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Eosinophilic Folliculitis

Last updated Feb. 20, 2018

Approved by: Krish Tangella MD, MBA, FCAP

Eosinophilic Folliculitis is an uncommon and benign skin condition that is characterized by the presence of skin rashes with acne-like appearance.

What are the other Names for this Condition? (Also known as/Synonyms)

  • Eosinophilic Pustular Folliculitis (EPF)
  • Ofuji Disease
  • Sterile Eosinophilic Pustulosis

What is Eosinophilic Folliculitis? (Definition/ Background Information)

  • Eosinophilic Folliculitis is an uncommon and benign skin condition that is characterized by the presence of skin rashes with acne-like appearance
  • Eosinophilic Folliculitis is generally observed in young adult males. The lesions usually form on the head, neck, and shoulder region. These are often marked by intense itching
  • The skin condition can be seen in individuals with normal health and immune system. However, in most cases, the condition is observed in immunocompromised individuals (such as in HIV-positive individuals)
  • The cause of development of Eosinophilic Folliculitis is not identified yet. But, research studies seem to indicate that certain viral infections, such as caused by retrovirus and hepatitis C virus (HCV), fungal infections of the skin, or certain malignancies including leukemia and lymphoma, may play a role in Eosinophilic Folliculitis formation
  • A diagnosis of Eosinophilic Folliculitis is made by blood tests and skin biopsy (microscopic examination of the skin lesions). Following its diagnosis, the condition may be treated using topical creams and gels, oral medications, and light therapy
  • There is no effective prevention of Eosinophilic Folliculitis. The prognosis of the condition depends upon the severity of symptoms, the extent of skin lesions, and the overall health status of the affected individual. In many cases, with appropriate treatment, the prognosis is good

There are a few variants of Eosinophilic Folliculitis that include:

  • Classic Eosinophilic Pustular Folliculitis
  • Immunosuppression-Associated Eosinophilic Folliculitis (or HIV-Associated Eosinophilic Folliculitis), which is the most common variant observed
  • Infancy-Associated Eosinophilic Folliculitis
  • Drug-Associated Eosinophilic Folliculitis
  • Cancer-Associated Eosinophilic Folliculitis

Who gets Eosinophilic Folliculitis? (Age and Sex Distribution)

  • Eosinophilic Folliculitis is an uncommon skin condition that is observed in a wide age group; both children and adults are affected
    • The most common period of incidence is between ages 20-40 years
    • The infancy-associated variant is seen when the infant child is between 5-10 months old
  • The condition affects both males and females, though majority of the cases are seen in males (male-female ratio is 5:1)
  • All racial and ethnic groups may be affected
  • Even though the condition is observed worldwide, it is more common in Asians. The classic type is more associated with individuals of a Japanese lineage

What are the Risk Factors for Eosinophilic Folliculitis? (Predisposing Factors)

The risk factors for Eosinophilic Folliculitis are not well-established; although, some studies indicate that the following factors may be responsible for the condition:

  • Certain infections that include:
    • Retrovirus infection
    • Hepatitis C infection
    • Fungal skin infections
    • Parasitic skin infections such as cutaneous larva migrans
  • Certain conditions and disorders such as:
    • Leukemia and lymphoma
    • Myelodysplastic syndrome (MDS)
    • Polycythemia vera
    • Sezary syndrome
  • Any condition resulting in decreased immunity such as HIV infection, organ transplantation, etc.

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Eosinophilic Folliculitis? (Etiology)

The exact cause of Eosinophilic Folliculitis development is not known. However, some researchers have proposed the following theories:

  • Increased levels of Malassezia furfur (a type of fungus) on the skin
  • Increased levels of demodex (small mites that live on humans) on the skin
  • Abnormal immune system causing dysfunctional immunity 

Eosinophilic Folliculitis is not contagious and it cannot be transmitted from one individual to another.

What are the Signs and Symptoms of Eosinophilic Folliculitis?

The signs and symptoms associated with Eosinophilic Folliculitis may include:

  • Presence of papules and pustules on the body
  • The skin condition may resemble acne
  • Most skin lesions occur on the head and neck region and the trunk (chest and back), but the palms and soles are rarely affected
  • The lesions may occur for a few days to several months at a time
  • The papules and pustules are generally itchy, which can result in continuous scratching

The signs and symptoms may be worse in immune-compromised individuals than in those who are immune-competent.

