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Clinical Summary

Eosinophilic folliculitis, commonly seen in advanced HIV patients, is a pruritic skin eruption usually involving the face, neck, trunk, and extremities manifesting in the form of pustules and papules. The skin lesions usually start as small pustular groups that later coalesce to create irregular erosions and plaques with central hyperpigmentation. The associated pruritus is often so intense that the lesions become excoriated. Most patients with this condition will demonstrate CD4 cell counts of less than 250/mm3. The etiology of eosinophilic folliculitis is unknown but is commonly thought of as an inflammatory process associated with immune dysfunction. It has become less common with the advent of HAART.

Management and Disposition

The diagnosis requires dermatology consultation and referral for biopsy. Antihistamines, potent topical steroids, itraconazole, topical permethrin, retinoids, metronidazole, dapsone, and ultraviolet B phototherapy have all shown variable levels of efficacy.

Pearls

  1. The severe pruritus associated with this condition helps distinguish it from bacterial folliculitis. Symptomatic treatment for pruritus is necessary, and the disease generally improves with effective ART.

  2. Dermatologic referral is warranted prior to initiating definitive therapy.

  3. Patients with eosinophilic folliculitis may present with prurigo nodularis and lichen simplex chronicus as a result of severe itching and rubbing.

  4. Secondary syphilis should be considered in all HIV-infected patients presenting with rash.

FIGURE 20.30

Eosinophilic Folliculitis. The rash of eosinophilic folliculitis consists of small groups of pustules and vesicles, as seen on the face of this patient. (Photo contributor: Department of Dermatology, National Naval Medical Center, Bethesda, MD.)

FIGURE 20.31

Eosinophilic Folliculitis. A magnified view showing pustules at the base of each hair follicle. (Photo contributor: Department of Dermatology, National Naval Medical Center, Bethesda, MD.)

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