPF), a sterile eosinophilic infiltration of hair follicles, often present with papulopustules that tend to form annular plaques. Histopathologic examination revealed eosinophilic infiltration around the pilosebaceous units and eosinophilic microabscess formation. Although the pathogenesis of EPF is unknown, T-helper type 2 immune responses were suggested to be important based on their stimulating effect on the sebaceous glands. Here, we report the first case of EPF associated with herpes zoster, indicating that herpes zoster and EPF are correlated with T-helper type 2 immune responses.

Inflammasome Activation Characterizes Lesional Skin of Folliculitis Decalvans

Folliculitis decalvans (FD) is a chronic inflammatory disease leading to scarring alopecia with poorly defined pathogenesis. The aim of this study was to investigate the expression of markers associated with the activation of innate immune signals, such as inflammasome (NALP1 and NALP3), interleukin (IL)-1β and IL-8 and type I interferon (MxA). A retrospective monocentric study was conducted and included 17 patients with FD with available biopsies. Disease activity (stable vs. active) was defined clinically and histologically. Immunostaining was performed using antibodies directed against NALP1, NALP3, IL-1β, IL-8, and MxA on FD skin biopsies. Results were compared with normal controls and lichen planopilaris. Eleven patients had active disease and 6 had stable disease. NALP1, NALP3, and IL-1β expression were significantly increased in hair follicles in FD compared with controls and lichen planopilaris. This study highlights the predominant immune signal associated with inflammasome activation in FD, suggesting the use of IL-1β blockade in FD.

Alopecia Areata in C3H/HeJ Mice Involves Leukocyte-mediated Root Sheath Disruption in Advance of Overt Hair Loss

Alopecia areata (AA) can be induced in C3H/HeJ mice by grafting full-thickness AA-affected skin. An 8- to 12-week delay between surgery and overt hair loss onset provides an opportunity to examine disease pathogenesis. Normal haired C3H/HeJ mice were sham-grafted or grafted with AA-affected skin. Mice were euthanatized 2, 4, 6, 8, 10, and 12 weeks after surgery along with chronic AA-affected mice as a positive control. Until 6 weeks after grafting, inflammation was only evident around anagen-stage hair follicles in host skin adjacent to but not distant from the AA-affected graft. From 8 weeks on, AA-grafted but not sham-grafted mice exhibited a diffuse dermal inflammation at distant sites that progressively focused on anagen-stage hair follicles at 10 and 12 weeks. Perifollicular inflammation was primarily composed of CD4+ and CD8+ cells associated with follicular epithelium intercellular adhesion molecule -1 expression. Only CD8+ cells penetrated intrafollicularly by 12 weeks after surgery, although both CD4+ and CD8+ intrafollicular cells were observed in chronic AA-affected mice. Under electron microscopy, intrafollicular lymphocyte and macrophage infiltration associated with hair follicle dystrophy was prominent 10 weeks after surgery, primarily within the differentiating outer and inner root sheaths. This study shows that focal follicular inflammation develops some time in advance of overt hair loss and focuses on the differentiating root sheaths in C3H/HeJ mice. The severity of inflammation and the degree of hair follicle dystrophy induced by the infiltrate appear to reach a threshold level before overt hair loss occurs.

The role of inflammation and immunity in the pathogenesis of androgenetic alopecia

BACKGROUND

Female pattern hair loss affects many women; its pathogenetic basis has been held to be similar to men with common baldness.

OBJECTIVE

The objective of this study was to determine the role of immunity and inflammation in androgenetic alopecia in women and modulate therapy according to inflammatory and immunoreactant profiles.

MATERIALS AND METHODS

52 women with androgenetic alopecia (AA) underwent scalp biopsies for routine light microscopic assessment and direct immunofluroescent studies. In 18 patients, serologic assessment for antibodies to androgen receptor, estrogen receptor and cytokeratin 15 was conducted.

RESULTS

A lymphocytic folliculitis targeting the bulge epithelium was observed in many cases. Thirty-three of 52 female patients had significant deposits of IgM within the epidermal basement membrane zone typically accompanied by components of complement activation. The severity of changes light microscopically were more apparent in the positive immunoreactant group. Biopsies from men with androgenetic alopecia showed a similar pattern of inflammation and immunoreactant deposition. Serologic assessment for antibodies to androgen receptor, estrogen receptor or cytokeratin 15 were negative. Combined modality therapy with minocycline and topical steroids along with red light produced consistent good results in the positive immunoreactant group compared to the negative immunoreactant group.

