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Folliculitis Flashcards

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1
Q

Causes of superficial folliculitis

A

Infectious: bacterial (staph, pseudomonal), fungal, viral (HSV), ectoparasite
Non-infectious:
- irritant
- drug induced
- immunosuppression associated eosinophilic
- Ofuji
- Eosinophilic pustular folliculitis in infancy

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2
Q

Gram negative folliculitis - who gets it?

A

Klebsiella, E coli, Proteus
Acne patients receiving long term antibiotic therapy
Get pustules in the facial T zone and perinasal distribution
Rx: gentamicin, benzoyl peroxide
Systemic: quinolones
Severe: roaccutane

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3
Q

Hot tub folliculitis - what causes it? How do you manage?

A

Pseudomonas aeruginosa from being in a hot tub or whirlpool 12-48 hours prior to onset
Develop oedematous pink to red follicular ppaules and pustules on the trunk
Serious if immunocompromised
Self limited, can use antibacterial soap
If severe or immunocomrpomised –> ciprofloxacin 500 mg BD for 7-14 days
Water in hot tub: treat wtih chlorine and maintain pH 7.2-7.4m, 0.4-1 ppm, and change every 6-8 weeks to lower organic carbon level

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4
Q

What causes dermatophyte folliculitis?

A

Tinea barbae: T mentagrophytes or T verrucosum
Rx: topical antifungals might not cut it, terbinafine for 2-3 weeks, griseofulvin for 4-6 weeks, itraconazole for a week a month

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5
Q

Risk factor for Majocchi granuloma

A 
Usually from T rubrum
Risk factors:
- Women who shave their legs
Occlusion
Immunosuppression
Use of potent topical steroids
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6
Q

Risk factors for malassezia folliculitis

A 
Younger adults
Warm weather
Occlusion and excessive sebum production
Antibiotic therapy - particularly tetracyclines
Iatrogenic immunosuppression
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7
Q

Clinical for malassezia folliculitis

A

Pruritic follicular papules and some pustules on the back, chest and shoulders
Central white-yellow colour represents compact keratin rather than pus
KOH preparation - yeast forms

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8
Q

Rx for malassezia folliculitis

A

Antifungals, selenium sulfide shampoo, 50% propylene glycol in water
Systemic: fluconazole, 100-200 mg/day for 3 weeks or 200-300 mg once weekly for 1-2 months, itraconazole 200 mg/day for 1-3 weeks

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9
Q

Candida folliculitis clinical gems and rx

A

Pruritic satellite pustules surrounding areas of intertriginous candidiasis
Facial lesions may look like tinea barbae
Primarily diabetics
GSCM, stop steroids, start topical antifungal, if severe may need fluconazole daily for a week then every other day for 1 months

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10
Q

Herpetic sycosis risk factors and diagnosis

A

Risk factors: facial HSV, shave with blade razor, HIV/immunosuppressed
Dx: Tzanck smear, biopsy MNGC, positive PCR

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11
Q

Demodex folliculitis clinical and rx

A

Associated with immunosuppression (not always)
Erythematous follicular papules and pustules on the face, especially nose, neck, background of diffuse erythema
Skin scrapings - Demodex mites
Rx: topical ivermectin, permethrin, or single dose of ivermectin

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12
Q

Drug induced folliculitis (acneiform) causes

A
  • Medications - did you MISPLACE your meds Bae?
MEK inhibitors (trametinib)
Iodides, isoniazid
Steroids
Phenytoin, progestins
Lithium
Anabolic steroids - danazol, testosterone
Corticotropin, cyclosporin
EGFR inhibitors

Bromide, B6, B12
Azathioprine

Comes up within 2 weeks of starting

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13
Q

Drug induced folliculitis clinical and rx

A

Monomorphic erythematous follicular papules and pustules on the trunk, shoulders and upper arms
Multiple papulopustules on the face and scalp, sometimes admixed with scale-crust
No comedones

Best rx: topical abx, benzoyl peroxide, retinoids, erythromycin
Systemic: tetracycline, doxycycline, minocycline

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14
Q

Necrotizing infundibular crystalline folliculitis

A

Yeasts and gram positive bacteria in affected follicles
Waxy papules that favour the forehead, neck and back
Birefringent, filamentous, crystalline deposits within follicular ostia
Topical or systemic antimycotics

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15
Q

Actinic folliculitis

A

Development of follicular pustules on the upper trunk and arms 24-30 hours after first sun exposure of the summer
Lesions spare the face
Not itchy
Its from sun exposure
Rx: photoprotection, mild steroids topically, isoretinoin if severe

