Methods: Extensive laboratory and radiographic evaluation for underlying etiology of rash and dyesthesia. Skin biopsy demonstrated mild lymphocytic spongiosis of infundibular region of hair follicle with parakeratosis at orifice of follicle opening consistent with DRIF.
Results: A 45 year-old African American male presented to our Allergy clinic with complaints of intense persistent upper and lower extremity burning and pruritis, chronic allergic rhinitis (mountain cedar and molds), and atopic dermatitis. Physical exam demonstrated intermittent wide spread flesh-colored 1-2 mm papules with superficial flaking. Over a two year period, the patient underwent an extensive work up in consultation with Allergy/Immunology, Dermatology, Rheumatology, Infectious Disease and Neurology services without elucidation of diagnosis. Management involved high dose anti-histamines, topical steroids, leukotriene modifier, nortriptyline, gabapentin, phototherapy and allergy immunotherapy without significant benefit. Following initiation of a prolonged doxycycline trial, the patient finally consented to skin biopsy after previously declining. Biopsy results were consistent with DRIF, and based on successful case reports, the patient was recently transitioned to isotretinoin.
Conclusions: Disseminated and recurrent infundibulofolliculitis is an uncommon entity of unknown etiology most frequently occurring in young African American males, although it has been reported in females and other races spanning all age groups. Unlike classic atopic dermatologic disease, antihistamines and topical steroids are of minimal benefit in this disease process. We encourage Allergists to consider DRIF and emphasize the benefit of obtaining a skin biopsy in patients who present with refractory papular rashes.