CONCLUSION

A lymphocytic microfolliculitis targeting the bulge epithelium along with deposits of epithelial basement membrane zone immunoreactants are frequent findings in androgenetic alopecia and could point toward an immunologically driven trigger. Cases showing a positive immunoreactant profile respond well to combined modality therapy compared to those with a negative result.

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.

Varicella-Zoster-Virus Folliculitis Promoted Clonal Cutaneous Lymphoid Hyperplasia

Post herpes zoster (HZ) reactions have been associated with panoply of neoplastic, inflammatory, and fibro-inflammatory cutaneous disorders. Varicella zoster virus (VZV) DNA has not been identified in most of these reports. After an episode of HZ, a healthy, active 90-year-old female developed ulcerative nodules in the affected trigeminal V1 dermatome and the contra-lateral trigeminal region over a 1-year period. Excision and/or biopsy of all these lesions showed similar pathologic changes that consisted of herpetic folliculitis, adjacent dense mixed nodular lymphocytic infiltrates with germinal centers (cutaneous lymphoid hyperplasia (CLH)), and in the deeper excision specimens, an obliterative vasculitis of a vessel with smooth muscle in its wall. Immunophenotype analysis revealed a mixed, predominate T- and B-cell population without loss of pan-T cell antigens or aberrant expression by B cells of T-cell antigens. Polymerase chain reaction for herpetic DNA was positive for VZV DNA. Lymphocyte gene rearrangement analysis revealed 2 distinct, anatomically and chronologically, monoclonal B-cell populations and a monoclonal T-cell population in one nodule. Treatment with valacyclovir has lead to almost complete resolution of her cutaneous nodules after 6 months of therapy. In this case, it can be surmised that persistence of VZV infection and lack of effective cell-mediated immunity lead to development of both immunopathology (vasculitis) and excessive lymphoid cell proliferation (CLH).

Successful treatment of eosinophilic pustular folliculitis with topical tacrolimus

We present two cases of Eosinophilic pustular folliclulitis (EPF) who were successfully treated with topical tacrolimus. Indomethacin is the most frequently used agent for the treatment of EPF, however, tacrolimus ointment may become the treatment of choice for patients with EPF.

Involvement of granulysin-producing T cells in the development of superficial microbial folliculitis

BACKGROUND

Granulysin is a recently identified antimicrobial protein expressed on cytotoxic T cells, natural killer (NK) cells and NKT cells. It has been shown that granulysin contributes to the defence mechanisms against mycobacterial infection. Superficial microbial folliculitis is a common skin disease. In a previous report, we showed that, as a first line of defence, alpha-defensin, a human neutrophil peptide, and beta-defensin (human beta-defensin-2) were expressed in infiltrating neutrophils and in lesional epidermal keratinocytes, respectively, in superficial folliculitis. As we also observed many infiltrating lymphocytes in lesional dermis, we hypothesized that infiltrating lymphocytes may possess antimicrobial substances, such as granulysin, and play a role in the defence mechanism as a second line of defence.

OBJECTIVES

Seven specimens of superficial microbial folliculitis diagnosed clinically and histologically were examined by means of immunohistochemistry. To identify the phenotype of cells expressing granulysin, confocal laser microscopic examination was performed.

RESULTS

A dense lymphoid cell infiltrate was observed in pustules, in the perivascular regions. A large number of these lymphoid cells were positive for granulysin. Phenotypically, cells consisted of CD3+ T cells, CD8+ T cells and UCHL-1+ T cells. CD20+ cells and CD56+ cells were not observed. Microscopic examination with a confocal laser showed that the lymphocytes producing granulysin were CD3+ and CD4+ T cells but not CD8+ T cells.

CONCLUSIONS

We showed that many granulysin-bearing T cells infiltrated affected follicles and perilesional dermis in superficial microbial folliculitis. However, few granulysin-positive lymphoid cells were observed in sterile pustular lesions. Our observations indicated that adaptive immunity such as granulysin, a lymphocyte-produced antimicrobial protein, may play an important role in the cutaneous defence mechanism.

