(Ch38) Folliculitis Flashcards
Ddx for oedematous folliculitis?
Eosinophilic
Demodex
Pseudomonas
Gram -ve folliculitis other than hot tub causes
KEEP
Klebsiella
E.coli
Entrobacter
Proteus
Folliculitis that is common in in T zone of face, oily skin after long term abx Rx?
Gram -ve Folliculitis due to KEEP
Klebsiella
E.coli
Entrobacter
Proteus
Tx for gram -ve Folliculitis?
- Topical: antibacteria soaps, BP, gentamicin
- Systemic: Quinolones( Cipro)
- Recurrent or Severe: isotretnoin.
Hot tub Folliculitis time interval?
12-48h
more on trunk
How to prevent Hot tub Folliculitis?
Add Chlorine
pH 7.2-7.4
Water change every 6-8w
Irritant Folliculitis trigger and tx?
- Irritants: Coal tar and application against hair growth direction
Tx: Topical steroids
Folliculitis with crusting and loose hair in the beard area of a farmer?
Tinea barbae
causes and Rx of Tinea Barbae?
Trichophyton Mentagrophytes
T.Verrucosum
tx: Systemic antifungals
Filliculitis on the legs of women who shave their legs and is MC in immuncompermised ?
Majocchi granuloma
risk factors:
Immmunocompermised
Potent topical CS
Occlusion
Pathogen for Majocchi granuloma ?
Trichophyton rubrum
Tx: systemic antifungals
Folliculitis of beard area?
- Irritant-> Irritant application
- Tinea Barbae (Dermatophytes)-> Crust
- Herpes -> Vesicles
mention 4 types of Folliculitis in Immunocompermised
Malassezia
Candida
HSV (generalized)
Demodex
CH-DM
Risk factors for Majocchi granuloma?
- Female who shave their legs
- Occlusion
- topical potent steroids
- Immunsupression
Malassezia( Pityrosporum) Folliculitis risk factors?
- Young Adult
- Warm weather
- Increased sebum
- Occlusion
- tetracycline use
- immunosuppression
Which fungal folliculitis require systemic tx?
Dermatophytes induced
Candida Folliculitis features ?
Folds look for stellate pustules
More in DM patients
Demodex folliculitis clinical features?
Facial follicular papules/pustules with erythematous background
Tx: ivermectin or permethrin
Drug induced folliculitis resembles ?
Acniform eruption
Folliculitis with wax papules on the forehead
Necrotizing infundibular crystalline folliculitis
Actinic folliculitis features?
Pustular
Spares face
not pruritic
initial summer sun exposure
Avoid sun
not prevented by sunscreens
what are the 3 eosinophilic folliculitis ?
- Eosinophilic pustular folliculitis (Ofuji).
- Immunosuppression-associated eosinophilic pustular folliculitis.
- Eosinophilic pustular folliculitis of infancy.
What type of folliculitis is treated with NSAIDs?
Ofuji disease
Prostaglandin D2 activates pilosebaceous units and recruitment of eosinophils hence, use of indomethacin
Clinical Characteristics of Ofuji disease?
- Intensely pruritic
- Recurrent crops of grouped, follicular papulopustules.
- +/- Annular or figurate lesions
- On sebaceous areas
- Last ~7–10d & relapse q3–4 wks.
Histopathological Hallmark of Ofuji disease?
Micropustule then infundibular eosin pustule
Rx of Ofuji disease
Pruritus: TCS, tacrolimus & oral anti-H
- 1LRx: Oral indomethacin (50 mg/d).
- 2LRx: UVB
Minocycline (100 mg BID)
Dapsone (100 to 200 mg/d for ≥2 wks)
Colchicine (0.6 mg BID).
SCS
- Refractory: CsA
Ofuji vs Immunosuppression-associated eosinophilic pustular folliculitis ?
Ofuji disease:
1. non immunosuppressed
2. recurrent rash Last ~7–10d & relapse q3–4 wks.
3. Responds to indomethacin
4. MC with Japanese young men.
Immunosuppression-associated eosinophilic pustular folliculitis:
1. AIDS or ART (IRIS)/ Lymphoma
2. Chronic rash
3. no response to NSAIDS.
