VDE229.

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Veterinary Dermatology 2001, 12, 279 283

BlackwellArtical
Original
Science, Ltd

Degenerative mucinotic mural folliculitis in cats

THELMA LEE GROSS*, THIERRY OLIVRY, CARLO B. VITALE and
HELEN T. POWER
*California Dermatopathology Service and IDEXX Veterinary Services, West Sacramento,
CA 956051600, USA
Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh,
NC 27606, USA
San Francisco Veterinary Specialists, San Francisco, CA 94117, USA
Dermatology For Animals, Campbell, CA 95008, USA
(Received 1 November 2000; accepted 21 December 2000)

Abstract A novel form of mural folliculitis is described in seven cats. Clinically, all cats exhibited generalized
alopecia with scaling or crusting that was more pronounced over the head, neck, and shoulders. The face and
muzzle of all cats was unusually thickened. Six of seven cats were progressively lethargic but did not demonstrate
any other consistent systemic abnormalities. Histologically, there was severe mixed inflammation of the wall of
the follicular isthmus in all cats, accompanied by some follicular destruction in five cats. Sebaceous glands
were not affected. All cats had variable, but often striking, follicular mucin deposition, as well as epidermal
hyperkeratosis and crusting. The cause of the severe mural folliculitis was not identified, and all cats responded
poorly to immunomodulating therapy. Follicular mucinosis may be a nonspecific finding, likely reflective of the
follicular lymphocytic milieu, and does not always herald follicular lymphoma.
Keywords: alopecia, cats, follicle, mucinosis, mural folliculitis.

INTRODUCTION
Mural folliculitis is characterized by inflammation
directed towards the follicular wall. Mural folliculitis
may affect the infundibular, isthmus, or bulbar portion
of the hair follicle.1 Multiple histopathologic subtypes,
such as those associated with interface, infiltrative,
necrotizing, and pustular patterns, have been described.1
Infiltrative mural folliculitis has been reported in
cats.13 The inflammation is typically directed to the
isthmus, or middle portion, of the follicular wall.
Pseudopelade, an immune-mediated disease of the
follicular isthmus, characterized by alopecia without
clinical evidence of inflammation, has been reported
in one cat.4 Cytotoxic T cells were identified in the
follicular isthmus. Another form of mural folliculitis
is attributed to dermatophyte infection.1 Clinically
there is mild scaling and alopecia; histologically, mild
lymphocytic isthmus mural folliculitis is observed.
Dermatophytes are identified via culture; however,
organisms frequently are not detected histologically.
Sebaceous adenitis in cats is characterized, clinically,
by heavy adherent scale and variable alopecia. Histologically, there is pyogranulomatous or lymphocytic
isthmus mural folliculitis with specific destruction of
the sebaceous glands.5,6

Correspondence: Thelma Lee Gross, 2825 KOVR Drive, West

Sacramento, California 95605-1600, USA.
Reprints will not be available.
2001 Blackwell Science Ltd

The authors have observed a new form of infiltrative

mural folliculitis in cats. In this paper, we describe the
clinical and histopathological findings in seven cats with
a degenerative and mucinotic form of mural folliculitis.

CASE SUMMARIES
Seven cats were presented to the authors; signalment
and clinical data are presented in Table 1. All cats had
several-month (cats 1, 35) to 12-year (cats 2, 6, 7)
histories of hair loss. Alopecia was generalized (Fig. 1),
but was more pronounced over the face, head, neck
and shoulders of cats 6 and 7. Alopecia typically began
on the neck or face. Pruritus was reported in cats 1, 2,
5 and 6, and was severe in cat 2. The skin of the face of all
cats had a thickened and swollen appearance, particularly
on the muzzle (Fig. 2). The eyes were often narrowed
into slits (Fig. 2). There was accompanying scaling or
crusting, and variable hyperpigmentation (Fig. 3). Skin
scrapings and dermatophyte cultures were negative.
General health screening tests (complete blood count,
serum chemistry panel, and urinalysis) were variably
performed and were not contributory to establishing a
diagnosis. Circulating antinuclear IgG autoantibodies
were assessed in the serum of cats 3, 4 and 5, and were
absent. All cats exhibited a negative FeLV serology. In
three of seven cats (cats 24), feline immunodeficiency
virus (FIV) antigens were detected in the serum.
Lethargy was present in all cats except cat 2. Cats 1
and 4 had lost weight. Cat 4 had cyclical fever, and
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T. L. Gross et al.

