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| CORRESPONDENCE |
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| Year : 2020 | Volume
: 38
| Issue : 3 | Page : 188-189 |
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A case of eosinophilic pustular folliculitis with Demodex mites
Masataka Satoh1, Toshiyuki Yamamoto2
1 Department of Dermatology, Shirakawa Kosei General Hospital; Department of Dermatology, Fukushima Medical University School of Medicine, Shirakawa, Fukushima, Japan
2 Department of Dermatology, Fukushima Medical University School of Medicine, Shirakawa, Fukushima, Japan
| Date of Submission | 19-Oct-2019 |
| Date of Decision | 22-Feb-2020 |
| Date of Acceptance | 10-Mar-2020 |
| Date of Web Publication | 10-Sep-2020 |
Correspondence Address:
Dr. Masataka Satoh
Department of Dermatology, Shirakawa Kosei General Hospital, 2-1 Toyochikamiyajiro, Shirakawa City, Fukushima 961-0005
Japan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ds.ds_7_20
How to cite this article:
Satoh M, Yamamoto T. A case of eosinophilic pustular folliculitis with Demodex mites. Dermatol Sin 2020;38:188-9 |
Dear Editor,
A 49-year-old female presented with a 3-month history of multiple pruritic papules and pustules, as well as dark red erythematous plaques on the face and upper back, which had not responded to a total of 200 mg of oral minocycline daily, in two doses or a topical combination of steroids and antibiotics [Figure 1]a and [Figure 1]b. In addition, the patient had a medical history of asthma and arrhythmia. Microscopy of a potassium hydroxide preparation (KOH test) revealed a high density of Demodex mites (6 mites/cm2 of lesional skin surface) [Figure 1]c. After making a diagnosis of Demodex folliculitis, treatment with oral minocycline, topical sulfur, and camphor lotion was initiated. Although Demodex folliculorum was not detected by the KOH test after treatment, the eruptions had not been improved. Histology of a skin biopsy taken from a pustule on the jaw revealed a dense neutrophil and eosinophil infiltration into the hair follicles and sebaceous glands, as well as accumulations of eosinophil granules on collagen bundles in the perifollicular dermis [Figure 2]a, [Figure 2]b, [Figure 2]c. Laboratory tests showed an increased white blood cell count (11,900/μl, with 19% eosinophils), IgE (724 IU/ml), and thymus and activation-regulated chemokine (TARC) (460 pg/ml), and the patient was negative for human immunodeficiency virus antigen-antibody. She was therefore diagnosed with eosinophilic pustular folliculitis (EPF), concomitant with Demodex mites. Oral administration of indomethacin farnesil at a daily total dose of 400 mg divided into two doses was initiated, and her eruptions were resolved within a few weeks. | Figure 1: Image of pruritic papules and pustules, dark red erythematous plaques on the face and upper back (a and b). A few Demodex mites were detected in just one follicle by the KOH test (c)
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 | Figure 2: Histological analysis revealed neutrophil and eosinophil infiltration into the hair follicles and sebaceous glands (a and b), as well as accumulations of eosinophil granules on collagen bundles (c). (Hematoxylin and eosin staining: a, ×20; b, ×200; c, ×400)
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Here, we presented a case of EPF in an immunocompetent patient, which had initially been misdiagnosed as Demodex folliculitis. EPF is a noninfectious inflammatory dermatosis of unknown etiology that mainly affects the hair follicles. A recent study reported that the prostaglandin D2-sebocytes-eotaxin-3 pathway plays an important role in the pathogenesis of EPF.[1] The involved follicles show spongiosis with exocytosis of lymphocytes and eosinophils and infundibular eosinophilic pustules. In the dermis, perifollicular and perivascular infiltration of eosinophils and lymphocytes can be observed. Neutrophils are also present in more inflamed lesions.[2] Diagnosing EPF is occasionally difficult because it may share the same clinical appearance of other diseases, including infectious diseases, infestations, inflammatory diseases, and lymphocytic neoplasms.[2],[3]Demodex folliculitis, which causes acneiform follicular papules and pustules on the face with a background of diffuse erythema, is one of the important diseases to be differentiated. In the histopathological analysis of Demodex folliculitis, the majority of inflammatory cells are neutrophils and lymphocytes, and eosinophils are a minor population.[2]Demodex mites, however, can induce a severe eosinophilic immune reaction, namely an eosinophilic follicular microabscess and flame figure formations in the dermis.[4] In cases of EPF with unexpectedly increased D. folliculorum in the lesional skin, it may be difficult to differentiate EPF from Demodex folliculitis, even if examinations such as microscopy of a KOH preparation or a skin biopsy are performed. Clinicians need to be careful when diagnosing EPF, especially in patients with a potentially increased amount of Demodex mites, such as HIV-positive patients and patients who have been previously treated with topical steroids.[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her names and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Nakahigashi K, Doi H, Otsuka A, Hirabayashi T, Murakami M, Urade Y, et al. PGD2 induces eotaxin-3 via PPARγ from sebocytes: A possible pathogenesis of eosinophilic pustular folliculitis. J Allergy Clin Immunol 2012;129:536-43.  |
| 2. | Fujiyama T, Tokura Y. Clinical and histopathological differential diagnosis of eosinophilic pustular folliculitis. J Dermatol 2013;40:419-23. |
| 3. | Nomura T, Katoh M, Yamamoto Y, Miyachi Y, Kabashima K. Eosinophilic pustular folliculitis: A proposal of diagnostic and therapeutic algorithms. J Dermatol 2016;43:1301-6. |
| 4. | Sabater-Marco V, Escutia-Muñoz B, Botella-Estrada R. Eosinophilic follicular reaction induced by Demodex folliculorum mite: A different disease from eosinophilic folliculitis. Clin Exp Dermatol 2015;40:413-5. |
| 5. | Nara T, Katoh N, Inoue K, Yamada M, Arizono N, Kishimoto S. Eosinophilic folliculitis with a Demodex folliculorum infestation successfully treated with ivermectin in a man infected with human immunodeficiency virus. Clin Exp Dermatol 2009;34:e981-3. |
[Figure 1], [Figure 2]
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