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DIFFERENTIAL DIAGNOSIS OF

PAPULAR LESIONS ON FACE


DR.MIKHIN GEORGE THOMAS
CLASSIFICATION

INFECTIONS

INFLAMMATORY DISORDERS

TUMOURS

OTHERS
INFECTIONS

• Molluscum contagiosum
• Tinea faciei
• Lupus vulgaris
• Demodicidosis
INFLAMMATORY DISORDERS
• Acne
• Rosacea
• Perioral dermatitis
• Lupus miliaris disseminatus faciei
• FACE
• Sarcoidosis
• Follicular mucinosis
• Pseudofolliculitis barbae
TUMOURS
BENIGN EPIDERMAL TUMORS
AND CYSTS:

DPN
Seborrhoeic keratosis
Keratoacanthoma
Milia
Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS

 Actinic keratosis
 Cutaneous horn

MALIGNANT

 Basal cell carcinoma


Tumors of skin appendages
• Eccrine gland tumors : syringoma, eccrine hidrocystoma

• Apocrine gland tumors : syringocystadenoma papilliferum

• Sebaceous gland tumors : sebaceoma, sebaceous adenoma,


sebaceous hyperplasia

• Tumor of hair follicle mesenchyme : trichodiscoma

• Hair follicle tumors : dilated pore, trichoadenoma

• External root sheath tumors : trichilemmoma

• Hamartomas : trichoepithelioma, trichofolliculoma


Soft tissue tumors

• Fibrous tumor : fibrous papule of face

• Fibrohistiocytic tumors : atypical fibroxanthoma


OTHERS

• Colloid milia

• Angiofibroma
INFECTIONS
MOLLUSCUM
CONTAGIOSUM
• Pox virus family

• MCV 1-4; majority : type 1

• Contact with infected persons or contaminated


objects, sexual abuse

• Peak incidence : 2-5 yrs


• IP: 14 days to 6 mths
• C/F : shiny, pearly white, hemispherical, umbilicated
papule, 5-10 mm
• Agminate form or giant molluscum
• Distribution depends on the mode of infection
• Widespread and refractory
mollusca on the face- HIV
infection and iatrogenic
immunosuppression.

• Viral entry into the basal layer


where an early increase in cell
division extends into the
supra basal layer.

• Molluscum bodies
Course & treatment :
Spontaneous clearance
• Curettage
• Cryotherapy
• Electrosurgery
• Phenol
• cantharidin
• tricholoroacetic acid
• pot.hydroxide solution
• topical salicylic acid preparations
tretinoin
• imiquimod cream
• cidofovir
LUPUS VULGARIS
• Chronic progressive post primary,
paucibacillary form of cutaneous tuberculosis
• Moderate or high degree of immunity
• Underlying focus- bone, joint or lymph node
• Haematogenous or lymphatic spread

• C/F: 80%- head and neck


India- buttocks and trunk
Initial lesion : small reddish brown plaque,
soft, with peripheral extension.
5 types: plaque, ulcerative, vegetating,
tumour like, papular and nodular forms.
• Diascopy : apple jelly nodules
• Diagnosis

• Treatment : standard ATT

• Differential diagnosis :

 Rosacea
 leprosy nodules: firmer
 Nodules of sarcoidosis :
resemble grains of sand
DEMODICIDOSIS
• Demodex folliculorum - follicle mite
• Areas of high sebum production
• Head down position in the follicle, 2-6 mites, motile
• Can produce papular and papulopustular lesions in
immunosuppressed individuals
• Pathogenic role: pityriasis folliculorum, rosacea, perioral
dermatitis, blepharitis
• Treatment : topical acaricides
TINEA FACIEI
• Ringworm of glabrous skin of face
• Trichophyton mentagrophytes, T.rubrum
• Direct inoculation or secondary spread from
other sites
• Itching, burning & exacerbation with sun
exposure
• Erythema +, Scaling less prominent
• Simple papular lesions or flat patches of
erythema
• D/D : PMLE and DLE
• Treatment : antifungals
TINEA BARBAE
• A disease of adult male
• Ringworm of beard and moustache areas of
face
• Invasion of coarse hairs
• Commonly farm workers
• Trichophyton verrucosum,
T.mentagrophytes
• C/F: highly inflammatory pustular
folliculitis
Hairs surrounded by red inflammatory
papules or pustules
Loose hairs in affected areas
• Treatment : antifungals
ACNE
• A chronic inflammatory disease of pilosebaceous units
• Usually starts in adolescence
• Seborrhoea , open & closed comedones, erythematous
papules & pustules, nodules, pseudocysts, scarring

