80: Acne Variants and Acneiform Eruption

Question 1

What is the typical age of onset for neonatal acne and how long does it usually last?

Answer 1

Neonatal acne typically occurs around 2 weeks of age and resolves spontaneously within 3 months.

Question 2

What are the common characteristics of infantile acne?

Answer 2

Infantile acne usually appears at 3-6 months of age and is characterized by:

1. Open and closed comedones on the cheeks and chin.
2. Presence of papules, pustules, and nodules on the face.
3. Possible pitted scarring even in mild cases.
4. Treatment options include topical retinoids and benzoyl peroxide.

Question 3

What distinguishes mid-childhood acne from other types of acne?

Answer 3

Mid-childhood acne appears between 1-7 years of age and is considered very rare due to the quiescent production of androgens from the adrenal and gonadal glands. It is important to check for other signs of androgenism in affected children.

Question 4

What are the key features of acne conglobata?

Answer 4

Acne conglobata is characterized by:

• Severe form of nodular acne, most common in teenage males but can occur in any sex.
• Presents as a mixture of comedones, papules, pustules, nodules, abscesses, and scars.
• Commonly located on the back, buttocks, chest, and to a lesser extent, the abdomen, shoulders, neck, face, upper arms, and thighs.
• Treatment may include isotretinoin and systemic glucocorticoids.

Question 5

What are the systemic symptoms associated with acne fulminans?

Answer 5

Acne fulminans, the most severe form of acne, may present with systemic symptoms such as:

• Fever
• Leukocytosis (10,000 – 30,000/mm3)
• Polyarthralgia
• Myalgia
• Hepatosplenomegaly
• Anemia
• Bone pain, especially in the clavicle and sternum (lytic lesions on x-ray)
• Erythema nodosum

The onset is often explosive, and lesions primarily affect the chest and back, becoming ulcerative and healing with scarring.

Question 6

A patient presents with acneiform eruptions and systemic symptoms such as fever and bone pain. What is the likely diagnosis and treatment?

Answer 6

The likely diagnosis is acne fulminans. Treatment includes systemic glucocorticoids and low-dose isotretinoin.

Question 7

A 15-year-old male presents with sudden onset of tender, oozing plaques with hemorrhagic crusts on his chest and back. He also has fever, myalgia, and bone pain. What is the likely diagnosis and initial treatment?

Answer 7

The likely diagnosis is acne fulminans. Initial treatment involves systemic glucocorticoids (e.g., prednisone 0.5-1.0 mg/kg/day) before starting isotretinoin at a low dose (0.1 mg/kg/day) to control inflammation.

Question 8

A teenage boy presents with draining lesions on his back that discharge foul-smelling material. What is the condition, and what is the most effective treatment?

Answer 8

The condition is acne conglobata. The most effective treatment is isotretinoin (initial dose 0.5 mg/kg/day or less) along with systemic glucocorticoids to reduce severe flares.

Question 9

A 6-month-old boy presents with open and closed comedones on his cheeks and chin. What is the likely diagnosis and treatment?

Answer 9

The likely diagnosis is infantile acne. Treatment includes topical retinoids and benzoyl peroxide. Oral therapy with erythromycin, azithromycin, trimethoprim, or isotretinoin can be used in severe or refractory cases.

Question 10

A patient presents with acneiform eruptions and erythema nodosum. What is the likely diagnosis and treatment?

Answer 10

The likely diagnosis is acne fulminans. Treatment includes systemic glucocorticoids and isotretinoin.

Question 11

What are the key characteristics of neonatal acne and how does it differ from acne vulgaris?

Answer 11

• Occurs in 20% of newborns
• Appears around 2 weeks of age and resolves within 3 months
• Small, inflamed papules congregate over the nasal bridge and cheeks
• Comedo formation is ABSENT, indicating different pathophysiology from acne vulgaris
• Sebum excretion rates are transiently elevated during the perinatal period
• May be associated with Malassezia sympodialis (causality not proven)
• Neonatal cephalic pustulosis presents with widespread papulopustular lesions on the face, scalp, upper chest, and shoulders.

Question 12

What are the treatment options for infantile acne and what factors influence its resolution?