Treatment of gram-negative folliculitis in patients with acne

Gram-negative folliculitis may be the result of long-term antibacterial treatment in acne patients. It is caused by bacterial interference and replacement of the Gram-positive flora of the facial skin and the mucous membranes of the nose and infestation with Gram-negative bacteria. These Gram-negative bacteria include Escherischia coli, Pseudomonas aeruginosa, Serratia marescens, Klebsiella and Proteus mirabilis. The occurrence of Gram-negative folliculitis should be considered in acne patients in whom oral treatment with tetracyclines has not resulted in a significant improvement of acne lesions after 3-6 months' treatment. The occurrence of Gram-negative folliculitis in acne patients is believed to be generally underestimated, since correct sampling and bacteriology is rarely performed by clinicians. Gram-negative folliculitis in acne and rosacea patients is best treated with isotretinoin (0.5-1 mg/kg daily for 4-5 months).

Tacrolimus ointment for the treatment of atopic dermatitis is not associated with an increase in cutaneous infections

OBJECTIVE

The purpose of this study was to evaluate the risk of cutaneous infection in patients with atopic dermatitis treated with tacrolimus ointment.

METHODS

Data for 1554 patients with atopic dermatitis, treated with tacrolimus ointment in 5 clinical trials, were analyzed.

RESULTS

In 3 controlled studies, the 12-week adjusted incidence of all cutaneous infections in patients treated with the vehicle, 0.03%, and 0.1% tacrolimus ointment, respectively, was 18.0%, 24.8%, and 17.7% for adult patients, and 20.9%, 19.6%, and 23.6% for pediatric patients. The incidence of any individual cutaneous infection was not significantly higher in the tacrolimus group than in the vehicle group, with the exception of folliculitis in adults. In two open-label studies, there was no evidence of an increased risk of cutaneous infections with long-term use of 0.1% tacrolimus ointment (up to 1 year), based on the incidence of adverse events, incidence by cumulative length of exposure, or hazard rates.

CONCLUSION

Treatment with tacrolimus ointment (0.03% or 0.1%) does not increase the risk of cutaneous bacterial, viral, or fungal infections in patients with atopic dermatitis.

The specific dermatoses of pregnancy: a re-appraisal

Pregnancy is associated with immunological, endocrine, metabolic and vascular changes that may adversely affect the skin. The specific dermatoses of pregnancy are disease entities almost exclusively related to the pregnancy or the puerperium.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be aware of the main entities of the specific pregnancy dermatoses, their clinical presentations, the main diagnostic criteria and therapeutic options.

Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry

BACKGROUND

The fact that Pityrosporum ovale plays a part in seborrhoeic dermatitis is well established but the mechanism of this relationship has not been established.

OBJECTIVES

To compare the number and type of inflammatory cells and mediators in skin biopsies from normal and lesional skin from the trunk and scalp in patients with seborrhoeic dermatitis, Pityrosporum (Malassezia) folliculitis and in normal skin from healthy controls.

METHODS

The skin biopsies were stained using the labelled Streptavidin-biotin

METHOD

The following markers were studied: CD4, CD8, CD68, HLA-DR, NK1, CD16, C1q, C3c, IgG, CD54 (ICAM-1), interleukin (IL) -1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-12, tumour necrosis factor-alpha and interferon-gamma.

RESULTS

HLA-DR+ cells were seen in the highest number, and were higher in lesional skin compared with normal skin from both patients and healthy volunteers. ICAM-1 expression was also increased in lesional skin. C1q and the interleukins showed an increased cellular and intercellular staining in patients compared with healthy controls and the intercellular staining was often more intense in lesions compared with non-lesional skin. Staining was often more intense when Malassezia (Pityrosporum ovale) yeast cells were present.

CONCLUSIONS

An increase in NK1+ and CD16+ cells in combination with complement activation indicates that an irritant non-immunogenic stimulation of the immune system is important. The result with the interleukins showed both an increase in the production of inflammatory interleukins as well as in the regulatory interleukins for both TH1 and TH2 cells. Similarities to the immune response described for Candida albicans infections indicate the role of Malassezia in the skin response in seborrhoeic dermatitis and Pityrosporum folliculitis.