• Pathogenesis : 4 factors
• 99% - lesions on face
• Early lesions – comedones

• Grading of acne
• Acne variants – infantile, occupational, mechanical,
tropical, acne excoriee, acne conglobata, acne fulminans
fulminans.
Treatment :

 Topicals – retinoids, benzoyl


peroxide, topical antibiotics,
nicotinamide, azelaic acid
 Physical modalities
 Systemic therapy : antibiotics,
oral retinoids, hormonal
therapy, zinc
 Acne surgery

Differential diagnosis :
rosacea, perioral dermatitis,
gram negative folliculitis
ROSACEA
• A vascular disorder affecting central face

• Presence of one or more of the following:


flushing, non transient erythema, papules and
pustules, telangiectasia
• Not a disorder of sebaceous glands, absence of
comedones
• Pathogenesis :
o Damage to dermal connective tissue
o Abnormal vascular reactivity
o Sensitivity to noxious stimuli
o High levels of cathelicidin
o H.pylori, Demodex folliculorum
Cont…
• Early : episodic flushing, mild telangiectasia, transient
edema
• Progressive : papules, pustules, sustained edema, extensive
telangiectasia
• Late : induration, rhinophyma
• Lymphoedema, eye involvement, salivary gland involvement
• Histopathology :
– Dilated capillaries & lymphatic channels in mid dermis
– Perivascular lymphohistiocytic infiltrates
– Solar elastosis
– Sometimes granulomas
– Pustules – neutrophilic infiltration
• Treatment
• Topical : metronidazole, tretinoin,
clindamycin, tacrolimus, azelaic acid
• Systemic : tetracyclines, metronodazole, isotretinoin
• Rhinophyma : surgical excision, intense pulsed light lasers,
dermabrasion
PERIORAL DERMATITIS
• Persistent erythematous eruption
of tiny papules and papulopustules
– perioral
• Periocular dermatitis
• Pathogenesis :
 Demodex, candida , fusiform
bacteria
 Irritant and allergic contact factors
 Atopy
 Topical steroids, cosmetic products
 Hormonal factors, sensititvity to
sunlight
• Begins in nasolabial areas  perioral areas; sparing lip
margins
Cont..
• Monomorphic papules & pustules

• Histopathology – eczematous changes, mononuclear


infiltrate; rarely granulomatous inflammation

• Treatment
– Discontinue topical steroids
– Avoid potential contact allergens
– Oral tetracyclines for 4 weeks
– Topical tetracycline, metronidazole, erythromycin
– Pimecrolimus 1% cream
ACNE AGMINATA
• Lupus miliaris disseminatus faciei – historical

• Acnitis or FIGURE

• A self limiting variant of granulomatous form of rosacea


• C/F : Multiple, monomorphic, symmetrical, reddish-brown
papules on the chin, forehead, cheeks and eyelids
• Clustering around mouth or eyelids or eyebrows - ‘agminata’
• Diascopy – apple jelly nodules
• Granulomatous histology with large area of caseation
• D/D : micropapular sarcoidosis
• Treatment : tetracyclines, dapsone, low dose prednisolone
Facial Afro-Caribbean childhood
eruption
• FACE or granulomatous periorificial dermatitis

• A juvenile form of perioral dermatitis or acne agminata

• Papular eruption confined to the face – clustering around


mouth, eyes and ears
• Pustules absent, vermilion border involved
• Histology – nonspecific inflammation with hyperkeratosis
or granulomatous mainly perifollicular
• Complete resolution
• Treatment – systemic erythromycin or minocycline or
topical metronidazole or tacrolimus
SARCOIDOSIS
• A disease characterised by formation in all or
several affected organs or tissues of epithelioid cell
tubercles, without caseation, proceeding either to
resolution or to conversion into hyaline fibrous
tissue.

