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


Pruritic papular


Eosinophilic folliculitis




Folliculitis: Bacterial (B)

Pityrosporum (P)

Clinical findings

Skin-coloured papules


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


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


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


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


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


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.

Source Eisman S.  Pruritic Papular Eruption in HIV. Dermatol Clin  2006;24(4):449-57.