Table 1. Clinical data for cats with degenerative mural folliculitis

Cat no.

Signalment

Systemic signs

Outcome

1
2
3
4

4 years; FS DLH
7 years; MC DSH
7 years; MC DLH
10 years; MC DSH

5
6
7

7 years; MC DSH
3 years; MC DSH
7 years; MC DLH

Lethargy and severe weight loss; diarrhoea, PUPD

None
Lethargy, nonseptic polyarthritis
Lethargy, weight loss, nonseptic polyarthritis;
cyclical fevers
Lethargy
Lethargy
Lethargy

Euthanasia, no postmortem
Euthanasia, no postmortem
Euthanasia, no postmortem
Euthanasia; bronchopneumonia,
chronic hepatitis and pancreatitis
Euthanasia, no postmortem
Euthanasia, no postmortem
Euthanasia, no postmortem

Figure 1. Cat 5. Severe generalized alopecia. Note diffuse involvement

of the head.

Figure 3. Cat 6. Close view of scaling and crusting.

Figure 2. Cat 2. Characteristic thickened appearance of muzzle;

note narrowing of the eyes.

Figure 4. Cat 7. Severe isthmus mural folliculitis. Note mild extension

to the infundibulum. (H & E; bar = 120 m).

cats 3 and 4 had polyarthritis, which was attributed to

their FIV infection.
All cats, with the exception of cat 7, responded
poorly to variable medications that included antihistamines, medicated shampoos, and injectable and/
or oral corticosteroid therapy. Six cats were euthanized
for gradually progressive skin disease and increasing
lethargy that occurred during the 28 weeks following
evaluation by the referral dermatologist (, , ).
Cat 2 was euthanized due to severe and refractory
pruritus. Cat 7 did not improve with oral prednisone
therapy, but had partial regrowth of hair with injectable
repositol corticosteroid therapy administered at monthly
intervals. Five months after therapy was begun, this cat

developed severe oral ulceration and anorexia and was

euthanized.

2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 279 283

HISTOPATHOLOGY
Lesional skin biopsies obtained from all cats showed
similar microscopic features. Moderate acanthosis was
accompanied by compact hyperkeratosis interspersed
with neutrophilic crusts. Moderate to severe inflammation, consisting of lymphocytes, macrophages, plasma
cells, and neutrophils, spread from the surrounding
dermis to the isthmus of the hair follicle, often with
extension to the infundibulum (Figs 4 and 5). Occasional

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Feline mural folliculitis

281

Figure 5. Cat 7. Higher power magnification of Fig. 4 demonstrating

pyogranulomas effacing the isthmus of two hair follicles. Note severe
inflammation and follicular degeneration of follicle at right. Sebaceous
glands are small. (H & E; bar = 60 m).

Figure 6. Cat 6. Follicular degeneration with giant cell surrounding

hair fragment at centre. (H & E; bar = 60 m).

Figure 7. Cat 2. Mucinosis manifested as clear spaces between

follicular keratinocytes. (H & E; bar = 60 m).

eosinophils were observed in cat 6. Mild inflammation

of the epidermis frequently was present. Pustular (neutrophilic) luminal folliculitis was sporadically observed
in all cats. In five cats, severe inflammation resulted in
follicular destruction and degeneration. In degenerate
foci, pyogranulomas centred upon the isthmus or in
the adjacent dermis (Fig. 5). Multinucleated giant cells
were seen in conjunction with these degenerative foci in
cats 5 and 7 (Fig. 6).