• Etiology : genetic factors, infectious agents,


immunological response
• Acute and subacute : erythematopapular lesions, scar
sarcoidosis , papular and lichenoid variety

• Sub acute and chronic : erythrodermic, nodular, annular,


angiolupoid, subcutaneous

• Chronic : plaque ( lupus pernio)

• Others : ulcerative, psoriasiform, palmoplantar, ungual,


mucosal

• Systemic features : cardiac, respiratory, muscle, CNS,


ocular, renal, liver, spleen, lymphnodes

• Raised ACE levels , hypercalcemia


Histopathology Cont…
– Well defined aggregates of epithelioid cells
– Few Langhan’s type giant cells
– Naked tubercle – paucity of lymphocytes
– MNG cells with asteroid bodies and Schaumann bodies
Treatment :
– Corticosteroids
– Immunosuppressants
– Biologics
– Other drugs – allopurinol,
doxycycline, chloroquine,
minocycline, levamisole,
isotretinoin, fumaric acid
esters, thalidomide
– Topical therapy – high potent
topical steroids, ILS,
tacrolimus
– PUVA, cryotherapy,
radiotherapy
FOLLICULAR MUCINOSIS
• Alopecia mucinosa
• 2 distinct forms: associated with MF and benign inflammatory form
• C/F are identical : follicular papules and boggy cutaneous plaques
• Severe pruritus and prediliction for face and scalp
• Prominent giant comedones and alopecia
• Pathology : degeneration of involved hair follicles with a prominent
pilotropic atypical T cell infiltrate, inter follicular epidermotropism
• CD3+ve, CD4+ve and CD8 –ve
• Treatment : dapsone for inflammatory forms
Associated with MF: bexarotene, radiotherapy, total skin electron
beam therapy
PSEUDOFOLLICULITIS BARBAE
•Inflammation due to penetration into the skin of sharp tips
of shaved hairs

•If shaven too long – the hair may curve backwards after
emerging from the follicle to penetrate the adjacent skin

•If cut very short – it retracts into the follicle; may directly
penetrate the follicle wall

•Curly hair – more prone

•Male beard – commonest area

•Complications – keloid, hyperpigmentation


Treatment
• Stop shaving for 4-6 weeks

• Lifting out of reentrant hairs

• Hair maintained at 1 mm length

• Steroid-antibiotic combination
creams and emollients

• Hair removal with chemical


depilatories or topical
eflornithine hydrochloride cream

• Laser
TUMOURS
Benign epidermal tumors and
cysts

• DPN

• Seborrhoeic keratosis

• Milia
• Dermatosis papulosa nigra

• Pigmented papular eruption of face and neck

• Nevoid developmental defects of pilosebaceous


follicles

• Histology resembling seborrhoeic keratoses

• C/F: black or dark brown, flattened or


cupuliform papules 1-5 mm

• Malar regions and forehead


• Also on neck, chest and back

• Treatment : electrosurgery
SEBORRHOEIC
KERATOSIS
• Benign tumor of epidermal keratinocytes

• Increasing age ; 5th decade ; M=F

• Most frequent on face and upper trunk

• Classical, DPN, stucco keratosis

• Hyperpigmented papules or plaques

• Sign of Leser-Trelat
• Histopathological types : clonal, hyperkeratotic,
acanthotic, irritated, reticulate, melanoacanthoma

• Treatment : curettage, electrosurgery, cryotherapy


KERATOACANTHOMA
• Molluscum sebaceum
• Rapidly evolving tumor of the skin composed of
keratinizing squamous cells originating in pilosebaceous
follicles
• M>F; middle aged ; white races
• Etiology : sunexposure, tar and mineral oil, sorafenib
• C/F: firm, rounded, flesh colored or reddish papule