Answer 12

• Infantile acne typically occurs at 3-6 months of age
• Characterized by open and closed comedones on the cheeks and chin, along with papules, pustules, and nodules on the face
• Pitted scarring may occur even with mild disease
• Due to transient elevation of dehydroepiandrosterone (DHEA)
• Treatment options include:
  
  1. Topical retinoids and benzoyl peroxide
  2. Oral therapy with erythromycin, azithromycin, trimethoprim, or isotretinoin for severe or refractory cases
• Typically resolves around 1-2 years of age.

Question 13

What are the clinical features and treatment strategies for acne fulminans?

Answer 13

• Acne fulminans is the most severe form of acne, potentially occurring with or without systemic symptoms.
• Clinical features include:
  
  • Sudden appearance of inflammatory, tender, oozing plaques with hemorrhagic crusts
  • Lesions predominantly on the chest and back, rapidly becoming ulcerative and healing with scarring
  • Systemic symptoms may include fever, leukocytosis, myalgia, hepatosplenomegaly, and bone pain
• Treatment strategies include:
  
  1. Systemic glucocorticoids and intralesional glucocorticoids
  2. Prednisone (0.5 - 1.0 mg/kg/day) before isotretinoin for 2-4 weeks, depending on severity
  3. Initial isotretinoin dosing should be low (0.1 mg/kg/day) until inflammation is controlled.

Question 14

How does mid-childhood acne present and what should be assessed in these patients?

Answer 14

• Mid-childhood acne appears between 1-7 years of age and is rare due to quiescent adrenal and gonadal androgen production.
• Key assessments include:
  
  • Checking for signs of androgenism (pubic/axillary hair, testicular enlargement, breast enlargement)
  • Determining child growth and bone age
• Severe forms of nodular acne are most common in teenage males but can occur in any sex and persist into adulthood.

Question 15

What is the recommended treatment for acne fulminans with erythema nodosum?

Answer 15

Dapsone in conjunction with isotretinoin has been reported beneficial in the treatment of acne fulminans with erythema nodosum, along with cyclosporine, anakinra, and TNF inhibitors for difficult cases.

Question 16

What are the characteristics of acne excoriee des jeunes filles?

Answer 16

Acne excoriee des jeunes filles is a variant of skin picking disorder that leaves a crusted erosion that may scar. It is more common in females and is recognized as an excoriation disorder in DSM-5, categorized under obsessive-compulsive disorders.

Question 17

What triggers acne mechanica and what are its two types of reactions?

Answer 17

Acne mechanica occurs after repetitive physical trauma (pressure, friction, rubbing). The two types of reactions are: 1. Flare in acne with comedones and inflammatory papules (acne mechanica). 2. Follicular inflammatory lesions (folliculitis mechanica).

Question 18

What is the treatment for solid facial edema associated with acne?

Answer 18

Treatment for solid facial edema includes low dose isotretinoin (0.2 - 0.5mg/kg/day) alone or in combination with oral glucocorticoids, ketotifen (1-2mg/day), or clofazimine for 4-5 months.

Question 19

What is SAPHO syndrome and its associated treatments?

Answer 19

SAPHO syndrome is characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis, predominantly associated with hyperostosis of the anterior chest and palmoplantar pustulosis. Treatment options include NSAIDs, sulfasalazine, infliximab, adalimumab, and methotrexate.

Question 20

What are the components of PAPA, PASH, and PAPASH syndromes?

Answer 20

PAPA syndrome includes pyogenic arthritis, pyoderma gangrenosum, and acne. PASH syndrome includes pyoderma gangrenosum, acne, and hidradenitis suppurativa. PAPASH syndrome includes pyogenic arthritis, pyoderma gangrenosum, acne, and hidradenitis suppurativa.

Question 21

A patient on isotretinoin develops explosive flares of friable plaques with systemic symptoms. What adjustments should be made to their treatment?

Answer 21

The isotretinoin dose should be reduced or discontinued, and prednisone should be started immediately.

Question 22

A patient with acne fulminans is not responding to standard treatment. What additional medications could be considered?

Answer 22

Additional medications include dapsone, cyclosporine, anakinra, and TNF inhibitors for difficult cases.

Question 23

A patient presents with woody edema of the mid-third face and erythema. Oral antibiotics are ineffective. What is the condition and treatment?

