Infantile Eosinophilic Folliculitis

Emily Neville, Dr Theresa Pitts

Case Report

We report the case of infantile eosinophilic folliculitis, which has been found to be an under-reported and under researched condition.

A two month old male (corrected gestational age of one week) was referred to our regional hospital with small discrete vesicular lesions on all limbs and the thorax, but sparing the face and genitalia. No immediate contacts had a similar rash. The infant was alert, afebrile and hemodynamically stable, with no additional findings on examination. The infant was born at 32 weeks gestation due to preterm labour and had a low birth weight. The neonatal period was complicated by respiratory distress syndrome and physiological jaundice. The family history was significant for asthma. There was no reported history of eczema, other skin conditions or autoimmune diseases. Regular medications included Pentavite and Ferro-liquid. The initial diagnosis was scabies, secondarily infected with staphylococcus aureus, so the baby was managed with permethrin and a course of oral Flucloxacillin. Despite compliance with treatment, the infant presented one week later with a florid, dry vesicular erythematous rash (figure 1a, b). There were no clinical signs suggestive of systemic infection or haemodynamic compromise.

Eosinophilic count was 1.4 (0.1-1.0) and gram stain revealed 65% eosinophils. This result was consistent with eosinophilic folliculitis. Immunoglobulins were mildly elevated disproving the differential diagnosis of severe combined immunodeficiency. HIV-Eosinophilic Pustular Folliculitis (EPF) was also excluded with relevant investigation. Paediatric dermatological input from a tertiary hospital suggested wet dressings with Advantan Fatty Ointment (methylprednisolone aceponate 0.1%) and Dermeze moisturiser as treatment. Marked improvement of the rash was seen after two weeks of this regime (figure 1c, d).

The literature surrounding infancy associated eosinophilic folliculitis is limited (1). It was first reported in 1992 (2),with sporadic reports over the past five decades. However, the bulk of literature focuses on older populations and the classical presentation of EPF (2-4). In 2016, the first treatment algorithm for infantile eosinophilic folliculitis was developed (4). With spontaneous resolution as the suggested initial treatment goal, first line drugs include a topical steroid and oral erythromycin (25-50mg/kg), with second line therapy including a systemic antibacterial, topical tacrolimus and ultra violet A light (4). Despite these recommendations, currently no treatment ensures cure (4).

This report highlights a lack of management guidelines and a need for research into pathogenesis and appropriate treatment modalities. Increased awareness of the clinical presentation and appropriate treatment of infantile Eosinophilic Pustular Folliculitis is required to establish diagnosis early and avoid chronic disease process.