rapid growth phase- 10- 20mm


Telangiectasias, central horny plug or crust concealing a
keratin filled crater
• Central part of face – nose,
cheeks, eyelids and lips
• Usually solitary
• Histopathology : epidermis
normal or acanthotic, composed
of mass of rapidly multiplying
squamous cells,
hyperchromaticity, atypical
mitotic figures, dyskeratosis and
loss of polarity
• D/D : SCC
• Treatment : curettage and
coagulation of base, excision
and suture, radiotherapy, 5-FU.
MILIA
• Small subepidermal keratin cyst
• All ages ; from infancy onwards
• Due to pilosebaceous or eccrine sweat duct plugging
• Primary or secondary
• Subepidermal blistering diseases(BP , EB, PCT), burns,
dermabrasion, radiotherapy
• Firm white or yellowish 1-2mm dome
shaped papules, on cheeks and eyelids
of adults
• Eruptive milia- rare
• Milia en plaque
• Histopathology : small
cysts lined by stratified
epithelium few cell layers
thick and contain
concentric lamellae of
keratin

• D/D : milia are whiter and


more translucent than
syringomas

• Spontaneous clearance

• Treatment : incision and


squeezing of contents,
chemical cautery,
electrosurgery.
Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS

 Actinic keratosis
 Cutaneous horn

MALIGNANT

 Basal cell carcinoma


ACTINIC KERATOSIS
• Or solar keratosis
• Premalignant epithelial lesion
• Hyperkeratotic lesions on chronically light exposed
skin
• Low risk of progression to invasive SCC
• Middle aged or elderly; fair skinned
• Relapsing or remitting lesions
• Face, scalp and dorsa of hands
• C/F : multiple macules or papules with a rough scaly
surface, 1mm to 2 cms, aymptomatic
• Hyperemic base with punctate bleeding points
• Histopathology :

• Treatment : curettage and cautery, cryotherapy, topical


5-FU, imiquimod, photodynamic therapy, dermabrasion
and chemical peels
CUTANEOUS HORN
• Horny plugs or outgrowths due to various epidermal
changes

• Infection : molluscum, viral wart


• Benign: keratoacanthoma, seborrhoeic keratosis,
trichilemmal and epidermoid cyst
• Malignant : BCC, SCC

• C/F : hard yellowish brown horn, curved,


circumferential ridges, surrounded by normal
epidermis or acanthotic collarette
• Upper face and ears
• Inflammation and induration beneath : malignant
transformation
• Histology : absent granular layer, no atypicality
• Treatment : excision
BASAL CELL
CARCINOMA
• Basalioma or rodent ulcer
• Most common malignant tumour of skin ; rarely metastasizes
• Composed of cells similar to basal cells an appendages
• M>F
• Etiology: UV exposure, arsenic, ionizing radiations and burns,
mutations in PTCH1 gene, immunosuppression
• C/F : small, translucent or pearly papule, raised and rounded
areas covered by thin epidermis, dilated superficial vessels,
nodule or plaque
• Erosions & crusting common, sometimes ulcerate
• Types
Pathology
-Tumor cells resemble
basal cells of epidermis
-Peripheral palisading of
nuclei
-Stroma
-Clefting artefact
-Atypia
Treatment

– Surgical excision

– Non-surgical approaches:
curettage and cautery,
cryotherapy,
laser, topical imiquimod,
topical 5FU, PDT,
systemic retinoids
Tumors of skin appendages
 Eccrine gland tumors : syringoma, eccrine hidrocystoma

 Apocrine gland tumors : syringocystadenoma papilliferum

 Sebaceous gland tumors : sebaceoma, sebaceous adenoma,


sebaceous hyperplasia

 Tumor of hair follicle mesenchyme: trichodiscoma

 Hair follicle tumors : dilated pore, trichoadenoma

 External root sheath tumors : trichilemmoma

 Hamartomas : trichoepithelioma, trichofolliculoma


SYRINGOMA
• Benign tumor with differentiation
towards eccrine acrosyringium
• F>M
• C/F : numerous small, firm, smooth
skin colored or yellowish papules,
<3 mm
• Outline – angular or crenated
• Face esp lower eyelids
• Other sites: neck, chest, trunk,
axillae, vulva,ventral trunk.
• Eruptive syringomas : familial in
adolescent girls
• Histopathology :
 collections of convoluted and cystic
duct spaces in upper dermis
 Lined by double layer of cells
 Tail like strand of cells into the stroma-
‘tadpole or comma appearance’