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16
Q

The three major forms of eosinophilic folliculities

A
  1. Eosinophilic pustular folliculitis - ofuji disease
  2. Immunosuppression/HIV associated eosinophilic pustular folliculitis
  3. Eosinophilic pustular folliculitis of infancy
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17
Q

Eosinophilic pustular folliculitis epidemiology

A

F>M 5:1
Japanese
Adults, rarely children

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18
Q

Eosinophilic pustular folliculitis pathogenesis

A

No idea

?hypersensitivity reaction to an antigen

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19
Q

Eosinophilic pustular folliculitis clinical

A

Intensely pruritic
Recurrent crops of group, follicular pustules and papulopustules, explosive
Can have erythematous patches and plaques with superimposed coalescent pustules, central clearing and a centrifugal extension –> annular and figurate
‘Sebaceous’ distribution, but can get on digits, palms, soles
Last 7-10 days, tend to relapse 3-4 weekly
Rarely have an early butterfly rash that can look like lupus
Peripheral eosinophilia

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20
Q

Eosinophilic pustular folliculitis histopathology

A

Spongiosis
Lymphocyte and eosinophil exocytosis into the follicular epithelium
Can extend from sebaceous gland and its duct up to the infundibular zone
Micropustular aggregation develops - hallmark finding of infundibular eosinophilic pustules
Can get secondary follicular mucinosis

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21
Q

Eosinophilic pustular folliculitis treatment

A

Just case reports or small series
Topical steroids, tacrolimus, anti-histamines
First line: oral indomethacin
Second line: NBUVB, oral minocycline, dapsone, steroids, colchicine
Cyclosporin in refractory

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22
Q

How is immunosuppression associated eosinophilic pustular folliculitis different to the non-immunosuppression one?

A

Immunosuppression
No large coalescent pustules or figurate lesions
Indvidual lesions more persistent

Histology is the same

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23
Q

immunosuppression associated eosinophilic pustular folliculitis associations

A

HIV/AIDS - correlates with low CD4 count (can improve when rises)
ART commencement - immune reconstitution inflammatory syndrome
Haem malignancy: lymphoma, CLL, AML
HSCT

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24
Q

immunosuppression associated eosinophilic pustular folliculitis pathogenesis

A

Don’t fully know
Th2 immune response
AIDS: have elevated IL-4, 5, RANTES (CCL5), eotaxin (CCL11)

