Suppurative Folliculitis Research Articles

Majocchi's granuloma after antithymocyte globulin therapy in a liver transplant patient

Majocchi's granuloma (MG) is an atypical and uncommon presentation of dermatophytic infection involving the invasion of dermal and subcutaneous tissue by fungal organisms. It usually begins as a suppurative folliculitis and may culminate in the development of widespread granulomas. Immunosuppressed patients are at increased risk, especially those with T-cell deficiencies. We describe a case of inguinal MG in a liver transplant patient who had received antithymocyte globulin for acute rejection.

Incidence and risk factors for the immune reconstitution inflammatory syndrome in HIV patients in South Africa: a prospective study

To determine the incidence, clinical manifestations, risk factors and outcome of immune reconstitution inflammatory syndrome (IRIS) in South Africa. Prospective surveillance cohort and nested case-control study in a large, University hospital-based antiretroviral therapy (ART) clinic. A total of 423 ART-naive HIV-infected South African patients were followed for signs and symptoms IRIS during the first 6 months of ART. We also performed a nested case-control study with controls matched to IRIS cases on ART duration. During the first 6 months of ART, 44 (10.4%) patients experienced IRIS for an overall incidence rate of 25.1 cases per 100 patient-years. Diagnoses included tuberculosis (18/44, 41%), abscess formation and suppurative folliculitis (8/44, 18.2%), varicella zoster (6/44, 13.6%), herpes simplex (4/44, 9.1%), cryptococcal meningitis (3/44, 6.8%), molluscum contagiosum (3/44, 6.8%), and Kaposi's sarcoma (2/44, 4.5%). Median IRIS onset was 48 days (interquartile range, 29-99) from ART initiation. In comparison with controls, IRIS cases had significantly lower CD4 cell counts at baseline (79 versus 142 cells/microl; P = 0.02) and at IRIS diagnosis (183 versus 263 cells/microl; P = 0.05), but similar virological and immunological response to ART. In multivariable analyses, higher baseline CD4 cell count was protective of developing IRIS (HR 0.72 per 50 cells/microl increase). Most IRIS cases were mild, with ART discontinued in three (6.8%) patients, corticosteroids administered to four (9.1%) patients, and hospitalization required in 12 (27.3%) patients. Two deaths were attributable to IRIS. IRIS may affect 10% of patients initiating ART in Africa, particularly those with advanced immunosuppression, but severe, life-threatening IRIS is uncommon.

