Localized toxic follicular pustuloderma

A 40-year-old woman with a history of duodenal ulcers consulted for an acut e outbreak of multiple pustular lesions without an underlying erythematous base affecting the face, neck, an, to a lesser extent, the upper third of t he trunk (Fig. 1). She had been taking amoxicillin-clavulanic acid over the past 6 days for pharyngitis and fever. Given the persistence of fever and the possible allergic reaction to the dr ugs administered, even though we could have been dealing with a viral phary nx infection, we replaced the amoxicillin-clavulanic acid with another anti biotic with wide range (clarithromycin) empirically, and symptomatic treatm ent was started with antihistamines (loratadine). At the following visit, 1 week later, the patient had no fever, and the les ions were in the desquamative phase, thus indicating resolution of the cond ition. The histologic findings were compatible with toxic pustuloderma (subcorneal pustules, perivascular lymphohistiocytic infiltrate, etc.) (Fig. 2), altho ugh a perifollicular inflammatory infiltrate was also observed, composed ma inly of neutrophils and eosinophils that penetrated and partially destroyed the external radicular sheath of the follicle (Fig. 3). Other histologic s ections showed an intense neutrophilic infiltrate constituting a subepiderm al pustule. Bacterial and fungal cultures of the lesions and pharyngeal smear proved ne gative. Laboratory tests revealed a globular sedimentation rate of 30 mm in the first hour, slight eosinophilia (5500 leukocytes, with 5.40% eosinophi ls), a discretely elevated ASLO titer (235 IU/mL), and slight thrombopenia (123,000 platelets). The remaining parameters were within the normal range.