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25
immunosuppression associated eosinophilic pustular folliculitis clinical
Chronic, pruritic follicular papular eruption of the face, scalp and upper trunk Papules are slightly oedematous and pustules may be present ++ pruritis Lymphopenia
26
How is necrotizing eosinophilic folliculitis different to immunosuppression associated eosinophilic pustular folliculitis
Necrotizing: associated with atopy, nodules, ulceration, and evidence of follicular necrosis and eosinophilic vasculitis
27
immunosuppression associated eosinophilic pustular folliculitis treatment
HIV: treat HIV with rise in CD4 cell count, may lead to a resolution If IRIS associated - continue ART as IRIS-related disease gradually subsides Topical and oral antipruritics, topical steroids NBUVB may be required Other: topical tacrolimus, permethrin Oral itraconazole, metronidazole, antibiotics, isotretinoin interferon beta and gamma
28
Eosinophilic pustular folliculitis of infancy epidemiology
<14 months usually (case series) | M>F 4:1
29
Eosinophilic pustular folliculitis of infancy pathogenesis
Sterile pustules Eosinophils involved ? reaction pattern to ?arthrobod ? dermatophytosis
30
Eosinophilic pustular folliculitis of infancy clinical features
``` Pruritic Follicular based pustules and vesiculopustules with an erythematous base Secondary crusting Cyclic: 1-12 weeks Resolves by age 3 ```
31
Eosinophilic pustular folliculitis of infancy pathology
Eosinophilic spongiosis Eosinophil infiltrate Variable neutrophils Peri-follicular inflammatory infiltrate: eos, neutrophils, lymphocytes, histiocytes
32
Eosinophilic pustular folliculitis of infancy ddx
1. Erythema toxicum neonatorum - occurs earlier in age, more widespread but histologically looks the same 2. Transient neonatal pustular melanosis - darkly pigmented skin, neutrophils predominate, time of birth, favour the face, neck and shins 3. Acropustulosis of infancy - darker skinned males, hands and feet, not really the scalp, occurs in neonatal period but can be 3-6 months, and is episodic as well ? is there an overlap 4. LCH - Papules, pustules, vesicles, crusts 5. Papulopustular eruption of hyperIgE syndrome 6. Vesiculopustular eruption of transient myeloproliferative disorder (Down syndrome)
33
Eosinophilic pustular folliculitis of infancy rx
Reassurance Topical steroids Anti-histamines
34
What is disseminate and recurrent infundibulofolliculitis?
Rare rash that occurs in darkly pigmented skin No association with atopy, but looks like papular eczema 1-2 mm, pruritic, skin-coloured papules pierced by hair, looks like goosebumps Trunk most commonly involved, followed by neck, buttocks, arms Lasts for weeks, months or years Ddx: papular eczema, lichen nitidus, folliculitis, less likely KP, PRP, LPP as no keratotic plug Histology: infundibular involvement: perifollciular oedema, infiltrate of lymphocytes and neutrophils Rx: topical steroids, lactic acids, PUVA, vitamin A, isotretinoin
35
Main disorders of follicular keratinization
Erythromelanosis follicularis faciei Keratosis pilaris atrophicans Lichen spinulosus Phrynoderma
36
Erythromelanosis follicularis faciei epi and path
All races and all sexes Does favour Asian ancestry Pathogenesis unknown
37
Erythromelanosis follicularis faciei clinical
Lateral aspects of cheeks, and sometimes neck Red-brown coloured skin due to hyperkeratosis and vasodilation If skin type 1 then only have erythema Numerous pinhead sized follicular papules, hypopigmented KP to arms, with small rim of erythema surrounding the follicular keratotic plug
38
Erythromelanosis follicularis faciei pathology
Follicular hyperkeratosis Increased epidermal pigmentation Thicker and compact horny layer Decrease in hair shaft and ORS diameter, and reduced thickness of IRS Adnexa surrounded by lymphocytic infiltrate
39
Erythromelanosis follicularis faciei ddx
Keratosis pilaris rubra Melasma + telangiectatic erythema from photodamage Poikiloderma of Civatte --> anterolateral aspects of neck, spares submental region, erythema is from interfollicular telangiectasias, and there is a rim of hypopigmentation around each follicle, can extend to mandible KP atrophicans Ulerythema ophryogenes - childhood, favour the eybrows, follicular atrophy and scarring alopecia of lateral eyebrpws Atrophoderma verniculatum - cheeks, honeycomb scarring or worm eaten appearance
40
Erythromelanosis follicularis faciei treatment
Topical keratolytics: urea cream 10-20%, ammonium lactate 6-12%, tretinoin, adapalene, ammonium lactate plus hydroquinone 4% All anecdotal Topical tacalcitol (D3 analogue) - reduces roughness and scaling, but doesn't affect facial erythema Severe - isotretinoin Laser treatment for background erythema
41
Types of keratosis pilaris atrophicans
Ulerythema ophryogenes (faciei) Atrophoderma vermiculatum Keratosis follicularis spinulosa decalvans Folliculitis spinulosa decalvans
42
Ulerythema ophryogenes - keratosis pilaris atrophicans faciei - tell me about it