• Treatment :
electrosurgery, cryotherapy, dermabrasion,
laser resurfacing
ECCRINE HIDROCYSTOMA
• Tumour by mature deformed eccrine sweat units; secretions dilate
the ducts
• Rare; middle aged women; exposure to heat
• Confined to cheeks and eyelids
• Cystic, blue, increase in size on exposure to heat and flattens with
exposure to cold
• Multiple, pigmented lesions on face
• Pathology : uni or multilocular dermal cystic lesion lined by 2 layers
of cells
• Inner layer- columnar , outer layer- myoepithelial cells
• Treatment : electrodessication, CO2 laser, pulse dye laser, excision
SYRINGOCYSTADENOMA
PAPILLIFERUM
• Exuberant proliferating lesion with apocrine differentiation
• Birth or childhood
• C/F : Multiple warty papules, translucent and pigmented
• Majority on face and scalp
• Pathology
– Papillomatosis with invaginations
– Cystic structures –
apocrine pattern
– Dermis – plasma cells
– Sometimes sebaceous, eccrine,
follicular differentiation
• Treatment – surgical excision
SEBACEOUS TUMOURS
• Sebaceous adenomas and
sebaceomas

• Benign tumors composed of


incompletely differentiated
sebaceous cells

• Rare; elderly

• C/F : rounded, raised, sessile or


pedunculated, <10 mm,waxy or
yellowish, plaques or ulceration

• Face and scalp


• Multiple - Muir Torre syndrome
• Pathology
– Sebaceoma – irregular cell masses of mostly undifferentiated
basaloid cells
– Sebaceous adenoma – sharply demarcated lesion with peripheral
basaloid cells and central mature sebaceous cells

• Treatment – surgical excision


SEBACEOUS HYPERPLASIA

• Benign proliferation in middle aged


and elderly

• Yellowish-pink papules 1-3 mm

• Forehead and temples

• Renal transplant patients on CsA

• Treatment – cautery, cryotherapy,


TCA, laser
TRICHODISCOMA
• Hamartomatous proliferation of
mesodermal component of the
Haarscheibe
• Haarscheibe – a slowly reacting
mechanoceptor associated with
hair follicle

• C/F : multiple, discrete, flat


topped papules 2-3 mm
• Central face
• Birt – Hogg- Dube syndrome
• Pathology : non encapsulated area
of myxoid, poorly cellular stroma
wirh focal collagen deposition in
dermis, proliferation of vessels
DILATED PORE
• Wiener’s pore or infundibuloma

• Area of expanded follicular infundibulum

• Dilated poral opening into subcutaneous


tissue

• C/F : comedo like lesion on head and neck


in elderly

• Pathology : wide crater like cavity, from


which acanthotic areas of follicular
epithelium radiate; follicle lined by outer
root sheath epithelium
TRICHOADENOMA
• Rare benign tumor, with multiple cystic
structures closely resembling
infundibular portion of hair follicle

• Differentiates towards follicular


infundibulum

• C/F : Papule or nodule on the face

• Pathology : lesions in upper dermis,


cluster of cysts
TRICHILEMMOMA
• Proliferation of external root sheath of hair
follicle
• Infundibular keratinisation
• C/F : small non specific papules on facial
skin in young adults
• Multiple : Cowden’s syndrome
• Pathology
– Lobular tumors extending from epidermis
– Clear cytoplasm – glycogen
– Peripheral palisading
– Sometimes prominent epidermal changes
– Variant – desmoplastic trichilemmoma
TRICHOEPITHELIOMA
• Hamartoma of the hair germ
composed of immature islands
of basaloid cells
• Focal primitive follicular
differentiation and induction of
a cellular stroma
• 3 forms : solitary, multiple and
desmoplastic
• Solitary- skin colored papules,
5-8 mm, on face esp around
nose, upper lips, cheeks
• Brooke spiegler syndrome –
trichoepitheliomas,
cylindromas and spiradenomas
• Pathology
– Well circumscribed lesion in
superficial dermis
– Horn cysts and basaloid cells
– Tumor islands show
peripheral palisading