Answer 23

The condition is acne with solid facial edema (Morbihan disease). Treatment includes low-dose isotretinoin (0.2-0.5 mg/kg/day) alone or in combination with oral glucocorticoids, ketotifen, or clofazimine for 4-5 months.

Question 24

A patient with acne and erythema nodosum is found to have hyperostosis of the anterior chest. What syndrome might this indicate, and what is the treatment?

Answer 24

This might indicate SAPHO syndrome. Treatment includes NSAIDs, sulfasalazine, infliximab, adalimumab, methotrexate, and bisphosphonates for bone pain.

Question 25

A patient presents with acneiform eruptions and woody edema of the mid-third face. What is the condition and treatment?

Answer 25

The condition is acne with solid facial edema (Morbihan disease). Treatment includes low-dose isotretinoin and oral glucocorticoids.

Question 26

A patient presents with acneiform eruptions and hyperostosis of the anterior chest. What is the likely diagnosis and treatment?

Answer 26

The likely diagnosis is SAPHO syndrome. Treatment includes NSAIDs, sulfasalazine, and TNF inhibitors.

Question 27

A patient presents with acneiform eruptions and pustules after starting isotretinoin. What is the likely cause and treatment?

Answer 27

The likely cause is isotretinoin-induced acne fulminans. Treatment includes reducing or discontinuing isotretinoin and starting prednisone immediately.

Question 28

What is the recommended treatment approach for acne fulminans with erythema nodosum when isotretinoin is used?

Answer 28

Dapsone in conjunction with isotretinoin has been reported beneficial in the treatment of acne fulminans with erythema nodosum. Additionally, cyclosporine, anakinra, and TNF inhibitors may be considered for difficult cases.

Question 29

What are the key characteristics of acne excoriee des jeunes filles and its management?

Answer 29

Acne excoriee des jeunes filles is a variant of skin picking disorder that leaves a crusted erosion that may scar, more common in females. It is recognized as an excoriation disorder in DSM-5 and should be co-managed with psychiatry.

Question 30

Describe the pathogenesis and types of reactions associated with acne mechanica.

Answer 30

Acne mechanica occurs after repetitive physical trauma (pressure, friction, rubbing) and results in two types of reactions: 1. Flare in acne with comedones and inflammatory papules (acne mechanica). 2. Follicular inflammatory lesions (folliculitis mechanica). Pathogenesis is not fully understood but may involve alterations in barrier function, microbiome, activation of the innate immune system, and keratinocyte disruption.

Question 31

What is the treatment strategy for solid facial edema associated with acne vulgaris?

Answer 31

The treatment for solid facial edema, also known as Morbihan disease, includes low-dose isotretinoin (0.2-0.5mg/kg/day) alone or in combination with oral glucocorticoids, ketotifen (1-2mg/day), or clofazimine for 4-5 months. Oral antibiotics are ineffective.

Question 32

What are the clinical features and treatment options for SAPHO syndrome?

Answer 32

SAPHO syndrome is characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis, predominantly associated with hyperostosis of the anterior chest and palmoplantar pustulosis. Treatment options include NSAIDs, sulfasalazine, infliximab, adalimumab, and methotrexate, with bisphosphonates for bone pain. Paradoxical worsening of skin manifestations can occur with anti-TNF therapy.

Question 33

What are the key features of Polycystic Ovarian Syndrome (PCOS) related to acne?

Answer 33

- Occurs in 5-10% of women. - Characterized by **hyperandrogenism**, **acne**, **insulin resistance**, and **acanthosis nigricans**. - Should be suspected in women with oligomenorrhea, hyperandrogenism, or polycystic ovaries on ultrasound. - Premenarchal women with acne and hirsutism should be screened for PCOS with free serum testosterone levels. - Women with PCOS are at increased risk of infertility, impaired glucose tolerance, type 2 DM, dyslipidemia, endometrial cancer, and cardiovascular disease. - OCP with spironolactone can be helpful in controlling acne and hirsutism.

Question 34

What is the significance of 21-hydroxylase deficiency in Congenital Adrenal Hyperplasia (CAH) related to acne?

