What is the role of infection in the etiology of acneiform eruptions?

Updated: Jul 29, 2019
  • Author: Julianne H Kuflik, MD; Chief Editor: Dirk M Elston, MD  more...
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Various infections may also display an acneiform pattern. Gram-negative folliculitis, a persistent papulopustular eruption, may be a complication in patients on prolonged treatment with oral antibiotics for acne vulgaris or rosacea. Antibiotic use, such as those of the tetracycline class, can alter the normal skin flora of the skin allowing for growth of gram-negative organisms in the nares of the nose. These gram-negative organisms are typically spread to the skin of the upper lip, chin, and jawline whether they cause a folliculitis. Culture of the papulopustules grows gram-negative bacilli and gram-negative rods, including Escherichia coli and Klebsiella, Enterobacter, and Proteus species. Typical history is a patient with a sudden acne flare despite no change in treatment or a patient unresponsive to traditional therapies. Oral isotretinoin is considered standard of care. For more information, see Gram-Negative Folliculitis, Acne Vulgaris, and/or Rosacea.

Pityrosporum folliculitis is another infectious folliculitis that is presumably caused by a host reaction to the yeast Malassezia furfur, previously named Pityrosporum ovale, a normal human skin commensal organism. It appears primarily on the trunk and upper extremities of late adolescents and young adults. Unlike acne vulgaris, it is pruritic, does not contain comedones, and responds to empiric antifungal therapy rather than antibiotics. Diagnosis is typically made clinically, although the yeast and hyphae can be observed in biopsy specimens in the widened follicular ostia along with keratinous material, and occasionally, rupture of the follicular wall may occur. Patients may be treated with topical leave-on, wash-off, or systemic antifungal therapy. For more information, see Pityrosporum Folliculitis.

Eosinophilic pustular folliculitis (EPF) is a disease of unclear etiology, thought to be an allergic hypersensitivity. It appears as a recurrent pruritic papulopustular eruption on the face, trunk, and extremities. Histopathology reveals a predominantly perifollicular infiltration of eosinophils with some mononuclear cells and subcorneal pustules composed of eosinophils. Three main types exist, (1) infantile form, (2) HIV associated, and (3) classic Ofuji disease in immunocompetent patients, typically Japanese patients. Patients may also demonstrate blood eosinophilia and leukocytosis. Treatment modalities and results vary greatly. Options include topical and systemic corticosteroids, oral antibiotics, dapsone, isotretinoin, and pulsed ultraviolet phototherapy (PUVA). Indomethacin is the treatment of choice for classic Ofuji disease. For more information, see Eosinophilic Pustular Folliculitis.

Several infectious diseases may result in acneiform eruptions, as follows:

  • In secondary syphilis, papulopustules and nodules, some crusted, may occur on the face, trunk, and extremities. The causative agent, the spirochete Treponema pallidum, may be easily observed in biopsy specimens with the Warthin-Starry stain. In addition, serologic tests and the presence of spirochetes on darkfield microscopy may reveal the diagnosis. For more information, see Syphilis.

  • Mycotic infections may also manifest cutaneously with papules and nodules that may ulcerate and crust.

  • Sporothrix schenckii, the responsible agent of sporotrichosis, commonly induces a lymphocutaneous reaction, but it can also produce a persistent fixed localized cutaneous papulonodular eruption that may involve the face. The organism can be demonstrated histologically, by peripheral blood smear, and by fungal culture. For more information, see Sporotrichosis.

  • Cutaneous coccidioidomycosis usually caused by inhalation and dissemination of Coccidioides immitis, may rarely occur by primary inoculation and appear as papulopustules, nodules, or plaques that can eventually ulcerate and crust. For more information, see Coccidioidomycosis.


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