DISORDERS OF THE

PILOSEBACEOUS UNIT

Lalaine R. Visitacion, REB, MD,

FPDS, FAAD
Pilosebaceous Unit
Hair Shaft ‘

Dermis Epidermis

Arrector Pili
Muscle
Sebaceous Gland
Hair Follicle
—~ Hair Bulb
Hair Papilla
 OBJECTIVES
After completing this module, the medical studentwill
Lele] 0) (Bo
Identify and describe the morphology of acne and
other disorders of the pilosebaceous unit
Discuss the pathogenesis of acne
iN
Nametherisk factors for acne
List the basic principles of treatment for acne and
the other diseases
Develop an initial treatment plan, including patient
education
Discuss when to refer to a dermatologist
 1610) =) =
ACNE VULGARIS
ACNE CONGLOBATA
ACNE FULMINANS
SAPHO SYNDROME
ACNEIFORM ERUPTIONS
GRAM-NEGATIVE FOLLICULITIS
ACNE KELOIDALIS
HIDRADENITIS SUPPURATIVA
PERIORAL DERMATITIS
ROSACEA
OTHERS
 ACNE VULGARIS
Chronic inflammatory
diseaseof the
pilosebaceous
follicles
Characteristic lesions:
Non-inflammatory:
- comedones
Inflammatory:
- papules
- pustules
- nodules
Scars
 ACNE VULGARIS

Non-inflammatory lesions:
Comedone — primary lesion

Open comedone or blackhead

 ACNE VULGARIS

Open comedone or
blackhead

- Flat or slightly
elevated papule
with dilated central
opening filled with
blackenedkeratin
 ACNE VULGARIS

Closed comedone or
whitehead

1-4 mm yellowish
papules
 ACNE VULGARIS

Inflammatory lesions: F he
- with erythema
and edema due
to inflammation

- Papules Pa . :
- Pustules a

we i
 ACNE VULGARIS
Inflammatory lesions:

- Nodules > Plaques

- sinus tracts

serosanguinous
discharge or
yellowish pus
SONY163
 ACNE VULGARIS
a . =
Resolution of lesions: e

Light skinned: short- ain

lived reddish-
purple macule
 ACNE VULGARIS

Resolution of lesions:

Dark skinned: macular

hyperpigmentation
for several months
 ACNE VULGARIS

ACNE SCARS-
heterogenous:

- Ice picks — deep and

narrow
- temples and cheeks
 ACNE VULGARIS
ACNE SCARS-
heterogenous:

- Canyon-type atrophic
(boxcar) face
 ACNE VULGARIS

ACNE SCARS-
heterogenous:

-Whitish-yellow
papular scars-
trunk, chin
 ACNE VULGARIS

ACNE SCARS-
heterogenous:

- Anetoderma-type —
tava.
 ACNE VULGARIS
ACNE SCARS-
heterogenous:

- Hypertrophic and
keloidal -
elevated scars —
neck and trunk
ACNE VULGARIS
 ACNE VULGARIS

SITES OF PREDILECTION:

- Face — cheeks, nose, forehead, chin

- Ears - large comedoneson conchae,
cysts in the lobes and pre- and
retro-auricular comedones and
cysts :
- Neck , nuchal area — large cysts
 ACNE VULGARIS
AGE OF ONSET:
- Puberty — first sign of increased sex hormone
iy
production
- 8-12 y/o — comedonal — forehead and
cheeks - mild with occ. papules
- Middle teenage years — inflammatory
lesions — pustules and nodules
- Start of acne at age 20 -35 y/o - papules,
pustules, nodule - jawline, chin and
upper neck
 PATHOGENESIS

we
Epidermis

Follicular
epithelium /

\UTj
W
Early comedo Later comedo Inflammatory papule/pustule Nodule/eyst
* Infundibulum * Accumulation of shed keratin + Propionibacterium acnes '* Marked inflammation
~ hyperkeratosis and sebum proliferation * Scarring
comeacyte cohesiveness ‘ Formation of whorled lamellar + Sebaceous lobule regression
* Androgen stimulation concretions + Mild inflammation
of sebum secretion '@ Comeocyte
‘Sebum
 renee

Sebooyte
ol etlele
Seborrhea
desquamation

Altered follicular milieu

Deeeterakesdane Nee eeeRevechCG eT)RCE BCX

 ACNE VULGARIS
Other Predisposing/Exacerbating Factors:
Comedogenic greasyor occlusive products like
cosmetics or oil-based facial wash
Mechanical orFrictional forces, e.g. over exuberant
washing like scrubbing
Provocative Factors: chin straps, violins, hats, collars,
surgical tape, orthopedic casts, chairs, and seats
Ahigh glycemic diet may worsen acne