Answer 34

- CAH is autosomal recessive and can present in both classic and nonclassic types. - 21-hydroxylase deficiency leads to increased androgens, which can cause acne. - Neonates are screened at birth for the classic type, which typically presents with ambiguous genitalia and salt wasting. - Nonclassic type may not be identified at birth and can present throughout childhood with normal cortisol levels but increased androgens. - Treatment includes low-dose replacement of glucocorticoids, OCPs, spironolactone, or flutamide in females.

Question 35

What are the characteristics of steroid folliculitis as an acneiform eruption?

Answer 35

- May appear as early as 2 weeks after initiation of systemic glucocorticoids or corticotropin. - Lesions consist of small pustules and red papules, usually in the same stage of development. - Primarily affects the trunk and shoulders with lesser involvement of the face. - Treatment involves discontinuing corticosteroids and using topical retinoids and antibiotics.

Question 36

What are the common causes of drug-induced acne?

Answer 36

- Other medicines can cause monomorphic diffuse popular eruption. - Halogenated compounds containing bromides or iodides are often found in cold and asthma remedies, sedatives, and other vitamin and mineral.

Question 37

What is the timeline for steroid folliculitis after initiation of systemic glucocorticoids?

Answer 37

Steroid folliculitis may appear as early as 2 weeks after initiation of systemic glucocorticoids or corticotropin.

Question 38

What are the characteristics of lesions in steroid folliculitis?

Answer 38

Lesions consist of small pustules and red papules, primarily on the trunk and shoulders, with lesser involvement of the face.

Question 39

What is the treatment for steroid folliculitis?

Answer 39

Treatment includes discontinuing corticosteroids and using topical retinoids and antibiotics.

Question 40

What are common causes of drug-induced acne?

Answer 40

Other medicines can cause monomorphic diffuse papular eruption.

Question 41

What medications are commonly associated with drug-induced acne?

Answer 41

Common medications include glucocorticoids, phenyltoin, lithium, isoniazid, and high-dose vitamin B complex.

Question 42

What is the relationship between EGFR inhibitors and acneiform eruptions?

Answer 42

EGFR inhibitors can cause perifollicular, papulopustular eruptions on the face and upper torso in 86% of patients treated.

Question 43

What are the treatment options for EGFR inhibitor-associated eruptions?

Answer 43

Treatment options include antihistamines, topical hydrocortisone, and antibiotics.

Question 44

What are the characteristics of occupational acne?

Answer 44

Occupational acne can be caused by industrial compounds such as coal tar derivatives and chlorinated hydrocarbons.

Question 45

What is the treatment for occupational acne?

Answer 45

Treatment includes avoiding exposure to the offending compounds and using topical or systemic retinoids.

Question 46

What diagnostic test should be performed for suspected PCOS in a woman with oligomenorrhea, acne, and hirsutism?

Answer 46

Free serum testosterone levels should be tested.

Question 47

When should testosterone testing be deferred in premenarchal women?

Answer 47

Testing should be deferred until 2 years after menarche due to irregular menstrual cycles in this age group.

Question 48

What is the condition when a patient develops acneiform eruptions after prolonged use of topical corticosteroids?

Answer 48

The condition is steroid folliculitis.

Question 49

What is the treatment for steroid folliculitis?

Answer 49

Treatment includes discontinuation of corticosteroids and use of topical retinoids and antibiotics.

Question 50

What is the condition when a patient presents with acneiform eruptions after exposure to industrial compounds?

Answer 50

The condition is occupational acne.

Question 51

What is the likely cause of acneiform eruptions after starting a new medication?

Answer 51

The likely cause is drug-induced acne.

Question 52

What is the treatment for drug-induced acne?

Answer 52

Treatment includes discontinuing the offending medication and using topical retinoids and antibiotics.

Question 53

What are the key clinical features of Polycystic Ovarian Syndrome (PCOS) in women?

Answer 53

Features include hyperandrogenism, acne, insulin resistance, and acanthosis nigricans.

Question 54

What are the risks associated with PCOS?

Answer 54

Women with PCOS are at increased risk of infertility, impaired glucose tolerance, type 2 DM, dyslipidemia, endometrial cancer, and cardiovascular disease.

Question 55

What treatment can help control acne and hirsutism in women with PCOS?