Figure 8. Cat 6. Demonstration of pale turquoise follicular mucin.

(Alcian blue at ph 2.5; bar = 30 m).

There was moderate (cats 1, 3, 6, 7) to severe (cat 2)

mucin accumulation in the superficial outer root sheath
in five of seven cats (Fig. 7), which was characterized
by pale blue material that widened spaces between
follicular keratinocytes. Cats 4 and 5 had mild follicular
mucin deposition. Alcian blue-PAS staining at 2.5 pH
was required to reveal mucinosis of mildly affected
follicles (Fig. 8). Follicular atrophy was observed in all
but cat 1, and tended to be multifocal, ranging from mild
to occasionally severe (Fig. 9). In all cats, sebaceous
glands generally were conserved, although small in most
areas (Figs 5 and 9). There was complete absence of these
glands in some of the skin sections from cats 1 and 5.
Post-mortem examination was allowed only for cat 4,
who had tested positive for FIV antigens. Suppurative bronchopneumonia, chronic lymphoplasmacytic
portal hepatitis and interstitial pancreatitis, and
lymphocyte depletion of lymph nodes were identified.
The bronchopneumonia, suspected to be bacterial,
and the lymph node lesions were attributed to immunological impairment from FIV infection.

DISCUSSION
The cause of this severe form of mural folliculitis in cats
is unknown. The combination of lesions exhibited by
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T. L. Gross et al.

Figure 9. Cat 2. Follicular atrophy. Sebaceous glands are small.

Note giant cell at centre of inflammation. (H & E; bar = 60 m).

these cats is unique, and cannot be ascribed to any

previously described feline dermatoses. As such, these
unique findings justify the individualization of this
disease as a novel and separate dermatological entity.
Three of seven cats were FIV positive. The cutaneous
signs were associated with lethargy in most cases (six
of seven cats), severe refractory pruritus in one cat, and
weight loss in two cats (one of which was FIV positive).
Other systemic abnormalities, as detected by physical
examination and routine blood testing, other than those
attributed to FIV infection (cyclical fever and polyarthritis), were not identified. The presence of lethargy may
imply a systemic disorder in these cats. As post-mortem
examination was not allowed for six of seven cats, the
possibility of a common underlying internal disease as
the cause for mural folliculitis cannot be excluded. In
cat 4, postmortem findings of bronchopneumonia and
lymphocytic depletion of the lymph nodes were considered to be associated with FIV infection. Chronic
portal hepatitis and interstitial pancreatitis, also identified in cat 4, are not uncommon post-mortem findings
in older cats. Their association with degenerative mural
folliculitis is unlikely.
Mural follicular mucinosis was observed in all cats
of this report. Alopecia mucinosa (follicular mucinosis),
progressing over several months to cutaneous epitheliotropic malignant lymphoma, has been reported in two
2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 279 283

