Depending on the cause, management varies, particularly if an infective cause such as scabies is found. The difficulty arises in the diagnosis of eosinophilic folliculitis and pruritic papular eruption, which are usually exclusion diagnoses (Table 4). Eosinophilic folliculitis and pruritic papular eruption can be difficult to manage with the pruritus often unresponsive to traditional therapies. Treatment options for eosinophilic folliculitis and pruritic papular eruption are similar with potent topical corticosteroids, oral antihistamines, oral antibiotics, emollients, antifungals, antiscabies and phototherapy treatments all being recommended.[168], [169]
WHO guidelines emphasise that In children, adolescents, pregnant women and adults with HIV infection with PPE or EF, ART should be considered as the primary treatment. If PPE or EF appears after the introduction of ART, it should not be discontinued. If there is no response or a failure in response, other causes of papular eruptions of HIV must be considered.[170]
Table 4. Differential diagnosis of pruritic papular eruptions |
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|
Pruritic papular Eruption |
Eosinophilic folliculitis |
Demodex folliculorum |
Scabies |
Folliculitis: Bacterial (B) Pityrosporum (P) |
Clinical findings |
Skin-coloured papules Excoriations Pustules rare Postinflammatory hyperpigmentation Prurigo-like nodules Scarring |
Oedematous papules Pustules not predominant Postinflammatory hyperpigmentation Prurigo-like nodules Scarring |
Rosacea-like erythematous papules with background erythema |
Papules/ plaques with crust or excoriations Burrows Vesicles Nodules Eczematous changes especially in crusted Norwegian scabies |
Pustules predominate Follicular pattern Perifollicular papules |
Distribution |
Symmetrical Extremities, face, trunk Rare on palms, soles, digital web spaces |
Forehead, eyelids, cheeks, neck, postauricular, upper arms and trunk |
Head, neck |
Hands, wrists, interdigital, ankles, ears face, scalp |
B: head, neck. upper trunk, axillae, groin, buttocks P: back, chest, shoulders |
Histopathology |
Dermal perivascular and interstitial lymphocytes, eosinophils Epidermal hyperplasia Follicular damage? |
Follicular spongiosis Folliculocentric infiltrate rich in eosinophils Flames figures Eosinophilic abscesses |
Spongiotic, infundibular folliculitis |
Scabies mite faeces or eggs in epidermis Eosinophils in reticular dermis |
B: Staphylococcus aureus: suppurative folliculitis, gram stain P: yeast forms |
Investigations |
Increase IgE Eosinophilia CD4 <100/μL Increase CD8 T cells increase IgG ? Antibodies to bullous pemphigoid antigen? |
increase IgE Eosinophilia CD4 <300/μL |
Skin scraping |
Skin scraping PCR from scale |
Skin swab P: KOH yeast forms |
Treatment |
Potent topical steroids Emollients Antipruritic lotions Antifungal creams Antiscabies therapy Antihistamines Oral antibiotics Pentoxifylline Antiretrovirals UVB phototherapy |
Potent topical steroids Antihistamines Prednisone Metronidazole Itraconazole Permethrin/ ivermectin Isotretinoin Dapsone UVB 1% tacrolimus ointment |
Permethrin Oral/topical metronidazole Ivermectin |
Permethrin Malathion Sulphur ointment Ivermectin |
B: intranasal mupirocin ointment Topical benzoyl peroxide Topical or oral antibiotics Antibacterial washes P: topical antifungals Selenium sulphide shampoo 50% propylene glycol in water Fluconazole Itraconazole |
KOH = potassium hydroxide; PCR = polymerase chain reaction; Ig = immunoglobulin, UBV = ultraviolet B light. |
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Source Eisman S. Pruritic Papular Eruption in HIV. Dermatol Clin 2006;24(4):449-57. |