Answer 55

OCP with spironolactone can help control acne and hirsutism.

Question 56

How does Congenital Adrenal Hyperplasia (CAH) present in neonates?

Answer 56

Classic type typically presents at birth with ambiguous genitalia and salt wasting.

Question 57

What is the treatment for CAH in females?

Answer 57

Treatment consists of low-dose replacement of glucocorticoids, OCPs, spironolactone, or flutamide.

Question 58

What is the condition characterized by acneiform eruptions after prolonged exposure to a hot environment?

Answer 58

The condition is tropical acne.

Question 59

What is the treatment for tropical acne?

Answer 59

Treatment includes systemic antibiotics and moving to a cooler environment.

Question 60

What is chloracne and its common causes?

Answer 60

Chloracne is a type of acne caused by chlorinated hydrocarbons found in fungicides, insecticides, and wood preservatives.

Question 61

What are the treatment options for chloracne?

Answer 61

Treatment includes topical or systemic retinoids and oral antibiotics.

Question 62

What characterizes gram-negative folliculitis?

Answer 62

Gram-negative folliculitis occurs in patients treated with long-term oral antibiotics, especially tetracyclines.

Question 63

What is the treatment for gram-negative folliculitis?

Answer 63

Treatment involves using an antimicrobial agent with appropriate gram-negative coverage, and recalcitrant cases may require isotretinoin.

Question 64

What is radiation acne and its associated syndrome?

Answer 64

Radiation acne can develop from ionizing, infrared, and UV radiation, leading to acneiform eruptions.

Question 65

What are the treatment options for radiation acne?

Answer 65

Treatment options include oral or topical retinoids, comedone extraction, or CO2 laser.

Question 66

What is acne aestivalis and its common demographic?

Answer 66

Acne aestivalis is a monomorphic eruption seen after sun exposure, commonly affecting women aged 20-30 years.

Question 67

What is the treatment for acne aestivalis?

Answer 67

Treatment includes topical retinoids and benzoyl peroxide.

Question 68

What is pseudoacne of the nasal crease?

Answer 68

Pseudoacne of the nasal crease is an anatomical variant that appears as a transverse linear groove across the middle of the nose.

Question 69

What is the treatment for pseudoacne of the nasal crease?

Answer 69

Treatment includes addressing the underlying cause, such as allergic salute, and using topical treatments as needed.

Question 70

What is Apert syndrome and its associated features?

Answer 70

Apert syndrome is characterized by synostoses of the cranium, vertebral bodies, and hands and feet, and presents with diffuse acneiform eruptions.

Question 71

What is the treatment for Apert syndrome?

Answer 71

Treatment includes isotretinoin, which has shown excellent response.

Question 72

What is radiation acne and what syndrome is associated with it?

Answer 72

Radiation acne can develop from ionizing, infrared, and UV radiation, leading to acneiform eruptions. It may present as comedo-like papules during the acute phase of radiation dermatitis. The Favre-Racouchot syndrome is associated with solar comedones and senile comedones, characterized by yellow atrophic plaques and nodular cutaneous elastosis. Treatment options include oral or topical retinoids, comedone extraction, or CO2 laser.

Question 73

Describe the features of tropical acne and its treatment.

Answer 73

Tropical acne is characterized by severe acneiform folliculitis that develops in tropical climates or scorching occupational environments, particularly affecting the trunk and buttocks. It presents as deep, large, inflammatory nodules resembling acne conglobata. The exact pathogenesis is unknown, but secondary infection with coagulase-positive staphylococci is common. Treatment typically involves systemic antibiotics and moving to a cooler environment.

Question 74

What are the clinical features of acne aestivalis and its treatment?

Answer 74

Acne aestivalis is a monomorphic eruption consisting of multiple, uniform, red, papular lesions that appear after sun exposure. It commonly affects women aged 20-30 years and is found on the shoulders, arms, neck, and chest. Treatment options include topical retinoids and benzoyl peroxide.

Question 75

What is pseudoacne of the nasal crease and its histological features?

Answer 75

Pseudoacne of the nasal crease is an anatomical variant that appears as a transverse linear groove across the middle of the nose. It is characterized by the development of comedones, milia, and acneiform red papules in preadolescent patients. Histologically, it shows keratin granulomas derived from ruptured, inflamed milia.