Autosomal dominant Onset in infancy Lateral third of eyebrows > temples, cheeks, forehead Erythematous follicular papules with central keratotic plug Follicular atrophy Scarring alopecia of lateral three eyebrows KP Associations: Noonan, cardio-facio-cutaneous, Woolly hair, Cornelia de Lange
43
Atrophoderma vermiculatum - tell me about it
?AD, onset childhood 5-12 years Cheeks >pre-auricular, upper lip Pitted, atrophic depressions in a vermiculate pattern ' worm eaten or honeycomb appearance' Association: ipsilateral congenital cataract, Loeys-Dietz, Rombo, Nicolau-Balus syndromes No KP
44
Keratosis follicularis spinulosa decalvans - tell me about it
XR transmitted Childhood onset, inflammation remits in puberty Face, scalp, limbs, trunk Erythematous follicular papules with central keratotic plugs, eventually leading to follicular atrophy Scarring alopecia of the scalp, eyebrow and eyelashes KP Associations: variable facial erythema, nail dystrophy, PPK, ocular: Keratitis, blepharitis, photphobia
45
Folliculitis spinulosa decalvans - tell me about it
``` AD, onset in puberty (or worsens then) In the scalp Follicular pustules Associated KP Associations: variable facial erythema and nail dystrophy, ocular: blepharitis, conjunctivitis, keratitis, photophobia ```
46
keratosis pilaris atrophicans treatments
``` Topical keratolytics Topical retinoids Topical or IL steroids Oral antibiotics Phototherapy Combination Anecdotally: oral retinoids and IPL Later: laser resurfacing, dermabrasion, and/or dermal fillers ```
47
Lichen spinulosus pathogenesis
``` We don't know the aetiology exactly Association with ?HIV --> type 6 PRP Other possible: Seb derm Drugs - omeprazole Hodgkin disease Crohn disease Syphilis Id to fungal ```
48
HIV associated follicular syndrome and type VI PRP
HIV PRP Nodulocystic acne Follicular spines - lichen spinulosus
49
Lichen spinulosus clinical
2-6 cm in diameter - multiple, skin-coloured keratotic follicular papules All have keratotic spines Neck, shoulders, extensor surfaces of arms, abdomen, buttocks, popliteal fossae Symmetric Face, hands and feet are spared Suddenly in crops, enlarge over a week, then remain stationary Idiopathic: childhood/teens, asymptomatic, although for some can be pruritic Spinulosis of the face can rarely occur - tiny follicular keratotic spicules of the cheeks
50
Lichen spinulosus pathology
Same as KP
51
Lichen spinulosus ddx
``` Phrynoderma Keratosis circumscripta Follicular ichthyosis Juvenile PRP (type 4 - extensors) Infectious: HIV associated follicular syndrome, Viral associated trichodysplasia, Demodicosis Follicular mucinosis MM BRAF inhibitors - and lithium - follicular plugging ```
52
Lichen spinulosus rx
``` 12% lactic acid 20-40% urea 6% salicylic acid Tacalcitol cream Tretinoin plus hydroactive adhesive applications Glycolic acid and salicylic acid peels ```
53
What is follicular ichthyosis?
Keratotic papules with follicular plugging and prominent follicular ostia Favours the head and neck region, can involve the extensors - fingers, elbows, knees
54
Phrynoderma
Toad skin Asia and Africa Rare in high income countries Intestinal malabsorption, anorexia, fad diets Vitamin A deficiency, but can be deficient in other things too Follicular papules of various sizes, conical keratotic plugs, favour the extensor surfaces of the extremities May spread to involve other locations Face is the last site to be involved, and hands and feet are spared
55
Major types of deep folliculitis
``` Furuncles Sycosis Pseudofolliculitis barbase Acne keloidalis HS ```
56
What does sycosis mean
Chronic inflammation of hair follicles
57
Types of sycosis
1. Barbae - staph aureus 2. Lupoid - scarring form, staph aureus, can have central atrophic scarring or cicatricial alopecia, granulomatous 3. Mycotic - dermatophyte folliculitis of bear area, usually caused by zoophilic organisms, hair can be painlessly removed 4. Herpetic
58
Pseudofolliculitis barbae epidemiology
African men, darkly pigmented skin | Women who shave in the groin
59
Pseudofolliculitis barbae pathogenesis
Intrafollicular and transfollicular penetration of hair --> so it is cut at an oblique angle and then curves into the skin and pierces it close to the hair follicle or in the hair follicle Grows in a spiral fashion Inflammatory reaction Also KRT75 has been identified as risk factor
60
Pseudofolliculitis barbae clinical
Anterolateral neck, not the moustache Pustules, abscesses, hyperpigmented firm papules with chronicitiy Scars - keloid and hypertrophic Chronic - creates grooves in the neck and makes it difficult to shave
61
Pseudofolliculitis barbae pathology
Down growth of hair Inflammatory infiltrate Abscess, pseudofollicle, foreign body giant cell reaction Fibrosis
62
Pseudofolliculitis barbae shaving guide
Shaving: don't pull skin taut, don't shave against hair growth, sharp razor, short strokes Remove pre-existing hairs with electric clippers, leave 1-2 mm stubble Wash area Rinse with water Shaving cream If significant burning or itching - topical steroid as aftershave
63
Pseudofolliculitis barbae treatment
Change shaving technique Compress and release of ingrowing hairs- compress for 10 minutes three times a day - water, saline, Burows solution (aluminium acetate) Topicals: steroids, clindamycin, tretiniod, benzoyl peroxide, alpha-hydroxy acids Antibiotics if infected Recalcitrant: prednisone for 7-10 days, topical eflornithine, laser hair removal, grow the beard out