** All these factorsirritate the follicular epithelium and

exacerbate the changesthat lead to comedogenesis
and follicular rupture
 ACNE VULGARIS
HYPERANDROGENIC STATES: to be considered in
women orchildren with acne:
1. Polycystic Ovarian Disease (PCOS)
- presenceofirregular menses, hirsutism, or
androgenetic alopecia
- ffserum testosterone, 150-200 ng/dL or an
ft LH/FSH ratio, >2—3
Il. Ovarian Tumors
- testosterone levels above 200 ng/dL
Ill. Adrenal Tumors
- DHEASlevels maybevery high, >800mcg/dl
TABLE CLINICAL PRESENTATIONS OF ACNE AND
SEVERITY
Acne Description of acne lesions
classification
Mild Comedones:Non inflamedlesions,initial acne, may
resolveorpersist
Closed comedones: Whiteheads caused by
distended pilosebaceous ducts
Open comedones: Blackheads caused by
hyperkeratinisation of duct
NOTE: Remember,black is notdirt, but due to
melanin should not be squeezed
Papules: Inflamed superficial lesions, take between
1-2 weeksto resolve
Comedones(open and closed)
Papules:Inflamed and raised papules continue to
develop as pustules
Pustules: Deeper than papules, become pus-filled
and take several weeksto resolve
Macules: Resolving papules and pustules form
macules, flat red areas, which canlast for weeks
Comedones,papules and pustules
Nodulesand cysts: Deep andpainful lesions
developing from pustules. These may scar, can last
for weeks and mayform sinustracts
ACNE VULGARIS -TREATMENT
GENERAL PRINCIPLES
HISTORY:
- Complete record of prior therapies including OTC
(elaTels)
- Family history of acne & tendencyto scarring
- Use of comedogenic products/cosmetics
- Menstrual irregularities
- Hirsutism

** Treatmentfailure maybe due to:

- drug interactions
- coexisting conditions
- antibiotic resistance
- LACK OF COMPLIANCE important cause
ACNE VULGARIS - TREATMENT
GENERAL PRINCIPLES

MEDICATIONS:

- Well tolerated
- Convenient dosing regimen
- Cosmetically acceptable
ACNE VULGARIS-TREATMENT
GENERAL PRINCIPLES
Explain the following:
1. How lesions are formed
2. Proper application of drugs — whole face-
daily
3. Expected response
4. Duration before efficacy is seen — 6 to 8 wks
5. Possible side effects
ACNE VULGARIS-TREATMENT
GENERAL PRINCIPLES
MISCONCEPTIONS TO BE ADDRESSED:

Avoidanceofspecific food is not necessary

Scrubbing ofthe face will not only increaseirritation
but may worsen acnedue tofriction
Utilization of only the prescribed meds and
avoidance of drying over-the counter products
such as astringent, harsh cleansers or
antibacterial soaps should be emphasized
Non-comedogenic cosmetics are recommended and
pressed powdersand oil-based products should
be avoided
 ACNE VULGARIS
TOPICAL TREATMENT

Preventative
Use for 6-8 weeks to judge efficacy
Entire acne affected is treated
MayaKlMUR:-<—
Effective as maintenance therapyafter
initial control is achieved
 ACNE VULGARIS
TOPICAL TREATMENT
TOPICAL RETINOIDS

- Vitamin A derivative
- Promotes normal desquamationof the follicular
epithelium =>reduce comedones and inhibit the
dev’t of new lesions
- Marked anti-inflammatory effect
- inhibits the activity of leukocytes, release of pro-
inflammatory cytokines and other mediators, and
the expression of transcription factors andtoll-
like receptors involved in immunomodulation
- Help penetration of other active agents
- Preferred agents in maintenance therapy
 ACNE VULGARIS
TOPICAL TREATMENT

TOPICAL RETINOIDS

Indications: acne vulgaris, photo-damaged

skin, fine wrinkles & hyperpigmentation
To decreaseirritation => use every other
night, use of a moisturizer
Common adverseeffects:
- dryness, pruritus, erythema, scaling
- photosensitivity
 ACNE VULGARIS
TOPICAL TREATMENT
TOPICAL RETINOIDS