Immunosuppression-associated eosinophilic pustular folliculitis Pathogenesis
Th2 response in AIDS;
↑Lesional IL-1, IL-4, IL-5, RANTES (CCL5) & eotaxin (CCL11) mRNA
↑Serum CCL17, CCL26 (eotaxin-3) & CCL27
Immunosuppression-associated eosinophilic pustular folliculitis Rx
HIV: Rx underlying viral infection
IRIS-exacerbations:
Goal is improvement despite ART.
Temporary interruption of ART is unlikely if eosinophilic folliculitis is primary Sx of IRIS.
All:
Oral & topical antipruritics + TCS
If inadequate; UVB.
Other Rx: TCI
Topical permethrin
Oral itraconazole (200–400 mg daily)
Oral metronidazole (250 mg TID)
Oral Abx
Isotretinoin (0.5–1mg/kg/d x1–4 wk)
INF (β and γ)
Eosinophilic pustular folliculitis of infancy characteristics?
Prior to age 14 mo
↑M > F
Characteristic: Chronic and recurrent last 1-12w
resolves by age of 3y
Disseminate and Recurrent Infundibulofolliculitis vs KP or papular eczema?
No hx of ATOPY with Disseminate and Recurrent Infundibulofolliculitis
all common in SOC
Rx:
Topicals: TCS
12% lactic acid
20–40% urea
If topicals unsuccessful:
PUVA (3x/wk for 3wks then maintenance 2x/mo)
Vitamin A (50 000 IU BID)
Isotretinoin (0.5 mg/kg/day x16 wks).
Erythromelanosis Follicularis Faciei As/w skin condition?
KP
Erythromelanosis Follicularis Faciei location?
Lateral cheeks
pinhead- sized follicular papules relatively hypopigmented on red–brown-colored skin d/t vasodilation & hyperpigmentation.
Erythromelanosis Follicularis Faciei Histopath Specific features?
↓Hair shafts & ORS diameters +↓ thickness of IRS
↑Superficial blood vessels a/w grading of erythema.
Which ethnic group gets Erythromelanosis Follicularis Faciei?
Asian F 2nd decade
Keratosis Pilaris Atrophicans pathogenic features and mention 4 of them?
Features:
1. Abnormal follicular keratinization
2. atrophy
3. scarring alopecia
list:
- Ulerythema ophryogenes
- Atrophoderma vermiculatum
- Keratosis follicularis spinulosa decalvans
- Folliculitis spinulosa decalvans.
Keratosis Pilaris Atrophicans mode of inheritance?
AD:
- Ulerythema ophryogenes (18p) +/- AR
- Atrophoderma vermiculatum
- Folliculitis spinulosa decalvans.
XLR:
Keratosis follicularis spinulosa decalvans (MBTPS1)
Keratosis Pilaris Atrophicans starts at infancy?
Ulerythema ophryogenes (Keratosis Pilaris Atrophicans Facei)
Papules+ lateral eyebrow Alopecia
Ulerythema ophryogenes As/w syndromes ?
Noonan
Cardio-Facio-Cutnaous syn
Monosomy 18
Wooly hair syn
Which of Keratosis Pilaris Atrophicans no As/w KP?
Atrophoderma vermiculatum
Childhood 5-12y
pitted/honey comb atrophy
As/W Rombo syn and if unilateral as/w unilateral cataract
Which of Keratosis Pilaris Atrophicans As/w palmoplanter keratoderam and nail dystrophy + alopecia and papule ?
Keratosis follicularis spinulosa decalvans
and
Follicularis spinulosa decalvans
XLR vs AD Follicularis spinulosa decalvans
AD more severe and exacerbate after puberty vs XLR remits after puberty
XLR Follicularis spinulosa decalvans As/w conditions
Blephritis, keratitis , photophobia
Lichen spinolsus clinical presentation
Sudden crops; enlarge in 1 wk, then remain stationary
Lichen spinolsus As/w
Type VI PRP
Seborrheic dermatitis
Drug reaction (omeprazole)
BRAF inhibitors
systemic lithium
Hodgkin disease
Crohn, syphilis
Id reaction to fungal
Phrynoderma “toad skin” As/w
vitamin A deficiency
malabsorption
anorexia nervosa
fad diets
Face is last site to be involved
Hands & feet are spared.
Associated SSx: e.g. ocular, CNS
Pseudofolliculitis Barbae gene
Polymorphism in 1A α-helical subdomain of K75
Pseudofolliculitis Barbae MOA
interfollicular or intrafollicular
Area spared by Pseudofolliculitis Barbae vs Tinea barbae?