Viral folliculitis on the face

The common clinical presentations of herpes simplex virus (HSV) and molluscum contagiosum (MC) are well known to dermatologists. However, folliculitis due to these viruses is an infrequently reported entity and might be considered a sign of immunosuppression [such as infection with human immunodeficiency virus, (HIV)], especially in cases of folliculitis due to MC. The purpose of this study was to describe the clinical and histopathological characteristics of viral folliculitis due to HSV and MC. We retrospectively collected all our cases with histologically proven folliculitis due to HSV and MC between 1994 and 1999. A total of seven patients aged 7-54 years was identified. Prior to establishment of the diagnosis of folliculitis due to HSV and MC, they were treated with topical antibiotics or topical steroids, without improvement. Tentative diagnoses were bacterial folliculitis, syringoma, perifollicular fibrosis, contact dermatitis or pseudolymphoma. Biopsy of the lesions revealed multiple molluscum bodies in the follicular epithelium with sparing of the epidermis in four patients, and ballooning degeneration and intranuclear viral inclusions in the follicular epithelium in the other three. Three patients had evidence of underlying immune suppression, such as pregnancy, chronic viral hepatitis B and nasopharyngeal carcinoma. One patient had suffered from epilepsy for 4 years. Testing for HIV by enzyme-linked immunosorbent assay was negative in the four patients in whom this was performed, and T-cell subsets were normal in the three patients in whom these were quantified. In cases of molluscum folliculitis treated with simple curettage, the lesions cleared without scarring or recurrence. In cases of herpetic folliculitis, the lesions improved with antihistamines or acyclovir. MC or HSV should be considered in cases that present with folliculitis-like dermatoses but which are refractory to anti-infective and anti-inflammatory treatment.

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.

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.

Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings

In a series of 18 patients with folliculitis decalvans attending the Oxford hair clinic, eight were found to have areas of tufted folliculitis either at presentation or follow-up. There was no difference between these two groups in their presentation, clinical course, growth of causative organism (Staphylococcus aureus) or investigations including histology. We suggest that these two entities form part of a spectrum of a single disease. We performed lymphocyte staining on affected scalp biopsies, including CD4: CD8 and T-cell/B-cell ratios, but found no evidence of local immune suppression or failure which would explain the abnormal host response to a common pathogen in this rare condition. We introduced a new treatment regimen for these patients, oral rifampicin and oral clindamycin together for 10 weeks. Ten of the 18 patients have responded well with no evidence of recurrence 2-22 months after one course of treatment, and 15 of the 18 responded after two or three courses.

[Eosinophilic pustulosis in an infant accompanied by immune deficit]

BACKGROUND

Eosinophilic is a skin eruption which occurs in the first years of life, progressing by pruriginous flare-ups with amicrobial papulopustulae on a hairless scalp. Eosinophil infiltration of the skin is variable (follicular or perifollicular dermal infiltration). In adults, eosinophilic pustulosis is often associated with immune deficiency, but this association has not been reported in children. We report two cases.

CASE REPORTS

Two boys had a pruriginous papulopustular eruption involving the scalp and the trunk which had progressed with periods of exacerbation since birth. Search for bacteriological or mycological involvement was negative. Histology showed folliculitis with major polynuclear eosinophil infiltration. Both children had a past history of repeated skin and extracutaneous infections strongly suggesting an immune deficit. Buckly syndrome was suspected in the second case.

DISCUSSION

Juvenile eosinophilic pustulosis belongs to the spectrum of childhood eosinophilic dermatoses. The presence of eosinophil infiltration in the skin demonstrates localized or systemic immune dysfunction. A hematology and immunology work-up is needed in case of associated skin or deep infections.

Eosinophilic pustular folliculitis effectively treated with recombinant interferon-gamma: suppression of mRNA expression of interleukin 5 in peripheral blood mononuclear cells