Tretinoin
- 0.025%, 0.05%, 0.1% in cream (preferred)
or gel form
- Applied at night
- Pregnancy Category C
Adapalene ;
- efficacy equivalent to lower conc.of Tretinoin
- light-stable; can be applied AM or PM
- Pregnancy Category C
Tazarotene
- strong and irritating
- Pregnancy Category X
 ACNE VULGARIS
TOPICAL TREATMENT
BENZOYL PEROXIDE

Potent anti-bacterial effect; comedolytic

Use w/topical antibiotics to prevent the
development of antibiotic resistance
Mosteffective in inflammatory acne1-2X/day;
creams, lotion, gel form or wash
Side effects: bleaching or hair, colored fabric,
peeling, allergic contact dermatitis (rare)
Pregnancy Category C
 ACNE VULGARIS
TOPICAL TREATMENT
TOPICAL ANTIBACTERIALS
Reduce the number of P. acnes and reduce
inflammation in acne”
Erythromycin 2% (solution, gel)
Clindamycin 1% (lotion, solution, gel, foam)
**Metronidazole 0.75%, 1% (cream, gel) a
usedin tx of rosacea
Well-tolerated and effective in mild-moderate
inflammatory as
mdK=xe AE 1ALeNs Sends
Use w/ Benzoyl Peroxide to limit resistance
Use w/topical retinoid, will hasten response
 ACNE VULGARIS
TOPICAL TREATMENT
SULFUR, SODIUM SULFACETAMIDE,
RESORCIN AND SALICYLIC ACID

Moderately helpful if newer medications are not

LS
tolerated
Sulfacetamide—sulfur combination
- mildly effective in acne and rosacea
- avoidedif allergic to sulfonamides
 ACNE VULGARIS
TOPICAL TREATMENT
AZELAIC ACID

A dicarboxylic acid
Free from adverse reactions
Mild efficacy for inflammatory and comedonal
ETolTae
Will lighten post-inflammatory hyperpigmentation
Pregnancy Category B
 ACNE VULGARIS
ORAL ANTIBIOTICS

Indications:
- moderate to severe acne
- failure or non-tolerance oftopical
combinations 5
- treatment of chest, back or shoulder
acne
- absolute control of acne is deemed
essential : scar, PiH
 ACNE VULGARIS
ORAL ANTIBIOTICS
Takes 6-8 weeksto judge efficacy
If no responseafter 3 months of therapy
consider:
Increasing the dose ;
Changing the treatment
Start at a high-dose then reduce after control
is achieved, around 2 months
Duration of treatment: 3-6 months
May decreaseefficacy of OCPs, 2"birth
control method should be offered (unproven)
 ACNE VULGARIS
ORAL ANTIBIOTICS

TETRACYCLINE .,
Safest and cheapest
Positive response — 70% of patients
Initial dose: 250-500 mg 1—4X/day; gradual
reduction depending on clinical response
Taken on an empty stomach, 30 min before
meals and 2 hrs afterwards
Calcium and Iron in food supplements
- reduce absorption by half
 ACNE VULGARIS
ORAL ANTIBIOTICS
TETRACYCLINE
Vaginitis and perianal itching may result in
5%; presence of Candida albicans
Other side effects:
Gl — nausea, vomiting, diarrhea; don’t
take at bedtime
Oral — staining of teeth; not for
pregnant women and children <10 yo
Skin — photosensitive; advise sunblock use
Avoided when renal function is impaired
 ACNE VULGARIS
ORAL ANTIBIOTICS
DOXYCYCLINE

50-100 mg onceor twice a day

Side effect: GI upset, photosensitivity
Doxycycline hyclate 20 mg BID b
- advantage: anti-inflammatoryactivity is being
utilized but no antibiotic resistance results due
to low dose
 ACNE VULGARIS
ORAL ANTIBIOTICS
MINOCYCLINE PIGMENTATION

Pigmentation - after months to years: small

percentage of pxs
First noticeable: alveolar ridge, palate, sclera; also
seenin teeth and nails
Skin deposition: brown or blue-grey.Blue-grey
pigmentation mayoccur in scars
Skin pigmentation may not fade after
discontinuation
If seen on gumsor sclerae, discontinue
 ACNE VULGARIS
ORAL ANTIBIOTICS
MINOCYCLINE PIGMENTATION