cats.7 The clinical appearance of the only illustrated cat

in that report, specifically the unusual, swollen appearance
of the facial skin, seems similar to the cases we report
here (Fig. 2). Severe mucin accumulation of the outer
follicular root sheath was described.7 Although the
clinical correlate of follicular mucinosis in cats might
be facial thickening, this seems unlikely since such
thickening would most likely be correlated with dermal
rather than follicular involvement. Also, mucin accumulation was mild in some of our cats, but facial thickening
was found in all. The cause of the distinctive facial
thickening in cats with this form of mural folliculitis
awaits further study.
The previously reported cats with follicular mucinosis
and subsequent malignant lymhoma were otherwise
healthy at the time of initial examination.7 This is in
contrast to the profound lethargy of the cats of this
report. Malignant transformation of skin lesions was
not observed in any of the cats of our study, despite the
prolonged (months to years) duration of the clinical
signs prior to biopsy. Thus, follicular mucinosis likely
does not always herald epitheliotropic malignant
lymphoma in cats. Follicular mucinosis in humans is
considered to be a nonspecific reaction pattern.8 Hempstead and Ackerman describe follicular mucinosis in
association with many skin diseases including allergic
contact dermatitis, arthropod bites, and epitheliotropic
malignant lymphoma.8 Similarly, our report and the
previous report7 indicate that follicular mucinosis in
cats also may be a nonspecific feature of mural follicular
inflammatory and neoplastic diseases alike.
Idiopathic follicular mucinosis (alopecia mucinosa)
in humans is characterized by high numbers of Langerhans cells and T lymphocytes in areas of follicular
degeneration.9 Follicular mucinosis recently was described
in association with an atypically high CD4+ T helper
cell population in alopecia areata.10 Mucin production
by follicular keratinocytes may be stimulated by T
lymphocyte infiltration of the hair follicle, perhaps
in specific helper/suppressor ratios, in the context of
diverse inflammatory as well as neoplastic diseases.
The cats in this report share some features with three
cats previously reported with lymphocytic mural
folliculitis.2,3 Previously reported hair loss with scaling,
and inflammation targeting the mid-portion of the
follicle, resembled that seen in our cats.2,3 Pruritus or
lethargy were not previously described, in contrast to
the cats described herein.2,3 The clinical description
and photograph of one of these three cats documented
thickened skin and a swollen facial appearance resembling the cats we report.2 Follicular mucinosis was not
described, however.2 Although that cat (as well as the
other two previously reported cats) reportedly exhibited
mural inflammation that was exclusively lymphocytic,2,3
we cannot exclude that this previously reported cat was
affected with a mural folliculitis of the type we document
in this paper.
In conclusion, we have described a distinctive clinical
and histopathologic form of mural folliculitis in cats
which is associated with mural mucinosis. To the best of

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Feline mural folliculitis

our knowledge, it is not associated with epitheliotropic
malignant lymphoma. The outcome was uniformly
poor due to debilitating lethargy or severe pruritus that
was refractory to immunomodulating or other supportive therapy. Further studies are needed to elucidate
the origin and pathogenesis of this unique dermatosis.

5.
6.

7.

REFERENCES
8.
1. Gross, T.L., Stannard, A.A., Yager, J.A. An anatomical
classification of folliculitis. Veterinary Dermatology 1997;
8: 147 56.
2. Declerq, J. Lymphocytic mural folliculitis in two cats.
Vlaams Diergeneeskundig Tijdschrift 1995; 64: 17780.
3. Declercq, J. A case of diet-related lymphocytic mural
folliculitis in a cat. Veterinary Dermatology 2000; 11: 7580.
4. Olivry, T., Power, H.T., Woo, J.C., Moore, P.F., Tobin, D.J.
Anti-isthmus autoimmunity in a novel feline acquired

9.

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alopecia resembling pseudopelade of humans. Veterinary

Dermatology 2000; 11: 26170.
Scott, D.W. Adnite sebace pyogranulomateuse strile
chez un chat. Le Point Veterinaire 1989; 21: 10711.
Baer, K., Shoulberg, N., Helton, K. Sebaceous adenitislike disease in two cats (Abstract). Veterinary Pathology
1993; 30: 437.
Scott, D.W. Feline dermatology 19831985: The secret
sits. Journal of the American Animal Hospital Association
1987; 23: 25574.
Hempstead, R.W., Ackerman, A.B. Follicular mucinosis:
a reaction pattern in epithelium. American Journal of
Dermatopathology 1985; 7: 24557.
Lancer, H.A., Bronstein, B.R., Nakagawa, H., Bhan, A.K.,
Mihm, M.C. Follicular mucinosis: a detailed morphologic
and immunopathologic study. Journal of the American
Academy of Dermatology 1984; 10: 7608.
Fanti, P.A., Tosti, R.M., Cameli, N., Sabattini, E., Pileri, S.
Follicular mucinosis in alopecia areata. American Journal
of Dermatopathology 1992; 14: 11.

