Folliculitis Flashcards
Causes of superficial folliculitis
Infectious: bacterial (staph, pseudomonal), fungal, viral (HSV), ectoparasite
Non-infectious:
- irritant
- drug induced
- immunosuppression associated eosinophilic
- Ofuji
- Eosinophilic pustular folliculitis in infancy
Gram negative folliculitis - who gets it?
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
Hot tub folliculitis - what causes it? How do you manage?
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
What causes dermatophyte folliculitis?
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
Risk factor for Majocchi granuloma
Usually from T rubrum Risk factors: - Women who shave their legs Occlusion Immunosuppression Use of potent topical steroids
Risk factors for malassezia folliculitis
Younger adults Warm weather Occlusion and excessive sebum production Antibiotic therapy - particularly tetracyclines Iatrogenic immunosuppression
Clinical for malassezia folliculitis
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
Rx for malassezia folliculitis
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
Candida folliculitis clinical gems and rx
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
Herpetic sycosis risk factors and diagnosis
Risk factors: facial HSV, shave with blade razor, HIV/immunosuppressed
Dx: Tzanck smear, biopsy MNGC, positive PCR
Demodex folliculitis clinical and rx
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
Drug induced folliculitis (acneiform) causes
- 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
Drug induced folliculitis clinical and rx
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
Necrotizing infundibular crystalline folliculitis
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
Actinic folliculitis
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
The three major forms of eosinophilic folliculities
- Eosinophilic pustular folliculitis - ofuji disease
- Immunosuppression/HIV associated eosinophilic pustular folliculitis
- Eosinophilic pustular folliculitis of infancy
Eosinophilic pustular folliculitis epidemiology
F>M 5:1
Japanese
Adults, rarely children
Eosinophilic pustular folliculitis pathogenesis
No idea
?hypersensitivity reaction to an antigen
Eosinophilic pustular folliculitis clinical
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
Eosinophilic pustular folliculitis histopathology
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
Eosinophilic pustular folliculitis treatment
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
How is immunosuppression associated eosinophilic pustular folliculitis different to the non-immunosuppression one?
Immunosuppression
No large coalescent pustules or figurate lesions
Indvidual lesions more persistent
Histology is the same
immunosuppression associated eosinophilic pustular folliculitis associations
HIV/AIDS - correlates with low CD4 count (can improve when rises)
ART commencement - immune reconstitution inflammatory syndrome
Haem malignancy: lymphoma, CLL, AML
HSCT
immunosuppression associated eosinophilic pustular folliculitis pathogenesis
Don’t fully know
Th2 immune response
AIDS: have elevated IL-4, 5, RANTES (CCL5), eotaxin (CCL11)
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
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
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
Eosinophilic pustular folliculitis of infancy epidemiology
<14 months usually (case series)
M>F 4:1
Eosinophilic pustular folliculitis of infancy pathogenesis
Sterile pustules
Eosinophils involved
? reaction pattern to ?arthrobod ? dermatophytosis
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
Eosinophilic pustular folliculitis of infancy pathology
Eosinophilic spongiosis
Eosinophil infiltrate
Variable neutrophils
Peri-follicular inflammatory infiltrate: eos, neutrophils, lymphocytes, histiocytes
Eosinophilic pustular folliculitis of infancy ddx
- Erythema toxicum neonatorum - occurs earlier in age, more widespread but histologically looks the same
- Transient neonatal pustular melanosis - darkly pigmented skin, neutrophils predominate, time of birth, favour the face, neck and shins
- 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
- LCH - Papules, pustules, vesicles, crusts
- Papulopustular eruption of hyperIgE syndrome
- Vesiculopustular eruption of transient myeloproliferative disorder (Down syndrome)
Eosinophilic pustular folliculitis of infancy rx
Reassurance
Topical steroids
Anti-histamines
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
Main disorders of follicular keratinization
Erythromelanosis follicularis faciei
Keratosis pilaris atrophicans
Lichen spinulosus
Phrynoderma
Erythromelanosis follicularis faciei epi and path
All races and all sexes
Does favour Asian ancestry
Pathogenesis unknown
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
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
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
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
Types of keratosis pilaris atrophicans
Ulerythema ophryogenes (faciei)
Atrophoderma vermiculatum
Keratosis follicularis spinulosa decalvans
Folliculitis spinulosa decalvans
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
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
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
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
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
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
HIV associated follicular syndrome and type VI PRP
HIV
PRP
Nodulocystic acne
Follicular spines - lichen spinulosus
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
Lichen spinulosus pathology
Same as KP
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
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
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
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
Major types of deep folliculitis
Furuncles Sycosis Pseudofolliculitis barbase Acne keloidalis HS
What does sycosis mean
Chronic inflammation of hair follicles
Types of sycosis
- Barbae - staph aureus
- Lupoid - scarring form, staph aureus, can have central atrophic scarring or cicatricial alopecia, granulomatous
- Mycotic - dermatophyte folliculitis of bear area, usually caused by zoophilic organisms, hair can be painlessly removed
- Herpetic
Pseudofolliculitis barbae epidemiology
African men, darkly pigmented skin
Women who shave in the groin
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
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
Pseudofolliculitis barbae pathology
Down growth of hair
Inflammatory infiltrate
Abscess, pseudofollicle, foreign body giant cell reaction
Fibrosis
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
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
Acne keloidalis epidemiology
Young African-American men
Rarely in DCaucasians
M>F 20:1
Puberty - 50 years
Acne keloidalis pathogenesis
Hairs curve back and penetrate the skin was an early hypothesis
Mast cells?
Irritation from shirt collars
Low grade folliculitis
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
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
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
Follicular occlusion tetrad
Acne conglobata
HS
Dissecting cellulitis of the scalp
Pilonidal sinus
Follicular occlusion tetrad
Acne conglobata
HS
Dissecting cellulitis of the scalp
Pilonidal sinus
HS pathogenesis
- Hair follicle abnormality –> rupture –> chemotaxis
- Genes identified: NOTCH1 and 2 deficiency, plus others
- Inflammatory mediators: IL-1beta and TNF-alpha
- Associations: smoking, lithium
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
Sartorius grading system
- Region - 3 points per region: axilla, groin, gluteal, other (unilateral)
- Number and scores of lesions for each region: nodules 1, fistulae 6
- Longest distance between 2 relevant lesions: <5 cm = 1, 5-10 cm = 3, >10 cm = 9
- Are all lesions clearly separated by normal skin? Yes 0, no 0
Complications of HS
Anaemia Secondary amyloidosis Lymphoedema Fistulae Hypoproteinaemia Nephrotic syndrome SAPHO SCC Autoinflammatory: PASH, PAPASH
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
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
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
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