Eosinophilic pustular folliculitis (EPF) is characterized clinically by pruritic grouped follicular papules and pustules on the trunk, limbs, and face, and, histologically, by follicular infiltration with eosinophils. The blood eosinophil count is elevated in most patients. Oral minocycline, nonsteroidal anti-inflammatory drugs, diaminodiphenylsulphone, and corticosteroids may induce remission. We report two Japanese men with EPF who responded poorly to the usual therapy. Intravenous injections of recombinant interferon-gamma (rIFN-gamma), 5 x 10(5) to 2 x 10(6) Japan Reference Unit (JRU) (1 JRU roughly corresponds to 4 NIH units) daily for 7 days, cleared the skin lesions and returned the peripheral eosinophil counts to normal in both patients. However, the lesions recurred 2-3 days after rIFN-gamma was stopped. Both patients have received intravenous rIFN-gamma once or twice a week for nearly 1 year without systemic side-effects. Reverse transcriptase-polymerase chain reaction revealed a decreased expression of interleukin 5 (IL-5) mRNA in peripheral mononuclear cells after the rIFN-gamma therapy. rIFN-gamma may become the treatment of choice in recalcitrant EPF, although further studies are needed. It may work by interfering with the immunological function of type 2 T-helper cells, including IL-5 production responsible for the growth and differentiation of eosinophils.

Eosinophilic pustular folliculitis in three atopic children with hypersensitivity to Dermatophagoides pteronyssinus

Three children will be described who present recurrent episodes of pruritic papulopustular follicular lesions on the face, the extremities and the trunk. The episodes lasted for 1-3 months with intermittent remission. Each flare was accompanied by hypereosinophilia and an increased total IgE titer. RAST and prick tests were positive for Dermatophagoides pteronyssinus (DPT). Laboratory tests disclosed no infectious or parasitic etiology. Histological examination showed eosinophilic pustular folliculitis (EPF) in each of the 3 cases. The lesions responded well to topical corticosteroids. The aim of this article is to underline the importance of hypersensitivity reactions (in these particular cases to DPT) in the pathogenesis of EPF.

Pityrosporum infections

Pityrosporum ovale is a lipophilic yeast that is part of the normal human adult cutaneous flora. It is both a saprophyte and an opportunistic pathogen associated with pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and some forms of atopic dermatitis. Systemic infections have also been described. In this article the diagnosis and management of pityriasis versicolor, Pityrosporum folliculitis, seborrheic dermatitis, and atopic dermatitis will be discussed.

The AIDS epidemic

The nature of the clinical presentation of HIV infection continues to evolve over time. New cutaneous (e.g., seborrheic dermatitis, onychomycosis, and tinea pedis) and systemic (e.g., Aspergillus fumigatus and Penicillium marneffei) opportunistic fungal infections can now be added to the classic clinical markers for progressive HIV infection, such as Kaposi's sarcoma, Pneumocystis carinii pneumonia, Mycobacterium avium intercellulare infections, and cryptococcal meningitis. The fact that the appearance of many of these fungal diseases is directly correlated with the patient's CD4 cell count is a valuable tool for ongoing clinical evaluation. Although systemic manifestations characterize a progression from asymptomatic HIV infection to AIDS, many of the signs of disease progression are cutaneous. Prophylaxis against many of the potentially life-threatening systemic opportunistic infections associated with HIV positivity has had a positive impact on the life expectancy of patients with AIDS.

Eosinophilic pustular follicular reaction: a paradigm of immune dysregulation

BACKGROUND

We encountered 10 patients whose biopsies showed an eosinophilic pustular follicular reaction, a histomorphology alleged to be pathognomonic of eosinophilic folliculitis (EF). Only seven of these patients fell within the clinical spectrum of EF. Seven patients had conditions associated with immune dysfunction, including three patients with an atopic history. Potential antigenic stimuli could be elicited in six cases.

METHODS

Formalin-fixed biopsy specimens from all 10 patients were available for examination. Hematoxylin and eosin-, alcian blue-periodic acid-Schiff (PAS)- and PAS-diastase-stained sections cut from paraffin-embedded tissue were examined by light microscopy. Immunoperoxidase preparations with antibody to IgE were performed on paraffin sections and the number of IgE-decorated cells quantitated in each case. Four patients also had biopsy material submitted in Michel's medium, on which direct immunofluorescent studies were conducted.

RESULTS

IgE-coated mononuclear cells were present in patients whose lesions would logically be expected to derive from dominant type I hypersensitivity mechanisms and absent or minimal in biopsies from those patients in whom the pathogenetic basis of lesions derived principally from cell-mediated immunity.

CONCLUSIONS

The eosinophilic pustular follicular reaction, while characteristic of EF, is not exclusive to that entity. It represents an expression of an excessive immediate or delayed-type hypersensitivity reaction to various auto-, epicutaneous, or ingested stimuli. A background of immune dysregulation may be contributory.

