key: cord-0782450-7sc53bzy authors: Chuh, Antonio title: Eosinophilic folliculitis due to wearing protective gear in citizens volunteering for sanitation services during the COVID‐19 pandemic – an original epidemiological, clinical, dermoscopic, and laboratory‐based study date: 2020-10-11 journal: Int J Dermatol DOI: 10.1111/ijd.15227 sha: 5f536820b7076cc98a153b1a83512ccf7a7ecc5b doc_id: 782450 cord_uid: 7sc53bzy BACKGROUND: An association between wearing protective gear and eosinophilic folliculitis has not been reported. We aimed to investigate such during the COVID‐19 pandemic. METHODS: In three outpatient clinics, we hand‐reviewed records of all patients having consulted us during a Study Period (90 days) in the early phase of the pandemic. Our inclusion criteria for Study Subjects were: (i) clear clinical diagnosis, (ii) dermoscopic confirmation, (iii) differential diagnoses excluded, (iv) eosinophilia, (v) protective gear worn during sanitation services, (vi) temporal correlation, (vii) distributional correlation, (viii) physician‐assessed association, and (ix) patient‐assessed association. Control Periods in the same season were elected. RESULTS: Twenty‐five study subjects fulfilled all inclusion criteria. The incidence was significantly higher than in the control periods (IR: 3.57, 95% CI: 1.79–7.43). Male predominance was significant (P < 0.001). Such for patients in the control periods were insignificant. Study subjects were 21.2 (95% CI: 11.0–31.4) years younger than patients in the control periods. For the study subjects, the distribution of erythematous or skin‐colored folliculocentric dome‐shaped papules and pustules were all compatible with body parts covered by the gear. Lesional biopsy performed on two patients revealed eosinophilic dermal infiltrates within and around the pilosebaceous units. Polarized dermoscopy revealed folliculitis with peri‐/interfollicular vascular proliferation. Lesion onsets were 6.4 (SD: 2.1) days after wearing gear. Remissions were 16.7 (SD: 7.5) days after ceasing to wear gear and treatments. CONCLUSIONS: Wearing protective gear in volunteered sanitizing works could be associated with eosinophilic folliculitis. Owing to the significant temporal and distributional correlations, the association might be causal. An association between wearing protective gear in sanitation works and the development of eosinophilic folliculitis (EF) has not been reported. In this study, we aim to investigate this association in civilians wearing gear during volunteered sanitation works during the early phase of the COVID-19 pandemic in Hong Kong. Our settings were three primary care clinics operating in two geographically different practices attached to a university teaching hospital. All patients were managed by a physician with training and qualifications in dermatology. He has published regarding clinical and dermoscopic diagnoses of different types of folliculitis previously [1] [2] [3] and should be able to make valid and reliable clinical diagnoses of EF. Hong Kong saw its first confirmed patient with COVID-19, then known as Wuhan pneumonia, on January 23, 2020. We searched our computerized registers and hand-reviewed the medical records of all patients who have consulted us during a study period from February 1 to April 30, 2020 (90 days), and diagnosed as having EF. Our criteria for inclusion as study subjects were (i) clear clinical diagnosis of EF (erythematous or skin-colored hemispherical or urticarial papules and pustules, sometimes edematous, and usually pruritic), (ii) dermoscopic confirmation (folliculocentric lesions usually with perifollicular and/or interfollicular vascular proliferation), (iii) differential diagnoses Twenty-one (84%) study subjects were males, and four (16%) were females. Male predominance was significant (z = 3.4, P < 0.001). In contrast, one male and three female patients with EF diagnosed in the study period but not related to wearing protective gear, and the patients in both control periods demonstrated insignificant sex predilection. The 25 study subjects ranged in age from 15 to 81 years (mean: 33.5 years, SD: 13.6 years). Although the range was Table 1 Incidence ratios, sex, and age differences of patients with eosinophilic folliculitis during the COVID-19 pandemic as compared to two control periods in the same season Figure 2b . For the patient in Figure 2a , the lesions were sparsely spaced on the upper back. All are typical dermoscopic appearances of EF. Temporal and distributional correlations All 25 study subjects did not have a previous history of EF or skin rashes akin to EF. All developed EF after wearing protective gear for three to 12 (mean: 6.4, SD: 2.1) days. The time from ceasing to wear gear and treatments to complete remission was seven to 32 (mean: 16.7, SD: 7.5) days. There exists an insignificant difference for male, female, and all study subjects ( Table 2 ). The time from onset of rash to complete remission was also insignificantly different for study subjects and patients in the control periods. The most commonly involved areas were the upper or lower back (84%), anterior trunk (48%), and lateral aspects of trunk (28%) ( Table 3 Other fit family members would take up their responsibility alternatively so that consecutive wearing of gear for each person was kept to a minimum. Responses to treatments were similar for patients in the study and control periods. EF is usually a very pruritic rash. In some countries and regions, the commonest associated factor is HIV infection. 