Sparing of previously irradiated skin from erlotinib-induced acneiform rash

To the Editor: Erlotinib is a human epidermal growth factor receptor type 1 (Her1/EGFR) thyrosine kinase inhibitor used in the treatment of non–small cell lung cancer (NSCLC) and pancreatic cancer.1Cohen M.H. Johnson J.R. Chen Y.F. Sridhara R. Pazdur R. FDA drug approval summary: erlotinib (Tarceva) tablets.Oncologist. 2005; 10: 461-466Crossref PubMed Scopus (340) Google Scholar, 2Moore M.J. Goldstein D. Hamm J. Figer A. Hecht J. Gallinger S. et al.Erlotinib plus gemcitabine compared to gemcitabine alone in patients with advanced pancreatic cancer. A phase III trial of the National Cancer Institute of Canada Clinical Trials Group [NCIC-CTG]. American Society of Clinical Oncology 2005 Annual Meeting Proceedings (abstract 1).J Clin Oncol. 2005; 23: 1PubMed Google Scholar Typically appearing within the first 2 weeks, the major physical manifestation of erlotinib toxicity is a cutaneous rash, seen in almost 70% of patients; the face, neck, and upper torso are commonly involed.3Perez-Soler R. Saltz L. Cutaneous adverse effects with HER1/EGFR-targeted agents: is there a silver lining?.J Clin Oncol. 2005; 23: 5235-5246Crossref PubMed Scopus (449) Google Scholar We report a patient with NSCLC developing a typical acneiform rash sparing the area of previous radiotherapy. A 43-year-old male patient was admitted to the hospital with fatigue and a cough. A computed tomographic scan of his thorax showed an 86 mm × 75 mm mass in the left upper lobe, with multiple mediastinal and hilar lymphadenopathies. Biopsy was consistent with NSCLC. No evidence of distant metastasis was present. Treatment with gemcitabin plus cisplatin was commenced, and radiotherapy to the mass and mediastinum was applied between the third and fourth cycles. After the sixth cycle, the mass and the lymphadenopathies had largely regressed. With the patient's approval, treatment with erlotinib was started. After 2 weeks of erlotinib treatment, a typical acneiform rash developed on the face, trunk, and upper extremities. The skin overlying the areas of previous radiotherapy, however, was spared, on both the anterior and posterior sides of the trunk (Fig 1). We performed skin biopsies from the acne-spared, previously irradiated skin and from the neighboring affected nonirradiated skin. Histologic examination revealed suppurative folliculitis destroying follicular epithelium and adnexial structures in the nonirradiated skin specimen. Although eccrine glands and piloerector muscles were normal, there was no follicular structure in the previosly irradiated skin specimen (Fig 2). We performed EGFR staining to see if EGFR expression was altered in the radiated area. No difference was seen between irradiated and nonirradiated skin. In both specimens, moderate intracytoplasmic and membranous EGFR staining of basal epidermal cells and follicular epithelium were observed. Four months after treatment began, the irradiated area remained acne-free and showed no signs of disease progression. Rash is a common adverse affect of Her1/EGFR-targeted agents. Histology of the lesions associated with erlotinib, cetuximab, and gefitinib are similar, indicating a class effect of Her1/EGFR inhibitors. The pathogenesis of the rash is not completely understood. Her1/EGFR is expressed by normal keratinocytes, skin fibroblasts, and in the outer root sheath of the hair follicle. A neutrophilic infiltrate has been reported in dermal tissue, particularly the infundibular part of the hair follicle, but the sebaceous glands are not affected.3Perez-Soler R. Saltz L. Cutaneous adverse effects with HER1/EGFR-targeted agents: is there a silver lining?.J Clin Oncol. 2005; 23: 5235-5246Crossref PubMed Scopus (449) Google Scholar Histologic analysis of rash samples from patients receiving cetuximab showed lymphocytic perifolliculitis or suppurative superficial folliculitis without any infectious etiology.4Busam K.J. Capodieci P. Motzer R. Kiehn T. Phelan D. Halpern A.C. Cutaneous side-effects in cancer patients treated with the antiepidermal growth factor receptor antibody C225.Br J Dermatol. 2001; 144: 1169-1176Crossref PubMed Scopus (391) Google Scholar The skin changes may start within the first hours of radiotherapy and might last for months, or they may be permanent. The estimated D50 follicle dose is around 40 Gy.5Lawenda B.D. Gagne H.M. Gierga D.P. Niemierko A. Wong W.M. Tarbell N.J. et al.Permanent alopecia after cranial irradiation: dose-response relationship.Int J Radiat Oncol Biol Phys. 2004; 60: 879-887Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The patient received 45 Gy total to the tumor bed, while the skin received 18.5 Gy. In the present case, we have shown that sparing of irradiated skin from erlotinib-related acneifom rash seems to be caused by radiation-induced follicular loss, and EGFR expresion is not altered.

Papular follicular eruptions in human immunodeficiency virus‐positive patients in South Africa

Papular and follicular eruptions, such as papulopruritic eruption, eosinophilic folliculitis, and infective folliculitis, are relatively common disorders in patients infected with the human immunodeficiency virus (HIV). These conditions may show considerable clinical overlap. To assess the relative proportion of pruritic papular cutaneous eruptions in South Africans with HIV-associated dermatoses, and to correlate the clinical and histologic features of these lesions. The clinical and histologic features of papular follicular eruptions were correlated in 40 consecutive black HIV-positive patients who underwent skin biopsy. The clinical features were similar in all patients and consisted of widespread papules and pustules involving the face, limbs, and trunk. The most common histologic finding was acute suppurative folliculitis, seen in 27 patients (67.5%). In most cases, no cause was found for the suppuration. Papulopruritic eruption of HIV was diagnosed in six patients (15%), HIV-associated eosinophilic folliculitis in four (10%), Pityrosporum folliculitis in two (5%), and acne in one (2.5%). Concordance between the initial clinical diagnosis and the final histopathologic diagnosis was achieved in only 27.5% of cases. Skin biopsy remains an important adjunct to the correct diagnosis and classification of papular and follicular eruptions in HIV-positive patients.