Question 76

What are the key features of Apert syndrome and its associated skin manifestations?

Answer 76

Apert syndrome, also known as Acrocephalosyndactyly, is an autosomal dominant condition characterized by synostoses of the cranium, vertebral bodies, and hands and feet, with a mutation in FGFR-2. It presents with diffuse acneiform eruptions involving the arms, buttocks, and thighs. Patients often show a resistant response to treatment, but isotretinoin has been reported to be effective.

Question 77

What is the typical demographic distribution for perioral/periorificial dermatitis?

Answer 77

Perioral/periorificial dermatitis occurs in a bimodal distribution, primarily affecting young children and young adults, with a female predominance.

Question 78

What are the common clinical features of perioral/periorificial dermatitis?

Answer 78

Common features include small inflammatory papules and pustules around the mouth in a well demarcated pattern, sparing the lip margin, variable scaling and dryness, and possible involvement of the nose, eyes, or groin region termed periforicial dermatitis.

Question 79

What distinguishes periorificial granulomatous dermatitis from other forms?

Answer 79

Periorificial granulomatous dermatitis is characterized by larger, granulomatous inflammatory papules that coalesce into a well delineated plaque around the mouth, more likely involvement of periocular, perinasal, and groin areas, and possible accompanying conditions such as blepharitis and chalazion.

Question 80

What is the Facial Afro-Caribbean Eruption (FACE) and how does it present?

Answer 80

Facial Afro-Caribbean Eruption (FACE) presents as uniform, granulomatous sarcoidal papules distributed over typical periorificial areas, involving upper eyelids and helices or ears.

Question 81

What are the potential triggers for perioral/periorificial dermatitis?

Answer 81

Potential triggers include topical or inhaled corticosteroids (especially fluorinated steroids) and fluoride in dentifrices.

Question 82

What is the recommended treatment for perioral/periorificial dermatitis?

Answer 82

Recommended treatments include discontinuation of topical steroids, topical antimicrobial and anti-inflammatory agents such as metronidazole, clindamycin, erythromycin, azelaic acid, sodium sulfacetamide, tacrolimus/pimecrolimus, and for severe cases, oral erythromycin or azithromycin for children and oral tetracycline for adults.

Question 83

A patient presents with acneiform eruptions and granulomatous sarcoidal papules on the face. What is the condition and treatment?

Answer 83

The condition is Facial Afro-Caribbean Eruption (FACE). Treatment includes antiparasitic agents (e.g., praziquantel, ivermectin) and topical or oral antibiotics.

Question 84

A patient presents with granulomatous inflammatory papules around the mouth and eyes. What is the likely diagnosis and treatment?

Answer 84

The likely diagnosis is periorificial granulomatous dermatitis. Treatment includes discontinuation of topical steroids, topical antimicrobials (e.g., metronidazole, clindamycin), and oral antibiotics for severe cases.

Question 85

A patient presents with acneiform eruptions and pustules around the mouth. What is the likely diagnosis and treatment?

Answer 85

The likely diagnosis is perioral dermatitis. Treatment includes discontinuation of topical steroids and use of topical antimicrobials or oral antibiotics for severe cases.

Question 86

What are the distinguishing features of Periorificial Granulomatous Dermatitis compared to typical Perioral Dermatitis?

Answer 86

Periorificial Granulomatous Dermatitis is characterized by larger, granulomatous inflammatory papules that coalesce into a well delineated plaque around the mouth, more likely involvement of periocular, perinasal, and groin areas, and possible accompanying conditions such as blepharitis and chalazion.

Question 87

What is the recommended treatment approach for Perioral/Periorificial Dermatitis, particularly in cases triggered by topical steroids?

Answer 87

The treatment approach includes discontinuation of topical steroids as a primary step, use of topical antimicrobial and anti-inflammatory agents, and for severe cases, consider oral antibiotics.

Question 88

What are the clinical implications of the histological findings in Perioral/Periorificial Dermatitis?

Answer 88

The histological findings in Perioral/Periorificial Dermatitis resemble rosacea and include perifollicular and perivascular granulomas admixed with lymphocytes, suggesting an inflammatory response that may be influenced by Demodex.