Se
ae

-
 ACNE VULGARIS
ORAL ANTIBIOTICS
CLINDAMYCIN

Excellent for Tx of acne

Potential dev’t of Pseudomembranous colitis;
limited-use
Initial dose: 150mg 3X/day, reduce gradually
 ACNE VULGARIS
ORAL ANTIBIOTICS
OTHER ANTIBIOTICS

Sulfonamides: TMP-SMX
- double-strength doses 2X/dayinitially
- effective in many cases unresponsive to
other antibiotics
- potential severe drug reactions;limited
X=
 ACNE VULGARIS
BACTERIAL RESISTANCE
Clindamycin and Erythromycin resistance
- present simultaneously
Tetracycline and Doxycycline resistance
- occur together; switching to
Minocycline might be necessary
BPO limit cutaneous drug resistance
however:
- S. aureus in the nares, Streptococci in
the oral cavity & enterobacteria in the
gut may also become resistant
 ACNE VULGARIS
LIMITING BACTERIAL RESISTANCE
Decrease duration of treatment
Stress good compliance
Restrictions of use to inflammatory acne
Encourage re-tx w/ sameantibiotic unlessit
has lostits efficacy
Avoid using dissimilar oral and topical
antibiotics at the same time
Using isotretinoin if unable to maintain
clearance w/o oral antibiotics
 ACNE VULGARIS
HORMONAL THERAPY
OrTalal (cETaek WTR Vel)
- late-onset, severe acne, not
responsive to other oral/topical tx
- acne that relapsed quickly after
isotretinoin tx
-PCOS °
- late onset adrenal hyperplasia
- other endocrine disorders
 ACNE VULGARIS
SPIRINOLACTONE

Usually w/ OCPuse,oral or topical tx

Dose — 25 to 200mg/day
DTUTalo)MeyMRRLenRNAUDA
Side effects: dose-dependent
- breast tenderness, headache, dizziness,
lightheadedness,fatigue, irreg menses,
diuresis
 ACNE VULGARIS
ORAL STEROIDS
Dexamethasone: 0.125 to 0.5 mg,once at
night, Wandrogen excess and mayalleviate
cystic acne
- effective in the treatment of adult-onset
adrenal hyperplasia
Prednisone: effective anti-inflammatory agents in
severe and intractable acne vulgaris, severe
cystic acne and acne conglobata
- only given to patients with severe
inflammatory acneduring the first few
weeksof treatment wW/isotretinoin, for
initial reduction of inflammatio nand to
reduceisotretinoin-induced flares
 ACNE VULGARIS
ORAL ISOTRETINOIN
A retinoic acid derivative
INDICATIONS:
1. Severe, nodulocystic acne failing other
therapies that improved by <50% after 6
months of Txw/ combined oral and
topical antibiotics
2. Acne that relapsesoff oral tx, scars or
acne that induces psychological distress
3. Gram (-) folliculitis, Inflammatory
rosacea, pyodermafaciale, acne
fulminans, hidradenitis suppurativa
 ACNE VULGARIS
ORAL ISOTRETINOIN
Dose: 0.5 to 1mg/kg/dayin 1-2 doses
Duration: a single 5-6 month course
Common side effects of isotretinoin include:
1. Dry lips, skin, eyes, and oral and nasal mucosa
- 90%;
- tx:moisturization.
- leads to colonization by S. aureus in 80—
90
2. Elevated liver enzymes
3. Hypertriglyceridemia — serum lipids
monitored
 ACNE VULGARIS
ORAL ISOTRETINOIN
Individuals with severe acne may suffer mood
changes and depression and should be
monitored
Inflammatory Bowel Disease
Severe headache can be a manifestation of
the uncommon side effect pseudo tumor
cerebri
Teratogenic and absolutely contraindicated in
pregnancy
Two formsof contraception must be used
during therapy and for one month after
treatment has ended
 ACNE VULGARIS
OTHER TREATMENT MODALITIES

Intralesional Steroids injection

- effective in reducing inflammatory
Mm tex 01-13
Local surgical treatment — tx of comedones
- Comedoextraction/Acne Surgery
- Electrocautery
- Chemical peels
 ACNE VULGARIS
OTHER TREATMENT MODALITIES
Treatmentof Inflammatory Lesions
- Photodynamic
- Blue light
- 1450 nm laser »
Treatmentof scarring
Chemical peels
Dermabrasion
Excisions
Subcision
Laser resurfacing
Filler substances
 ACNE
COMPLICATIONS
Scarring
- pitted scars, wide-mouthed depressions,
and keloids
MMsenaeiCaerten
Pyogenic granuloma formation (esp from
Acne Fulminans)
Osteoma Cutis
- small, firm papules from long-standing
acne vulgaris
Solid facial edema: persistent, firm, facial
swelling
Before and after oral Isotretinoin
Other Acne Treatment Modalities