64
Acne keloidalis epidemiology
Young African-American men Rarely in DCaucasians M>F 20:1 Puberty - 50 years
65
Acne keloidalis pathogenesis
Hairs curve back and penetrate the skin was an early hypothesis Mast cells? Irritation from shirt collars Low grade folliculitis
66
Acne keloidalis clinical
Posterior scalp and/or neck folliculitis, followed by the development of 2-4 mm dome shaped firm follicular papules that may or may not be pruritic Pustules, short-lived --> easily rupture No comedones Chronicity: hard papules, enlargen Coalesce to form keloid-like plaques, band like distribution near the posterior hairline Alopecia, tufted hairs Subcutaneous abscesses with draining sinuses may occur
67
Acne keloidalis pathology
Inflammation in upper 1/3 of hair follicle Initial infiltrate: neutrophils and lymphocytes, reports of plasma cells Sebaceous glands reduced or absent Advanced: hair follicles disrupted, fragments of naked hair shafts, granulomatous inflammation Dermal fibrosis, collagen fibres look like scar tissue Lower portion of follicle, including matrix, spared until later in the disease process
68
Acne keloidalis rx
Prevention: no head dress or head gear that causes mechanical irritation Start treatment early Tretinoin gel BD + mid-high steroid gel Topical or systemic antibiotics IL-steroids Punch excision - below the level of the hair follicle, and can use lignocaine + triamcimolone for anaesthesia, and then can do IL-steroids a=post procedure Excision, some argue post procedural topical aldara for 6-8 weeks If >1.5 cm in vertical diameter --> don't close primarily because causes a hairless, flat scar, instead do marsupialization, takes 8-12 weeks to close CO2 laser with post op IL-steroids NdYag and diode for papular lesions Cryotherapy After procedures, can use topical/IL-steroids, antibiotics, tretinoin-steroid gel mixture
69
Follicular occlusion tetrad
Acne conglobata HS Dissecting cellulitis of the scalp Pilonidal sinus
70
Follicular occlusion tetrad
Acne conglobata HS Dissecting cellulitis of the scalp Pilonidal sinus
71
HS pathogenesis
1. Hair follicle abnormality --> rupture --> chemotaxis 2. Genes identified: NOTCH1 and 2 deficiency, plus others 3. Inflammatory mediators: IL-1beta and TNF-alpha 4. Associations: smoking, lithium
72
Hurley staging
1: One or more abscesses with no sinus tract or scar formation 2: One or more widely separated recurrent abscesses, with sinus tract and scar formation 3: Multiple interconnected sinus tracts and abscesses throughout an affected region, more extensive scarring
73
Sartorius grading system
1. Region - 3 points per region: axilla, groin, gluteal, other (unilateral) 2. Number and scores of lesions for each region: nodules 1, fistulae 6 3. Longest distance between 2 relevant lesions: <5 cm = 1, 5-10 cm = 3, >10 cm = 9 4. Are all lesions clearly separated by normal skin? Yes 0, no 0
74
Complications of HS
``` Anaemia Secondary amyloidosis Lymphoedema Fistulae Hypoproteinaemia Nephrotic syndrome SAPHO SCC Autoinflammatory: PASH, PAPASH ```
75
List all treatments for HS
``` Lifestyle measures etc Topical: clindamycin, mupirocin to intertriginous areas, zinc gluconate, topical resorcinol IL-steroids Systemic antibiotics for bacterial infection Oral anti-biotic therapies: - Rifampicin + clinda - Tetracycline - Doxycycline - Dapsone - Bactrim Oral anti-androgen: finasteride, OCP Systemic retinoids Immunosuppressives: Humira, infliximab, cyclosporin, IL12/23, IL-23, IL-17 Metformin for insulin resistance ``` ``` Surgical: Marsupialization CO2 laser ablation with secondary healing Nd:YAG Early wide surgical excision Botox PDT Cryotherapy ```
76
List all treatments for HS
``` Lifestyle measures etc Topical: clindamycin, mupirocin to intertriginous areas, zinc gluconate, topical resorcinol IL-steroids Systemic antibiotics for bacterial infection Oral anti-biotic therapies: - Rifampicin + clinda - Tetracycline - Doxycycline - Dapsone - Bactrim Oral anti-androgen: finasteride, OCP Systemic retinoids Immunosuppressives: Humira, infliximab, cyclosporin, IL12/23, IL-23, IL-17 Metformin for insulin resistance ``` ``` Surgical: Marsupialization CO2 laser ablation with secondary healing Nd:YAG Early wide surgical excision Botox PDT Cryotherapy ```
77
What is trichostasis spinulosa?
Asymptomatic comedo like lesions, contain keratin and vellus hairs, mostly on face Histo: follicular hyperkeratosis and multiple vellus hairs, enveloped by a keratotic sheath within a dilated hair follicle Rx: keratolytics, depilatories, topical tretinoin, lasers
78
Viral associated trichodysplasia
Associated with polyomavirus Skin coloured papules and follicular spines favour the central face Loss of eyebrows and eyelashes, and alopecia to scalp Histo: large and distended anagen type follicles, high number of IRS cells with excessive amounts of trichohyaline granules Rx: stop immunosuppression, topical cidofovir, tazarotene gel or oral valganciclovir

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