• Treatment – surgical excision,


curettage, electrosurgery,
cryotherapy ,dermabrasion
TRICHOFOLLICULOMA
• Hamartoma of pilosebaceous follicle
• Several hairs form within the follicular
opening , protruding onto the epidermal
surface
• Young adults
• Prediliction for face
• C/F : small raised nodules, 2-3 hairs
protruding in a small tuft
• Pathology
– Cystic cavity lined by squamous
epithelium
– Keratinised material & fragments of hair
shafts
– Several pilosebaceous structures opening
into the canal

Treatment : excision
Soft tissue tumors

• Fibrous tumor : fibrous papule of face

• Fibrohistiocytic tumors : atypical fibroxanthoma


FIBROUS PAPULE OF FACE
• Benign tumor

• Small facial papule with distinctive


fibrovascular component

• C/F: slowly developing dome shaped skin


colored or red or pigmented papule, sessile,

• Nose, forehead, cheeks, chin or neck

• Pathology: normal epidermis, clear cells


overlying the lesion, increased collagen in
the dermis, dilated vascular channels,
increased cellularity
• Treatment : excision or surgical paring
ATYPICAL FIBROXANTHOMA
• Fibrohistiocytic tumor
• Sun damaged skin of elderly ; M>F
• UV induced p53 mutations
• C/F : papules or nodules with ulceration
, red fleshy appearance
• On ears, cheeks, bald scalp of elderly
males
• Local recurrence, metastasis to
lymphnodes and internal organs
• Pathology: large spindle shaped and
histiocytic cells, multinucleated in
dermis, mitotic figures, atypical forms
• Resembles a highly malignant soft
tissue sarcoma histologically
• Treatment : mohs micrographic surgery
COLLOID MILIA
• Degenerative change on light exposed skin

• Nonfamilial occurring in later life

• UV, trauma, hydroquinone

• C/F : small dermal papules, 1-2 mm, yellowish


brown , irregular groups
• Face esp around orbits, sides of neck, ears, dorsa of
hands and back.
• Rare juvenile and nodular form
• Histopathology : colloid globules at tips of dermal
papillae
• Treatment : electrosurgery, dermabrasion, Er:YAG
laser, topical retinoids
ANGIOFIBROMA
• Small flesh colored to brownish
red papules – usually on central
face

• Multiple lesions – Tuberous


Sclerosis Complex

• Composed of hyperplastic blood


vessels, sebaceous glands,
immature hair follicles

• Treatment – electrosurgery, laser


HOW TO
APPROACH??
HISTORY
Onset
Duration
Evolution
Mucosal lesions
Systemic Complaints
Treatment history

? Symptomatic
Triggering factors
Photosensitivity
Past history
EXAMINATION…
Morphology of predominant lesion
Number of lesions, symmetry
Size, colour and surface
? Flat topped ? Translucent
Umbilication? Erythema ? Telangiectasia
Annular lesions
Diascopy
Other types of lesions
? Scarring ? Ulceration
Distribution over face
Nasolabial fold, perioral & periocular regions
Involvement of other areas
Other systems
Investigations
GOECKERMAN REGIMEN
• Applied over the lesions for period of 24hrs
2-5% CRUDE
COAL TAR
• Excess wiped off with mineral oil

• Sub erythmogenic dose for 2-5 mins


UV- B

• 90mL of coal tar in 120L water


COAL TAR
BATH
INGRAM REGIMEN
• 15-30 mins
COAL TAR BATH

• Exposed to suberythmogenic
UV-B dose(1/3 to ½ of MED)

• Apply with spatula over lesions


ANTHRALIN(0.1%) • Paste is powdered with talc
BATH PUVA
• A special room with non skid bath tiles with bath
tub containing markings for 50,65,80,100L.
SPECIFICATIONS
• Geyser for warm water

• Final concentration- 3.75mg/L


Principle
• 3.75mL of 1% psoralen in 100L of water

• 10mins in supine and prone, maximum coverage


Procedure
• Avoid splashing of face and eyes
BATH PUVA
• Gently pat dry, and exposed to UV-
A with special precautions
Procedure • 3 times a week

• 12-15 sessions for improvement


Follow up • Maintenance for 3-4 months