How is Eosinophilic Folliculitis Diagnosed?

The diagnosis of Eosinophilic Folliculitis may involve:

  • A complete evaluation of medical history along with a thorough examination of the skin lesions
  • Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
  • Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
  • Complete blood count (CBC), which may show increased eosinophils in peripheral blood. Also, serum immunoglobulin E (IgE) may be increased with a simultaneous decrease in levels of serum IgG and IgA
  • Tests for detecting any underlying conditions or infections, such as HIV infection, should be undertaken
  • Skin biopsy: A skin biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis
  • Differential diagnosis of the following skin conditions, infections, or tumors presenting similar symptoms should be ruled out:
    • Acne
    • Follicular mucinosis
    • Granuloma faciale
    • Rosacea
    • Scabies
    • Skin fungal infections

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Eosinophilic Folliculitis?

Complications associated with Eosinophilic Folliculitis may include:

  • Intense itching may cause psychological stress
  • The stress may also arise from cosmetic concerns
  • Scratching may result in secondary infections (superimposed bacterial and viral infection)
  • Decreased or increased skin color (hypopigmentation or hyperpigmentation respectively) following healing of the condition

The condition can be chronic and the skin lesions may appear and disappear over time (come and go). This is also called recurrent Eosinophilic Folliculitis.

How is Eosinophilic Folliculitis Treated?

There are no universally accepted treatment protocols for Eosinophilic Folliculitis. The treatment options are considered on a case-by-case basis. The treatment for Eosinophilic Folliculitis may include:

  • Administration of non-steroidal anti-inflammatory medications (NSAID)
  • Topical steroid creams
  • Oral medications such as tetracycline, dapsone, and metronidazole
  • Allergic medications such as oral anti-histamines
  • Anti-fungal creams and ointments
  • Isotretinoin creams (which should not be used in pregnant women)
  • Phototherapy
  • Antibacterial and antiviral medicines for any super-imposed bacterial or viral infections respectively
  • Treating any underlying immunodeficiency 
  • Regular follow up visits with the healthcare providers are important

The following tips are helpful and may be noted for Eosinophilic Folliculitis:

  • If any of the prescribed treatment causes new stinging or burning symptoms, then it is important to stop using them immediately and inform the physician’s office
  • Taking care of oneself, being clean and hygienic (especially face and hands), avoiding the urge to touch/break the blisters, avoiding oily make-ups and creams, drinking lots of water, etc. are all simple practices that can ensure a faster recovery from the condition
  • Avoid excessive washing and scrubbing of the skin
  • Do not pop or lance the affected skin; this merely spreads bacteria and leads to excessive scarring
  • Completely avoid scratching the affected areas

How can Eosinophilic Folliculitis be Prevented?

Currently, there are no specific methods or guidelines to prevent Eosinophilic Folliculitis.

  • Undertake early treatment for any infection including conditions causing weak immune systems
  • Regular medical screening at periodic intervals with physical checkups and blood tests are important

What is the Prognosis of Eosinophilic Folliculitis? (Outcomes/Resolutions)

  • The prognosis of Eosinophilic Folliculitis depends on the extent and severity of the signs and symptoms. Nevertheless, in general, the prognosis is usually good. The skin lesions are known to heal on their own in some cases
  • Individuals with milder signs and symptoms (having focal skin lesions) have a better prognosis than those with severe signs and symptoms. Individuals with poor immunity may have poorer prognoses

Additional and Relevant Useful Information for Eosinophilic Folliculitis:

  • There is no evidence to prove that oily foods and chocolate-based products have an influence on Eosinophilic Folliculitis
  • Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that could potentially worsen the condition
  • The presence of dirt on the body is not a causative factor for Eosinophilic Folliculitis. However, it helps to be clean and hygienic, which will help the condition from getting worse

What are some Useful Resources for Additional Information?

References and Information Sources used for the Article:

Helpful Peer-Reviewed Medical Articles:

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: Aug. 21, 2017
Last updated: Feb. 20, 2018