1) Intralesional steroid injection

2) Microdermabrasion/Diamond peel

3) Chemical peels

4) Lasers — Starwalker, Agnes,

Fractional CO2
Before and after chemical peel
Before and after Agnes laser
treatment

Acne Treatment before & after

Before and after Agnes laser
treatment
¥
Before and after Starwalker laser
 OTHER FORMS OF ACNE
Neonatal Acne
Infantile Acne
Childhood Acne
Acne Conglobata
Acne Fulminans
SAPHO Syndrome
Tropical Acne
Acne Aestivalis
Excoriated Acne
 NEONATAL ACNE

- develops a few days

afterbirth <
- male sex
cn
preponderance “~ ™~
- transient facial
papulesor pustules
ow
- clear spontaneously :
in a few days or
NX>) .6)
- (-) comedone
formation
 INFANTILE ACNE

- Acne that persist beyond

neonatal period or have
onsetafter the 1% 4
weeks oflife
- can extend into
childhood, puberty
or adult life
 INFANTILE ACNE
- Treatment:
A. In prolonged cases —
topical benzoyl peroxide,
erythromycin, or the
retinoids
B. Inflammatory cases
Oral Erythromycin, 125 mg
1311 Deg
Trimethoprim, 100
mg BID
C. Oral Isotretinoin
 CHILDHOOD ACNE
- acne that evolve from
persistentinfantile
acne or begin after
age 2

B 2005Logical Images, Inc

- uncommon with male
preponderance
- grouped comedones,
papules, pustules

>
and nodules on the
face
 CHILDHOOD ACNE
- variable duration — few
weeksto several years
- occasionally extends
LS
into more severe
pubertal acne
- (+) strong family history
of moderately severe
acne
 ACNE CONGLOBATA
Severe cystic acne
Young men, 16yo
Maypersist up to 5
decade oflife
Numerous comedones
- double or triple
Large abscesses with
interconnecting
Tale ro een1M Tae)
grouped
inflammatory
nodules
 ACNE CONGLOBATA

Suppuration is
characteristic
Pronounced scars -

Cysts occur on the

back, buttocks,
chest, forehead,
cheeks, anterior
neck, and shoulders
 ACNE CONGLOBATA

With thick, yellowish, viscid, stringy,

blood-filled fluid
After incision and drainage of the cyst
=> promptrefilling with the same
type of material
Suggestive of the type found in HS
Follicular occlusion triad:
. Hidradenitis suppurativa
Dissecting cellulitis of scalp
Acne conglobata
 ACNE CONGLOBATA
TREATMENT
Isotretinoin - 0.5—1 mg/kg/dayto a total
dose of 150 mg/kg
- w/ a 2" course if no
resolution occurafter a rest period of 2
months
Pretreatment w/ prednisone and lowinitial
dosesofisotretinoin are recommended
=>avoid flaring of disease.
CO2 laser to open the sinus tracts and
Fractional laser for the scars
 ACNE FULMINANS
Rare form of extremely severecystic acne.
Primarily in teenage boys
Characterized by highly inflammatory nodules
and plaquesthat undergo swift
suppurativedegeneration =>ragged
ulcerations, mostly on chest and back.
Face-less severely involved
Fever and leukocytosisare common
Polyarthralgiaand polymyalgia, destructive
arthritis, and myopathy have been
reported
Focal lytic bone lesions may be seen
ACNE FULMINANS
 ACNE FULMINANS
TREATMENT
Prednisone, 40-60 mg, is necessary during
the initial 4-6 weeks to calm the dramatic
inflammatory response.
After 4 weeks, 10-20 mg ofisotretinoin is
added - slowly increased to standard
doses and continued for a full 120-150
mg/kg cumulative course
Large cysts — Intralesional corticosteroids will
aid resolution
Infliximab mayalso be useful
 SAPHO SYNDROME
ynovitis
cne — face & upper back
ustulosis — usually palms & soles
yperostosis
steitis