Moustache spared in Pseudofolliculitis Barbae
Treatment Recommendations for Pseudofolliculitis Barbae?
Compress
Topical or ILK Rx
2ndry infection Rx
Resistant disease
PIH rx
shaving care for Pseudofolliculitis Barbae
Do not pull the skin taut.
Do not shave against the grain/direction of hair growth.
Use a sharp razor each time, preferably multi-blade.
Take short strokes (with the grain of the hair) and do not shave over the same areas more than twice
Acne Keloidalis As/w
2/3 have concomitant seborrheic dermatitis
1/3 have concomitant pseudofolliculitis barbae.
?↑Mast cell density of neck/occipital scalp
rubbing & manipulation → Acne keloidalis.
clinically band-like distribution on posterior hairline
Acne Keloidalis vs Acne
No comedones
Acne keloidalis histopath
Naked hair shaft in dermis
Perifollicular fibrosis
Surrounding multi giant cells granuloma
⇓⇓Sebaceous glands in all stages.
Inflammation in upper 1/3 of follicle
What size of Acne keloidalis rx with 1ry intention ?
Plaques 1.0–1.5 cm in vertical diameter.
What size of Acne keloidalis rx with 2ndry intention ?
Plaques >1.5 cm in vertical diameter
Acne keloidalis Rx ladder
- Non-inflamed Papules and Plaques:
Mixture of tretinoin gel and potent corticosteroid gel, applied twice daily. - Inflamed Lesions with
Pustules:
Perform bacterial culture.
Administer appropriate systemic antibiotics or a course of oral isotretinoin.
Small Papules:
Perform punch excision to a depth below the level of hair follicles, followed by either primary closure or second intention healing.
Laser hair removal for permanent hair reduction.
Plaques ≤1.5 cm in Vertical Diameter:
Excise and close primarily.
Larger Plaques and Nodules
(>1.5 cm in Vertical Diameter):
Excise with a horizontal ellipse.
Extend excision below the posterior hairline to include fascia or deep subcutaneous tissue.
Allow healing by second intention.
Do not inject corticosteroids into the postoperative site.
Laser excision and cryosurgery are sometimes successful.
Postoperative Care:
Apply topical imiquimod daily for 6 weeks (or every other day for 8 weeks if irritation occurs).
Maintenance:
Use a tretinoin–corticosteroid gel mixture.
Apply intermittent intralesional corticosteroids and/or oral or topical antibiotics as needed.
what is a must when taking excision for Acne keloidalis
Punch must extend below level of follicle.
group at risk of HS?
↑♀ of African descent at puberty (F:M 3:1)
What could exacerbate HS?
Both smoking & lithium exacerbate HS
Familial HS mode of inheritance and genes
AD Mx
γ-secretase complex:
-Presenilin-1
-presenilin enhancer-2
-nicastrin
-Anterior pharynx-defective 1;
which cytokines increased in lesion of HS?
⇑ IL-1β & TNF-α
Which cytokines As/w disease activity?
⇑ Serum IL-2
Complications of HS?
Anemia
2° amyloidosis
lymphedema
Fistulae to urethra, bladder, peritoneum or rectum.
Hypoproteinemia
nephrotic syndrome
Microbiome in HS:
↓commensal microbiome (specifically Cutibacterium)
↑anaerobic bacteria (e.g. Prevotella)
Genetic disorders in which HS can be an associated finding
Dowling–Degos disease
Down syndrome
Pachyonychia congenita
Familial Mediterranean fever
Darier disease
Keratitis–ichthyosis–deafness
Trichostasis Spinulosa
Asymptomatic comedo-like lesions w/ keratin & vellus hairs
Rx for cosmetic appearance;
Keratolytics
Depilatories
Topical tretinoin
Lasers; long- pulsed Alex, short-pulsed Alex, pulsed diode
Periodic application of hydroactive adhesive pad
Viral-Associated Trichodysplasia risk factors
CsA tx
?In transplant patients
Viral-Associated Trichodysplasia cause
polyomavirus
Viral-Associated Trichodysplasia histopath
H&E:
Enlarged distended anagen-type follicles
↑IRS cells
Viral-Associated Trichodysplasia rx
If immunosuppressive Rx cannot be reduced:
Topical cidofovir or tazarotene gel
Oral valganciclovir (900 mg OD-BID)
Mention forms of sycosis
- Barbe
- Lupoid
- Mycotic
- Herpetic
which sycosis presents with scarring alopecia ?
Lupoid