The association of HLA-B5 antigen with specific manifestations of Behçet's disease

The HLA-B5 phenotype was investigated in 235 patients with Behçet's disease and in 100 healthy persons. HLA-B5 was more frequent in the patients (77 vs. 30% p < 0.001, relative risk = 7.8). The frequency of HLA-B5 was higher in patients with genital ulceration than without (82.3 vs. 63%, p < 0.01). Patients with thrombophlebitis showed a less frequent positivity of HLA-B5 antigen than the patients without thrombophlebitis (50 vs. 79.2%, p < 0.02). These results suggest that HLA-B5-related genes not only affect the development of Behçet's disease but also the occurrence of its clinical manifestations.

An immunologic and cultural study of Pityrosporum folliculitis

In patients with Pityrosporum folliculitis the mean serum antibody titer against Pityrosporum orbiculare was significantly higher than in healthy control subjects (p less than 0.01). The mean number of P. orbiculare organisms per square centimeter cultured from normal-looking skin in patients was not significantly higher than the number cultured from normal-looking skin in control subjects. Results of prick tests against P. orbiculare extract were negative or weak, indicating that patients with Pityrosporum folliculitis had no type I hypersensitivity against P. orbiculare. Immunohistochemical staining of skin lesions showed perivascular dermal cell infiltrates near the hair follicles dominated by anti-Leu 3a-reactive T lymphocytes. Human lymphocyte antigens with the DR locus, but not those with the DQ locus, on keratinocytes were observed in one case.

Ofuji's disease: high circulating titers of IgG and IgM directed to basal cell cytoplasm

A patient with Ofuji's eosinophilic pustulosis and peculiar immunofluorescence findings is described. High titers of circulating IgG and IgM have been found directed to the cytoplasm of the basal cells of epidermis and the outer sheath of hair follicles. Such antibodies appear to be related to the course of the disease.

Mechanisms of pustule formation in cutaneous bacterial and viral infections: alterations of neutrophil membrane surface receptors

Changes in membrane surface receptors have been demonstrated by rosetting methods in polymorphonuclear leukocytes obtained from the pustules of different infectious dermatoses. There was a distinct difference in numbers of receptors in neutrophils from bacterial and viral pustules, i.e., C3b receptors were decreased on neutrophils from both bacterial and viral pustules, whereas IgG-Fc receptors were decreased only in neutrophils from viral pustules. The difference appears to be due to variations in the defence mechanisms against the invading micro-organisms.

Dissociated impairment of neutrophil functions and recurrent infections

This report concerns the study of a 43-year-old woman with a four-year history of recurrent infection caused primarily by staphylococci. The patient was treated with various antibiotic combinations without long-term success. We found phagocytosis, directed migration and the capacity to kill Staphylococcus aureus to be impaired; the capacity to adhere to nylon fibre was normal, the non-quantitative NBT reduction test was unaffected and we were unable to detect any humoral abnormality (e.g. in complement or immunoglobulins). The dissociated impairment of neutrophil functions was clearly improved by levamisole.

Larva migrans with eosinophilic papular folliculitis

A patient with typical larva migrans lesions associated with a highly pruritic papular folliculitis is presented. The time course of the evolution and the pathological picture - with local accumulation of lymphocytes, mast cells and eosinophils - mirror a typical thymus-dependent reaction to parasitic infestation. The papular and serpiginous lesions did not respond to the same type of therapy.

Eosinophilic pustulosis with pemphigus-like antibody

A 75-year-old male with eosinophilic pustulosis Ofuji complicated by superinfection with Pseudomonas aeruginosa and Proteus mirabilis is described. This is the first case of eosinophilic pustulosis with an antiepidermal antibody. This antibody was directed against the intercellular substance of the lower epidermis and it was detected by direct immunofluorescence in the patient's normal and lesional skin. As revealed by indirect immunofluorescence the patient's serum reacted with intercellular substance of human lower epidermis but not with guinea pig esophagus. Possibly the detected autoantibody is not characteristic for eosinophilic pustulosis Ofuji but rather an accompanying feature of this case similar to the antiepidermal antibodies found in patients with drug reactions and burns.