Pyoderma caused byPseudomonas aeruginosainfection in dogs: 20 cases

In this report we describe the historical, clinical, histopathological and microbiological features, as well as treatments and clinical outcome, of pyoderma where Pseudomonas aeruginosa alone was isolated on bacterial culture from lesional skin. Twenty dogs were included in this retrospective study. Seven dogs without prior history of systemic or skin disease presented with acute deep pseudomonal pyoderma characterized by a sudden onset of dorsal truncal pain. Skin lesions in these dogs consisted of erythematous papules, haemorrhagic bullae, ulcers and haemorrhagic crusts confined to the dorsum. An excellent clinical response was achieved with 3-4 weeks of treatment with oral fluoroquinolones. Thirteen dogs with a more gradual onset of skin lesions associated with pseudomonal pyoderma had a history of prior skin, ear or systemic disease and had previously been treated with antibiotics and/or immunomodulatory drugs. Skin lesions in these dogs were variable and similar to those described for superficial and deep staphylococcal pyoderma. In this group, one dog was euthanized prior to commencement of treatment, two dogs were lost to follow up, and 9 had resolution of lesions following treatment with topical silver sulfadiazine (one dog), fluoroquinolones (six dogs) or cephalexin (two dogs) administered orally for 3 to 12 weeks. Rod-shaped bacteria were not always detected on cytology. Histopathology of dogs with deep pseudomonal pyoderma was characterized by severe perforating suppurative folliculitis and furunculosis.

Manifestations cutanées des inhibiteurs du récepteur du facteur de croissance épidermique

Inhibitors of epidermal growth factor receptors (EGFR) constitute a new alternative treatment for patients presenting certain advanced stage solid cancers (bowel, breast, ovary). Adverse cutaneous effects of these drugs are now starting to be described. Our study involved 2 men and 2 women with no previous history of acne included in a treatment protocol comprising EGFR inhibitors. Mean age was 52 years. The primary cancers were breast, ovary, bowel and unidentified. The EGFR inhibitors used were gefitinib (ZD1839) (2 cases), carnetinib (Cl1033) and cetuximab (IMC-C225). Skin lesions appeared after 7 days and included erythematous papules and follicular pustules of the face, back and upper chest. No comedons were seen, and there were no nodules or cysts. The severity of the rash resulted in discontinuation of treatment in 2 patients with complete disappearance of skin lesions in both cases. In one patient, reduction of the dosage of gefitinib (IMC-C225) led to gradual resolution of the rash. Histological examination of papules and pustules concluded on an acute suppurative folliculitis. Smears and cultures ofa nasal lesion and pustules revealed coagulase-positive Staphylococcus aureus in 2 patients. Combined doxycycline 100 mg daily and benzoyl peroxide was prescribed for 3 months and a favourable outcome was achieved after a mean 2 weeks. EGFR inhibitors act by inhibiting mechanisms oftumour proliferation in certain cancers at advanced stages or refractory to other treatments. Our findings in these four patients are similar to the published cases in terms of rapid onset of monomorphous, papulopustular, follicular eruption without comedons. Rapid response to cyclines and benzoyl peroxide is also reported in literature. This treatment must be instituted rapidly and patients must be informed about the cutaneous side-effects of EGFR inhibitors before the start of therapy. The pathophysiology of these eruptions is still unknown. Skin signs are probably due to interaction with EGFR functions, including overexpression of EGFR in keratinocytes and hair follicles.

Kerion and dermatophytic granuloma. Mycological and histopathological findings in 19 children with inflammatory tinea capitis of the scalp

Inflammatory tinea capitis or kerion is the result of a hypersensitivity reaction to a dermatophytic infection. Majocchi's granuloma, in contrast, usually begins as a suppurative folliculitis and culminates in a granulomatous reaction. To present clinical, mycological and histopathological findings for 19 cases of kerion of the scalp in children. Nineteen children were investigated (14 boys and five girls) with a mean age of 6.5 years. A potassium hydroxide (KOH) exam and culture in Sabouraud dextrose agar were performed, followed by a biopsy with hematoxylin and eosin, periodic acid-schiff (PAS) and Gomori-Grocott stains. The same investigations were carried out in four control cases of noninflammatory tinea capitis. Clinical history varied from 2 to 16 weeks (mean 6.6 weeks). Diagnosis was confirmed by a positive KOH exam: all cases except one had a positive culture. The following dermatophytes were isolated: Microsporum canis (32%), Trichophyton mentagrophytes (27%), Trichophyton tonsurans (21%), Trichophyton rubrum (10%) and Microsporum gypseum (5%). The histopathological findings were: suppurative folliculitis (SF) 11%, SF plus suppurative dermatitis 37%, suppurative and granulomatous dermatitis (SGD) 26% and SGD plus fibrosing dermatitis 26%. Fungi were observed in 63% of the histopathological sections. Perifollicular infiltrates (PF) around the parasitized hair follicles were identified in the four noninflammatory control cases due to M. canis. Kerion Celsi is an inflammatory or suppurative type of tinea capitis caused by zoophylic dermatophytes (M. canis and T. mentagrophytes), but also by antrophophylic (T. tonsurans and T. rubrum) and geophylic (M. gypseum) dermatophytes. Histopathological findings showed a spectrum from mild suppurative folliculitis to dense granulomatous infiltrates without a clear relationship with the clinical features.

