Management | HIV Management Guidelines

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