Rsum Une nouvelle forme de folliculite murale est rapporte chez sept chats. Cliniquement, tous les chats
prsentaient une alopcie gnralise avec des squames ou des crotes, plus prononce sur la face, le cou et les
paules. La face et le museau de tous les chats taient inhabituellement paissis. Six chats taient lthargiques, sans
autre atteinte systmique. Sur le plan histologique, une inflammation marque de la paroi de listhme folliculaire
a t observe dans tous les cas, avec une destruction folliculaire chez cinq chats. Les glandes sbaces ntaient
pas atteintes. Tous les chats prsentaient des degrs variables, mais souvent graves, de dposition de mucine dans
le follicule, ainsi quune hyperkratose pidermique et des crotes. Aucune cause na pu tre dtermine pour ces
folliculites murales, tous les chats ont mal rpondu une thrapeutique immunomodulatrice. La mucinose
folliculaire pourrait tre une observation non spcifique, lie lenvironnement lymphocytaire folliculaire, et ne
pas tre toujours rvlatrice dun lymphome folliculaire. [Gross, T. L., Olivry, T., Vitale, C. B., Power, H. T.
Degenerative mucinotic mural folliculitis in cats. (Folliculite murale mucineuse dgnrative chez le chat.) Veterinary
Dermatology 12: 279 283.]
Resumen Se describe una nueva forma de foliculitis mural en siete gatos. Clinicamente, todos los gatos mostraban
alopecia generalizada con descamacin o costras de mayor intensidad en el rea dorsal de la cabeza, cuello y espaldas. El rea facial y el hocico de todos los gatos se encontraban anormalmente engrosados. Seis de siete gatos
mostraron una letargia progresiva pero no presentaron otras anormalidades sistmicas. Histologicamente, haba
una inflamacin mixta intensa de la pared del istmo folicular en todos los gatos, acompaada por cierta destruccin
folicular en cinco gatos. Las glndulas sebceas no se encontraban afectadas. Todos los gatos tenan deposicin
de mucina variable, aunque a menudo muy intensa, as como hiperqueratosis epidrmica y costras. La causa de la
intensa foliculitis mural no se identific, y todos los gatos respondieron mal a la terapia con inmunomoduladores.
La mucinosis folicular puede ser un hallazgo inespecfico, probablemente reflejo del medio linfoctico, y no siempre
anuncia un linfoma folicular. [Gross, T. L., Olivry, T., Vitale, C. B., Power, H. T. Degenerative mucinotic mural
folliculitis in cats. (Foliculitis mural mucintica degenerativa en gatos.) Veterinary Dermatology 12: 279283.]
Zusammenfassung Bei sieben Katzen wird eine neuartige Form einer muralen Follikulitis beschrieben. Klinisch
zeigten alle Katzen eine generalisierte Alopezie mit Schuppen und Krusten, die am Kopf, Nacken und ber den
Schultern am ausgeprgtesten war. Das Gesicht und die Schnauze aller Katzen war ungewhnlich verdickt. Sechs
der sieben Katzen waren ungewhnlich lethargisch, zeigten aber regelmssig keine anderen systemischen
Vernderungen. Histologisch war eine schwere und gemischte Entzndung des follikulren Isthmus-Epithels zu
sehen, die bei fnf Katzen mit Zerstrung der Follikel einherging. Talgdrsen waren nicht betroffen. Alle Katzen
hatten eine variable, aber klar erkennbare follikulre Ablagerung von Muzin und epidermale Hyperkeratose und
Krustenbildung. Die Ursache der schweren muralen Follikulitis wurde nicht herausgefunden und keine der
Katzen sprach auf eine immunmodulierende Therapie an. Follikulre Muzinose ist ein unspezifischer Befund,
wahrscheinlich eine Reflektion des follikulren lymphozytischen Milieus, und kndigt nicht immer follikulres
Lymphom an. [Gross, T. L., Olivry, T., Vitale, C. B., Power, H. T. Degenerative mucinotic mural folliculitis in cats.
( Degenerative muzinse murale Follikulitis bei der Katze.) Veterinary Dermatology 12: 279283.]

2001 Blackwell Science Ltd, Veterinary Dermatology, 12, 279283