Disseminate and recurrent infundibular folliculitis (DRIF) was first described in 1968 by Hitch and Lund.[1] The clinical presentation is much like miliaria or keratosis pilaris. It is mostly seen in young healthy people, and most patients have a dark skin color. It consists of generalized flesh-colored papules. Therapy has generally been unsuccessful.
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Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.
The validity of disseminate and recurrent infundibular folliculitis as a separate entity has been questioned. However, it does have such a characteristic clinical picture that for the present it is accepted as an entity.
Although the first case of disseminate and recurrent infundibular folliculitis was not reported until 1968, other more recent reports indicate that it is a fairly common occurrence. Clinics that see a large number of young dark-skinned patients report that disseminate and recurrent infundibular folliculitis is a common condition. Indeed, it may occur in large numbers in hot, humid weather.
International
Cases of disseminate and recurrent infundibular folliculitis have been reported from Europe and India.
Race
Disseminate and recurrent infundibular folliculitis has been reported primarily in people of African American origin in the United States.[2] Why a number of dermatoses tend to be papular and follicular in dark-skinned people is not known. This phenomenon is well documented in atopic dermatitis.
Sex
Although most of the patients are men, disseminate and recurrent infundibular folliculitis has been reported in women.
Age
Most of the reported disseminate and recurrent infundibular folliculitis patients have been healthy young adults.
Disseminate and recurrent infundibular folliculitis may last for years. Pruritus is the troublesome symptom of disseminate and recurrent infundibular folliculitis. In the past, this was difficult to relieve. Disseminate and recurrent infundibular folliculitis may make it uncomfortable for the patient to work in a hot, humid environment.
Most patients report a sudden onset of a widespread pruritic papular eruption. Disseminate and recurrent infundibular folliculitis has been reported to be exacerbated by hot showers and relieved by anything that cools (eg, cool showers, lotions, swimming). Occasionally, a patient may report that a number of peers have been affected at the same time. Often, disseminate and recurrent infundibular folliculitis patients have a personal or family history of atopy.
Physical examination in disseminate and recurrent infundibular folliculitis reveals a papular eruption that has a follicular location. In a given area, all the follicles are involved, with no skipping of any follicles in the area involved. The usual sites are the chest and mantle and the upper arms. Infundibular folliculitis is rather monomorphic without noted rubor, calor, and dolor.
See the images below.
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Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.
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Courtesy of San Antonio Uniformed Services Health Education Consortium slide files.
The exact cause of disseminate and recurrent infundibular folliculitis is unknown. The history often suggests a hot, humid environment as a precipitating cause. Once established, disseminate and recurrent infundibular folliculitis tends to persist or recur over a prolonged period.
In the workup of suspected disseminate and recurrent infundibular folliculitis (DRIF), patch testing or a potassium hydroxide wet mount may be performed to investigate possible allergic contact dermatitis or Pityrosporum folliculitis.
Histologic examination reveals superficial spongiotic dermatitis associated with a hair follicle and the adjacent epidermis superficially; this finding is not specific. Exocytosis is noted into the spongiotic area. The subadjacent dermis has inflammatory cells, and the deeper dermis is uninvolved.
Cooling, soothing emollients have been used for 30 years, with variable success, in disseminate and recurrent infundibular folliculitis (DRIF).
Corticosteroids have not been demonstrated effective, with the exception of a single case report by Hinds and Heald using potent topical corticosteroids.[3]
In 1999, Ruvikumar et al reported that psoralen plus ultraviolet light A (PUVA) therapy was successful in disseminate and recurrent infundibular folliculitis.[4]
In 1998 and again in 2004, Aroni et al reported successful treatment of disseminate and recurrent infundibular folliculitis with isotretinoin.[5]
Keeping a patient in a cool, dry environment has been successful in relieving symptoms of disseminate and recurrent infundibular folliculitis.
Emollients have been used for decades in disseminate and recurrent infundibular folliculitis, with variable success. Early reports indicated treatment with vitamin A.[6] Later, vitamin A therapy was reported to be ineffective. Several authors have reported success with isotretinoin systemic therapy. However, the standard dosing protocol has not been established.
Clinical Context:
Clobetasol propionate is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Clobetasol propionate decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.
Christopher R Gorman, MD, Dermatologist, McGuire VA Medical Center
Disclosure: Nothing to disclose.
Specialty Editors
Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Disclosure: Nothing to disclose.
Chief Editor
William D James, MD, Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine
Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.
Acknowledgements
Acknowledgments
Medscape Drugs & Diseases wishes to recognize Stephen W White, MD† for his original contributions to this article.
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