Bone changesof the anterior chest wall on

nuclear scans - most specific diagnostic
findings
Chest wall & mandible: common sites for
musculoskeletal complaints
SAPHO SYNDROME
 SAPHO SYNDROME
ix AUN
Systemic retinoids and infliximab
Isotretinoin if used:
- initiated at a low dosage, such as 10 mg per
day w/ prednisone for the IS* month to
Pyeoulen eu ay
Pamidronateis effective in treating the
osteo-articular manifestations
 TROPICAL ACNE
Severe acne in tropics
Nodular, cystic, and
pustular lesions
Conglobate abscesses
occur often at the
oFTe1,¢
Comedonesare sparse
Also occurs at buttocks
and thighs
Face: spared
Secondary infection w/ S.
aureus

Tx: Sameas cystic acne

 ACNE AESTIVALIS
(Mallorca acne)
- Rare form; starts in spring, —
PYReyARNCAMA ate) om s-d Fi
resolvesin fall
Pa A(elton 48S
- Dull, red, dome-shaped, hard,
small papules, not>3-4mm
- Cheeks, sides of neck,
shoulders & upper arms
- Comedones & pustules:
dermatologia.net
absent or sparse
- Tx: Retinoic acid; doesn’t
respond to antibiotics
 EXCORIATED ACNE ~
Picker’s acne & Acne excorie des
Rules less
Superficial type of acne
Primary Lesion: trivial or nonexistent
(+) compulsive neurotic habit of picking &
squeezing, produces secondarylesions that crust
Cal eae
Young women
Sign of depression or anxiety
OC symptom
Tx: SSRIs, behavior modification,
psychotherapy
EXCORIATED ACNE
ACNEIFORM ERUPTIONS
Follicular eruptions: papules & pustules
resembling acne
Breaks in epithelium & spillage of follicular
CofolaTeam Aleem eC=aaah
Sites differ from acne
Sudden, monomorphous, past adolescence
Etiology — drugslike lodide, lithium,
cyclosporin
- industrial chemicals like chlorine
If 2° to drugs: begin w/in days of meds, (+)
fever & malaise; resolves w/ cessation
ACNEIFORM ERUPTIONS
ACNEIFORM ERUPTIONS
Steroid acne: when high doses taken for 3-5
EWA
Sudden outcropping of inflamed
papules; upper trunk and arms
histo: follicular w/ Mete
formation
Treatment:
1. Remove cause
Oa gorekere
- tretinoin 0.05% cream |-2X/day,
- oral antibiotics & other acne meds
ACNEIFORM ERUPTIONS
STEROID ACNE
 GRAM-NEGATIVE
FOLLICULITIS
Multiple, tiny yellow pustules
on top of acne vulgaris;
3-6mm
Flaring out from the anterior
naresor fluctuant, deep-
seated nodules
Result of long-term
antibiotics; gram (-) inc
in#
Culture: Klebsiella, E. coli,
Enterobacter, Proteus
Isotretinoin — tx of choice
Amoxicillin or TMP-SX
 ACNE KELOIDALIS
Young, healthy adult men:
Black, Hispanic or Asian
NOTassociated w/ acne,
but a primarycicatricial
alopecia variant
ees elalmn ce)CeUl tua
perifolliculitis of the back of
the neck; presents as papules
and pustules
Overtime:fibrosis—coalesce—
Leofede)Lett)
At times, sinus tract formation
results