Keratosis follicularis spinulosa decalvans and acne keloidalis nuchae

A 27-year-old man presented with a 10-year history of scarring alopecia on the vertex of the scalp associated with follicular crusting and pustule formation, and a papular eruption on the posterior neck. Additionally, there was keratosis pilaris on the cheeks, eyebrows and thighs. Histology from the vertex showed scarring with a mixed perifollicular inflammatory infiltrate and foci of acute suppurative folliculitis. With clinical correlation, the diagnosis of keratosis follicularis spinulosa decalvans and concurrent acne keloidalis nuchae was made. The association of keratosis follicularis spinulosa decalvans with acne keloidalis nuchae has not previously been described. The patient responded to treatment with oral isotretinoin 20 mg (0.25 mg/kg) daily for 12 months.

Pustular Drug Eruption to Voriconazole

A 52‐year‐old male with Crohn’s disease presented with florid pustulosis of the face and trunk. Six months prior to presentation, he received amphotericin for pulmonary aspergillosis. Amphotericin was discontinued after five months due to toxicity, and pharmacotherapy was changed to voriconazole. After four weeks of voriconazole, the acneiform eruption occurred which prompted referral to dermatology. Physical examination revealed innumerable 0.5 cm–1.5 cm pustules, cysts, and inflammatory papules concentrated predominantly over the central face, ears, and conjunctiva, but also involving the chest, shoulders, and back. The clinical differential diagnosis included suppurative folliculitis, papulonecrotic tuberculid, cutaneous Crohn’s disease, acne fulminans, and pustular drug eruption. Multiple biopsies demonstrated diffuse neutrophilic and granulomatous dermal inflammation in a predominantly follicular and perifollicular distribution. Microorganisms were not identified by either histology or culture. The histologic differential diagnosis included cutaneous Crohn’s disease and pustular drug eruption. Voriconazole was discontinued with gradual clearing of the skin lesions. Three months later, worsening of the pulmonary disease necessitated restarting voriconazole. A recurrent pustular eruption, similar to the original eruption, occurred within weeks and subsequently cleared upon discontinuation of voriconazole. To our knowledge, this represents the first reported case of a voriconazole induced pustular drug eruption.

Cutaneous side-effects in cancer patients treated with the antiepidermal growth factor receptor antibody C225

C225 is an antibody to the epidermal growth factor receptor (EGFR), and inhibits growth of various tumour cells. The antibody is currently being used as a therapeutic agent in several clinical trials of patients with carcinomas. Objectives To determine and investigate the cutaneous side-effects in cancer patients treated with C225. Methods We clinically examined 10 patients treated with C225, and performed immunohistochemical and in situ hybridization studies on skin biopsies. Results The most common cutaneous reaction to C225 therapy was the development of an acneiform follicular eruption, which was most pronounced on the face, chest and upper back and typically manifested a week after the onset of treatment. The consistency of the morphology and timing of the clinical findings in 10 different patients following monotherapy with C225 strongly suggested a direct biological effect of the antibody. Additional dermatological side-effects included focal areas of tender paronychial inflammation of toes and fingers and small aphthous ulcers of the oral mucosa. Serial punch biopsies of chest skin before and after treatment (at 8 days) revealed two main reaction patterns: a superficial dermal inflammatory cell infiltrate surrounding hyperkeratotic and ectatic follicular infundibula, and a suppurative superficial folliculitis. In two biopsies focal intraepidermal acantholysis was found. Microbiological cultures failed to reveal an infectious aetiology. Immunohistochemical and in situ hybridization studies on a subset of the biopsies showed an increase in the expression of p27Kip1 in epidermal keratinocytes after treatment with C225. Conclusions Our findings support the concept that p27Kip1 plays a part in the in vivo regulation of follicular and epidermal homeostasis by EGFR.

