Eosinophilic Pustular Folliculitis of Infancy

Eosinophilic pustular folliculitis (EPF) of infancy presents as recurrent, grouped itchy papulopustules most often on the scalp.
EPF of infancy has unique characteristics that distinguish it from the adult and HIV related forms.

Lesions appear as recurrent crops of papules and papulopustules on an erythematous base located primarily on the scalp but the hands, feet, and trunk can also be affected (Fig. 2.26).
EPF can be intensely itchy.
Lesions evolve into yellow, crusted papules over 7 to 10 days and then heal without scarring but may leave residual hyperpigmentation.
New crops will appear every 2 to 8 weeks.
EPF typically presents in early infancy and eventually “burns out” between 6 to 36 months of age.

Diagnosis is based on recognition of the characteristic location, clinical course, and appearance of lesions.
Pustules in EPF are sterile; a Gram stain, KOH, and Tzanck smear will be negative for organisms.
A Wright stain of pustule contents will show abundant eosinophils.

Differential Diagnosis

Infantile Acropustulosis

Scabies Infestation or Insect Bites

Bacterial Folliculitis

Follicular pustules on an erythematous base may be scattered on scalp and elsewhere on body.
Gram stain and culture will reveal bacteria.
Does not recur in crops.

Management

EPF of infancy will self-resolve by 3 years of age in most patients.
Treatment is symptomatic.
Itch during flares can be severe and usually requires mid- to high-potency topical corticosteroids (mometasone 0.1% ointment or clobetasol 0.05% ointment).
The antihistamine cetirizine can also be helpful for its eosinophil antimigration effect. Sedating antihistamines can help induce sleep in patients unable to sleep because of the itch.
Dapsone and oral antibiotics (erythromycin and cephalexin) have been used with variable success in recalcitrant and highly symptomatic cases.

Points to Remember

EPF of infancy is a benign self-limited eruption that usually resolves by 3 years of age.
It is important to clearly distinguish EPF of infancy as a distinct entity from the adult-onset and the HIV-associated types to prevent unnecessary parental anxiety from internet searches.