Amoxicillin or TMP-SX
 ACNE KELOIDALIS
© Histology:
- perifollicular, chronic (lymphocytic and
plasmacytic) inflammation
- mostintenseat the level of the isthmus
and lower infundibulum
- lamellar fibroplasia
Cacereltaal- a18
* Potent steroid ointments - IL Triamcinolone acetonide
* Tretinoin gel o Deep excision
* Oral antibiotics - CO,laser ablation
 HidradenitisSuppurativa
(Acne Inversa)
e Chronic disease
e Recurrent abscessw/in folded areas of skin
that contain both terminal hairs & apocrine
glands: ;
- Axillae, inguinal, perineal areas as well as
buttocks & submammary
e Post-puberty; F>M (4:1)
e Initiating event: unknown
e Predisposing factors: obesity, genetic
predisposition to acne, follicular plugging of
apocrine regions, secondary bacterial
infection
HidradenitisSuppurativa
(Acne Inversa)
 HidradenitisSuppurativa
(Acne Inversa)
Dev'’t of tender, red nodules w/c arefirm then
becomefluctuant & painful.
Rupture of the lesion, suppuration, formation of
sinus tracts, and extensive scarring are distinctive.
As one area heals, recurrent lesions form => eventually
lead to the formation of honeycombed, fistulous
tracts with chronicinfection. :
Lesions contain a thick, viscous, mucoid, suppurative
material
Sartorius scale — to assess disease severity by #, type
andsite of lesions
Risk of squamouscell carcinoma (rare) occurring as an
ulceration or thickening in a skin crease can
metastasize and cause death
 HidradenitisSuppurativa
(Acne Inversa)
Permanent cure: uncommon
Earliest lesions: IL steroid therapy w/ topical cleocin or
oral tetracycline or minocycline.
edKe\A-18NM eteS0 Lie
- Topical daily cleansing w/ antibacterial soap,
chlorhexidine solution, or benzoyl peroxide wash
- Laser hair removal, if performed; done in unaffected
sites
Reduction offriction by wearing loosefitting clothing and
weightloss
Avoidance of excessive sweating through the use of
topical aluminum chlorideor botulinum toxin A
 HidradenitisSuppurativa
(Acne Inversa)
Dev'’t of tender, red nodules w/c arefirm then
becomefluctuant & painful.
Rupture of the lesion, suppuration, formation of
sinus tracts, and extensive scarring are distinctive.
As one area heals, recurrent lesions form => eventually
lead to the formation of honeycombed, fistulous
tracts with chronicinfection. :
Lesions contain a thick, viscous, mucoid, suppurative
material
Sartorius scale — to assess disease severity by #, type
andsite of lesions
Risk of squamouscell carcinoma (rare) occurring as an
ulceration or thickening in a skin crease can
metastasize and cause death
 HidradenitisSuppurativa
(Acne Inversa)
Permanent cure: uncommon
Earliest lesions: IL steroid therapy w/ topical cleocin or
oral tetracycline or minocycline.
eae\1A)NM creSOL oie
- Topical daily cleansing w/ antibacterial soap,
chlorhexidine solution, or benzoyl peroxide wash
- Laser hair removal, if performed; done in unaffected
sites
Reduction offriction by wearing loosefitting clothing and
weightloss
Avoidance of excessive sweating through the use of
topical aluminum chlorideor botulinum toxin A
 HidradenitisSuppurativa
(Acne Inversa)
In draining sinuses, culture of pus may reveal S. aureus
or Gram-negative organisms(chronic cases)
Systemic antibiotics: tetracyclines, amoxicillin,
sulfamethoxazole/trimethoprim DS, dapsone,
clindamycin or antibiotic plus rifampincombination
Isotretinoin effective in some cases
Wide surgical excision, using intraoperative color-
marking of sinus tracts, is most effective at limiting
recurrence
CO2laser may also destroy lesions and sinus tracts
 Perifolliculitis Capitis
Abscedens et Suffodiens
Aka Dissecting cellulitis of
the scalp
Uncommon, chronic
suppurative disease
Follicular &perifollicular
erythematous papules
Fleeyoheed
intercommunicating
sinuses— scarring &
alopecia
 Perifolliculitis Capitis
Abscedens et Suffodiens

Seropurulent drainage maylastindefintely

iba
Combi:IL steroid injections,isotretinoin, oral
antibiotics, oral zinc :
Surgery: marsupialization; excision of sinus
fae.Lela
Lasers to removethe hair
Acne Miliaris Necrotica
(Acne Varioliformis)
Follicular vesicopustules
Pruritic
Scalp & adjacent areas
Rupture early & dry up after a few
chWAS
im (NZCLomer HPA6180111COLCA
Tx:Antibiotics (tetracycline or
minocycline)
TCAsand anxiolytic: Doxepin — if pxs
manipulate their lesions
Acne Miliaris Necrotica
(Acne Varioliformis)
 ROSACEA

Persistent erythema of
convex surfaces of face
Cheeks>nose>brow>chin
Usually spares periocular
skin
Light-skinned; F>M; 30-50yrs
Rhinophyma: more in males
Telengiectasia + flushing +
erythematous papules &
pustules
 ROSACEA - TYPES
1. Erythrotelangiectatic
- prominent history of a prolonged (over 10 min)
flushing reaction to various stimuli, such as
emotional stress, hot drinks, alcohol, spicy
foods, exercise, cold or hot weather, or
hot baths and showers
- burning or stinging sensation accompanies the
si LUE 1a)
- skin is of fine texture, may have a roughness
and scaling of the affected central facial
sites
- Over time a purplish suffusion and prominent
ROSACEA-Erythrotelangiectatic
 ROSACEA - TYPES
2. Papulopustular
- red central facew/ erythematous papules often
surmountedbya pinpoint pustule
- (+) flushing in most patients, irritancy are not
prominent ;
- skin is of normal or at times slightly sebaceous
quality
(+) edema ofthe affected sites
- Morbihan’s disease; mostlikely to
complicate the papulopustular and
glandular types
ROSACEA — Papulopustular
 ROSACEA - TYPES
3. Glandular

