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

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.

[Pustular diseases of the newborn]

In the newborn, there exists a wide spectrum of pustular skin diseases. These range from transitory, benign adaptation disorders up to systemic, life threatening illnesses. In 30-60% of newborns pustules are observed in association with the relatively harmless Erythema toxicum, the origin of which is still unknown today. It is necessary to differentiate this from the pustular diseases which may be of infectious or non-infectious nature and which require therapy. Typical pathogens include Malassezia furfur, Staphylococci, Streptococci, Candida spp. and the herpes virus group.

Eosinophilic Pustular Folliculitis in Infancy

In the standard literature of dermatology and dermatopathology "eosinophilic pustular folliculitis in infancy" is presented as a distinctive inflammatory disease of the skin, to wit, a variant of "Ofuji's eosinophilic folliculitis". Assessment critically of the first publication devoted to the subject revealed a potpourri of findings clinical and histopathologic, with no clear criteria being set forth by the authors to enable diagnosis, with precision. Our review of all articles dedicated to the matter of "eosinophilic pustular folliculitis in infancy" shows that criteria for diagnosis are found with great difficulty. The majority of patients reported on had neither "eosinophilic folliculitis," nor did they present themselves clinically in any way similar to what was originally described by Ofuji. The findings histopathologic told of most commonly were dense and diffuse infiltrates in the dermis that contained many eosinophils, sometimes with periadnexal distribution. We think that the findings reported on in several articles suggest that the patients more likely had a variety of different diseases, among them scabies, insect bites, impetigenized nummular dermatitis, and linear IgA-dermatosis. For clarification of terminology, we suggest that "eosinophilic folliculitis" is better defined as a pattern histopathologic than as a distinctive disease entity. It may be encountered in a variety of conditions (eg, Ofuji's disease, arthropod bites, scabies, or dermatophytosis). In sum, no clear criteria have been established for diagnosis of "eosinophilic pustular folliculitis of infancy" and there is no convincing evidence, at present, that "eosinophilic pustular folliculitis of infancy" qualifies as a distinctive inflammatory disease of the skin.

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.

Neonatal eosinophilic pustular folliculitis

Eosinophilic pustular folliculitis (EPF) of infancy is a rare disorder which may begin in the neonatal period and cause considerable parental anxiety. It must be distinguished from other causes of a pustular eruption in neonates, including infection and erythema toxicum neonatorum, and rare disorders such as transient neonatal pustular melanosis, infantile acropustulosis and Langerhans' cell histiocytosis. Skin smears and occasionally skin biopsy may be necessary to reach a diagnosis. We report a case of a Caucasian child with an unusually early onset of EPF in the first day of life. We wish to emphasize the importance of recognizing this self-limiting condition in order to prevent inappropriate antimicrobial treatment.

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.

Expression of neuronal nitric oxide synthase in dermal infiltrated eosinophils in eosinophilic pustular folliculitis

Nitric oxide (NO) is produced by a wide variety of human cells and affects physiological and pathophysiological processes. In this study, we demonstrated for the first time that neuronal NO synthase (NOS) is expressed in eosinophils infiltrating into the dermis and follicular epidermis in eosinophilic pustular folliculitis (EPF). EPF is a cutaneous inflammatory follicular disorder first described in Japan. The clinical and histological features of EPF are characterized by erythematous papules, infiltration of numerous eosinophils, and a spongiotic appearance of the follicular epidermis, but the pathophysiology of EPF remains unclear. Our results suggest that NO produced from eosinophils plays an important part in the pathogenesis of EPF. Furthermore, we speculate that NOS inhibitors may be useful in the management of EPF.

Eosinophilic pustular folliculitis (Ofuji's disease) in myelodysplastic syndrome

We describe a case of eosinophilic pustular folliculitis (EPF, Ofuji's disease) in a 12-year-old male who suffered from myelodysplastic syndrome. Bone marrow study revealed an increase in the eosinophil cell line without peripheral blood eosinophilia in our case. We suggest that the immunologic abberations ascribed to myelodysplastic syndrome and the increase in the eosinophil cell line in the bone marrow might play roles in the development of EPF in our case.