4 For these patients, the trunk of males and the face and trunk of females are principally affected. 4 It has been controversial whether EF and eosinophilic pustular folliculitis (EPF) are the same or different disease entities. Patients with EPF were mainly reported in Japan. Some investigators consider EF and EPF as belonging to the same spectrum of diseases. [4] [5] [6] The four subtypes would be (i) EF/ERP described in this article (principally affecting the trunk, associated with HIV or not), 7, 8 (ii) EPF principally affecting the face of adults not associated with HIV infection (also known as Ofuji disease), 4-6,9 (iii) infantile EPF principally affecting the scalp and face, 10, 11 and (iv) EPF associated with hematological malignancies and transplantations. 12, 13 Many study subjects wore different combinations of protective gear on multiple occasions. It has been postulated that the immunopathogenesis of EF involves eosinophils flaring an intense, probably autoinflammatory, 15 response to the Demodex folliculorum and Demodex brevis mites in the pilosebaceous units. 16, 17 Some reports did demonstrate the effectiveness of topical permethrin in EF. 18, 19 This was why we treated some patients with topical permethrin. The autoinflammatory response also targets Pityrosporum spp yeasts 16, 20 and bacteria 16, 21 in the perifollicular regions. However, it was beyond our financial resources to investigate the immunopathogeneses for our patients. Dermoscopy has been reported to endorse high accuracy in differentiating the various types of folliculitis. 3, [22] [23] [24] We docu- The study subjects were male-predominant and around 20-22 years younger than other patients with EF. This was because young and fit males were more willing to perform sanitation services. An 81-year-old male patient was an exception. His body was good and strong until EF developed on his trunk. Other family members promptly took up his services. We postulate that the occlusion of protective gear could have compromised physiological skin ventilation, leading to the accumulation of sweat, dirt particles, or bacteria. Such could activate inflammatory responses attacking the mites, yeasts, or bacteria in the hair follicles and the pilosebaceous units as a whole. Moreover, the increased humidity of the skin by wearing protective gear could have caused an imbalance between the Demodex mites and the immunological skin condition of EF. We were uncertain as to why professionals such as firemen wearing protective gear have not been reported to develop EF. One reason could be that their gear is specifically designed and manufactured with materials of higher quality. Some of the materials might be hypoallergenic and more permeable. Their gear is mostly designed to be worn repeatedly, with proper maintenance of their conditions. However, our study subjects were wearing gear not specifically designed for cleaning and sanitary purposes, and the gear was made of materials of lesser quality. Moreover, some of the protective gear were meant to be disposed after a singleuse. These items were of inadequate supply in the earlier phase of the pandemic and were worn repeatedly with inadequate cleaning and drying by the study subjects. Another factor could be that citizens in Hong Kong have been in political unrest since June 2019 up to the present moment. It was reported that psychological stress could predispose individuals to higher risks of cutaneous diseases. 26 The major limitation of this study is that we have performed a lesional biopsy for histopathological investigations for only two study subjects. However, many study subjects and patients in the control periods promptly responded to oral indomethacin treatment. In a proposed diagnostic and therapeutic algorithm, it was stated that if biopsy was not feasible, topical or systemic indomethacin can be used as a diagnostic therapy. 27 Moreover, we have performed dermoscopy for all patients, as dermoscopy has been reported to be highly accurate in diagnosing various types of folliculitis. 2, [20] [21] [22] We have also demonstrated eosinophilia for all patients. The involvement of only three clinics by one physician is also an important limitation. Other studies in multiple centers are necessary to confirm the association. Our study being retrospective in nature could be a limitation. However, retrospective assessments might minimize observer bias, which could be a strength in our study. Although the pandemic is waning in many parts of the world, our findings are important as the association of wearing protective gear and the development of EF has not been reported previously. We now possess the knowledge that EF is sometimes a preventable disease and is nearly always treatable in such a scenario. We should, therefore, be more prepared to prevent and treat EF in epidemics and pandemics in the future. During 90 days in the early phase of the COVID-19 pandemic, we thus identified 25 patients, predominately being males (21, 84%) with a history of wearing protective gear volunteering to do sanitation services for their homes, working places, and neighborhoods, having developed EF. They were significantly younger by around 20-22 years than other patients with EF. Wearing protective gear in voluntary sanitizing works could, therefore, be associated with EF. As the temporal and distributional correlations were significant, we believe that the association might be causal. 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