Men with thick sebaceous skin predominate

papules are edematous, the pustules are 0.5—
1.0 cm in size
Nodulocystic lesions may be present
Cluster in the central face
History of adolescent acne
Flushing and telangiectasiais less common
Persistent edema maybe problematic
 ROSACEA - TYPES
3. Glandular

- Rhinophyma - most commonly occurs.

- Hypertrophic, hyperemic, large nodular
massesare centered over the distal half of
the nose
- Histology: pilosebaceous gland hyperplasia
with fibrosis, inflammation, and
telangiectasia.
ROSACEA- Rhynophyma
 ROSACEA
Staging (Plewig & Kligman Classification)

Rosaceadiathesis:episodic erythema,
“flushing & blushing”
StageI: Persistent erythema w/ telengiectases
Stage Il: Persistent erythema, telengiectases,
papules, tiny pustules
StageIII: Persistent deep erythema, dense
telengiectases, papules, nodules; rarely
persistent “solid” edema of central part of
face
 ROSACEA - ETIOLOGY

Ola) aaronyal
Abnormal vasomotorresponseto thermal
co oraaM
Chronic solar damage
a S W om
Pilosebaceous unit abnormalities
 ROSACEA - MANAGEMENT
Control of Inflammation
Topicals: Metronidazole, Benzoyl peroxide,
Azelaic acid, Topical antibiotics, Tretinoin
Oral meds:Tetracyclines, Macrolides,
Ly
Metronidazoe, Isotretinoin
Repair of Structural Damage
Laser, IPL, Surgery,Tretinoin
Prevention of Further Damage
Sunscreens, Cosmetics, Avoidance oftrigger
factors
 PYODERMA FACIALE
(ROSACEA FULMINANS)

Intense reddish or cyanotic erythema

Superficial & deep abscesses,
Cystic lesions
+ Sinus tracts
Cerra molm (211(CMM LUMO LCLtem arTeclarel|
Post-adolescent women(flushers &
blushers)
(-) Comedones,(-) Acne on the back
Rapid onset
Vian arekal ny-aecoLe aX)
 PYODERMA FACIALE
(ROSACEA FULMINANS)
 PERIORAL DERMATITIS
Discrete papules & pustules on erythematous/
scaling base symmetrically around the
mouth
(-) itching
(+) burning sensation ,
Women:20-35yrs
Etiology: Use of topical fluorinated steroids
Tx: oral or topical antibiotics; topical
adapalene,azelaic acid & metronidazole
PERIORAL DERMATITIS
 PERIORBITAL DERMATITIS

Variant of periooral
re(TanarLata
Fluorinated topical
steroids implicated
as cause
Lower eyelids & skin
adjacent to upper &
lowereyelids
GRANULOMATOUS FACIAL DERMATITIS
Persistent facial erythema:of 1 or
more convex surfaces
Histology: granulomatous reaction
Included within rosacea, but nosology
unclear

acial Idiopathic Granulomatas

w/Regressive Evolution

1. Lupus Miliaris Disseminatus Facie

2. Granulomatous Perioral Dermatitis in
Children
GRANULOMATOUS FACIAL DERMATITIS
Lupus Miliaris Disseminatus Facie
(+) Firm, yellowish-brown or red, 1-3 mm,
monomorphous, smooth-surfaced papules
e butterfly areas, lateral areas, below the
mandible, and periorificially
6 ) Hx of flushing
(-) persistent erythema
(-) telengiectasia
(+) eyelid involvement :
(+) heal w/ scarring
Histo: caseating epitheliod cell granulomas
Tx: minocycline, isotretinoin
Self-involution in a few years
GRANULOMATOUS FACIAL DERMATITIS
GRANULOMATOUS FACIAL DERMATITIS
2. Granulomatous Perioral Dermatitis
in Children
Grouped papules may develop on the
perioral, periocular, and perinasal
PTRrhy
Healthy, prepubertal children
Tx: topical metronidazole,erythromycin,
sulfacetamide-sulfur;oral macrolide
or tetracycline
Topical Steroids may worsen condition
GRANULOMATOUS FACIAL DERMATITIS
Thank you!