Eosinophilic Folliculitis — SCE Dermatology MCQ

Correct answer: C — Topical potent corticosteroid and oral antihistamines

C) Topical potent corticosteroid and oral antihistamines is the first-line treatment for HIV-associated eosinophilic folliculitis. This is a pruritic, sterile, follicular eruption seen typically as CD4 counts fall below 300, and the mainstay of initial management is symptomatic control of the intense itch and inflammation rather than systemic immunosuppression or antimicrobial therapy. Potent topical steroids reduce the perifollicular eosinophilic infiltrate and papulopustular inflammation, while oral antihistamines (sedating agents often preferred for nocturnal itch) control pruritus; optimising antiretroviral therapy to raise the CD4 count is the other key long-term measure. This combination is favoured over systemic agents because the condition, although intensely symptomatic, is not infective and usually responds to topical measures before escalation to phototherapy or isotretinoin is considered in resistant cases. Why the other options are wrong: B. Oral Griseofulvin: This is an antifungal used for dermatophyte infections; eosinophilic folliculitis is not fungal, and biopsy shows an eosinophil-rich perifollicular infiltrate rather than fungal elements, so antifungals have no role. A. Oral Prednisolone long-term: Systemic corticosteroids are avoided as first-line because of the risks of long-term immunosuppression in an already immunocompromised HIV patient, and they are reserved, if used at all, for severe refractory disease under specialist supervision. E. Topical antifungal: This treats conditions such as Pityrosporum (Malassezia) folliculitis, a key differential, but the eosinophilic infiltrate and clinical distribution here point away from a yeast aetiology, so antifungals are ineffective. D. Oral Dapsone: Dapsone is reserved for refractory cases unresponsive to topical steroids and antihistamines, carries risks of haemolysis and methaemoglobinaemia (requiring G6PD screening), and is not first-line therapy. Key point: In HIV-associated eosinophilic folliculitis, initial management is symptomatic (potent topical corticosteroids plus oral antihistamines) alongside optimising ART, reserving systemic agents like dapsone, isotretinoin or phototherapy for refractory disease.

Reference: DermNet NZ, Eosinophilic Pustular Folliculitis, 2025, https://dermnetnz.org/topics/eosinophilic-pustular-folliculitis