Papulonecrotic Tuberculid

We report 10 women and five men with papulonecrotic tuberculid, an uncommon form of cutaneous tuberculosis (TB). The mean age was 22.6 years (range, 2 1/2-35 years) at presentation. The Mantoux test was strongly positive in 13 patients. Five patients showed presumptive evidence of associated TB; in one case, the presence of TB was proven by culture. Response to anti-TB was dramatic in all cases. Clinical findings were similar to those previously published. We emphasize the simultaneous occurrence of erythema induratum, associated Takayasu's disease, possible associated phlebitic tuberculid, and clinical mimicry of acute bacterial endocarditis. The main histopathological findings obtained from 27 biopsy specimens included dermal necrosis (26 of 27 cases), a poorly formed granulomatous infiltrate (27 of 27 cases), vasculitis (11 of 27 cases), perivascular spongy edema (11 of 27 cases), and follicular necrosis or suppuration (five of 27 cases). A Ziehl-Neelsen stain was negative in all biopsy specimens. Immunohistochemical labeling revealed a preponderance of T-lymphocytes (UCHL-1+), monocytes-macrophages (S-100+), and Langerhans cells (ACT+), indicative of a type IV hypersensitivity reaction. B-lymphocytes (L26+) were sparse. Conditions that may be confused with PNT on clinical or histopathological ground include pityriasis lichenoides et varioliformis acuta, papular urticaria, papulopustular syphilide, miliary TB, septicemia, perforating granuloma annulare, chondrodermatitis nodularis, reactive perforating collagenosis, allergic granulomatosis, suppurative folliculitis, and infectious causes of palisading granulomas. Papulonecrotic tuberculid has distinct clinical, histopathological, and immunohistochemical features. Awareness of this entity is important since an appropriate diagnosis is necessary for the institution of timely curative treatment.

Hot tub dermatitis: A familial outbreak of Pseudomonas folliculitis

Pseudomonas folliculitis resulting from the use of spa pools, whirlpools, and hot tubs is a newly described disease that typically develops 8 to 48 hours after exposure in a contaminated facility. The eruption consists of pruritic papules, papulopustules, nodules, and urticarial lesions on the trunk and extremities. A family of three and a neighbor developed Pseudomonas folliculitis after using a home hot tub from which P. aeruginosa was cultured. Skin biopsies showed an acute, suppurative folliculitis and dermal abscess formation. Although the eruption usually resolves spontaneously within 7 to 10 days, proper maintenance of equipment and adequate disinfectant levels are necessary to prevent its recurrence.

A Diffuse Pustular Eruption Associated With Ulcerative Colitis

Two patients each with a two-year history of chronic ulcerative colitis developed, over a 24- to 48-hour period, painful pustules involving the skin and oral mucosa. The pustular eruption was associated with a severe exacerbation of the colitis. Culture of the lesions and of the blood failed to reveal an infectious cause for the eruption. Histologic study of a pustule in case 2 revealed suppurative folliculitis. The lesions subsided rapidly in case 1 when intravenous hydrocortisone and intravenous and intramuscular antibiotics were administered, and further resolution occurred after colectomy. A similar rapid resoultion of the pustules occurred in case 2 after initiation of treatment with intramuscular cortisone acetate and antibiotics and with colectomy. This pustular eruption may represent a variant of pyoderma gangrenosum.

Bocage, A., Lérine, R. and Chevè, J. Presence of Nicolas-Favre disease on suppurative folliculitis of the preputial sac. (Bull. Soc. Fr. De Derm, et Syph. No. 8, 1936)

A 23-year-old man, with acute gonorrhea, was treated in Barcelona with lavages and infusions of gonacrine. Twelve to fifteen days after the start of treatment, two folliculitis appeared on the preputial sac. After another 5 days, fever with a temperature of up to 39. Soon, adenitis appears in the groins, characteristic of lymphogranulomas. Folliculitis resembled "gonoric abscesses" in appearance. The gonorrhea urethritis was over, the urine was clear. Folliculitis pus was inoculated into mice. The produced Frey's antigen was applied to the patient and the intradermal reaction was positive. Under the influence of iodine treatment, the adenopathy was cured. The authors consider folliculitis to be "chancres" of Nicolas-Favre disease.