Folliculitis and other follicular disorders Flashcards
Four major types of infectious folliculitis?
Bacterial, Fungal, Viral, Other (demodex)
3 major types of bacterial folliculitis?
Staphylococcal aureus infxn, Gram-negative bacili, Hot tub folliculitis
3 major fungal folliculitis organisims?
Dermatophyte, Malassezia spp. (pityrosporum), Candida spp
2 major types of viral folliculitis?
HSV, VSV
5 major types of non-infectious folliculitis?
Culture-negative/normal flora, Irritant, drug-induced, Eosinophilic (3 types within it), disseminate and recurrent infundibulofolliculitis
5 major types of deep folliculitides?
Furuncles, Syncosis, Pseudofolliculitis barbae, acne keloidalis, follicular occlusion tetrad (1. Acne conglobata, Hidradenitis suppurativa, dissecting cellulitis of the scalp, pilonidal sinus/cyst)
How does folliculitis present clinically?
Follicular-based papules and pustules on an erythematous base. Often itchy and sometimes painful
What is the most common type of folliculitis?
Culture-negative, followed by bacterial folliculitis 2/2 to S. aureus
What are the 3 most common causes of gram-negative folliculitis?
Klebsiella, enterobacter, proteus
- Also E. Coli
What is the most common location for bacterial folliculitis?
Face, trunk, axillae, buttocks
(areas under occlusion)
How to treat for S. aureus folliculitis?
Tx for nasal carriage with mupirocin TID x 7-10 days
Elston discusses using clindamycin as beta-lactams, TCN and Bactrim don’t penetrate the nose well
Common patient population to see gram-negative bacterial folliculitis in?
Favor acne pts on long-term abxs –> Pustules in T-zone and perinasal regions
What can be given in patients with severe gram-negative folliculitis/acne?
- First: Topicals –> Gentamicin, BP
- Second: Systemics –> Quinolones (cipro)
- If severe and reucurrent –> Isotretinoin 0.5-1mg/kg/day
When does hot tub folliculitis occur after exposure?
Occurs after 12-48 hrs after hot tub/public facilities use
How does hot tub folliculitis present?
Presents with edematous pink-red follicular papules and pustules
- Favors the trunk
- Pruritic
Treatment for hot tub folliculitis?
Self-limited in most patients, in immunocompromised can do ciprofloxacin 500mg BID for 7-14 days
What organisms cause tinea barbae?
T. Mentagrophytes or T. verrucosum
Clinical of tinea barbae?
inflammatory papulopustules in beard area >> mustache with crusting, loosened hair can be removed w/o pain
Treatment of tinea barbae?
Tx with oral antifungals (griseofulvin, terbinafine, itraconazole)
What organism is often involved in Majocchi granuloma?
T. Rubrum
Clinical of Majocchi granuloma?
Presents with follicular pustules or nodules, pustules at edges of tinea cruris or corporis
Treatment of Majocchi granuloma?
Oral antifungals
Where can you often see Majocchi granuloma?
Women who shave their legs w/ blade razor
Clinical of malassezia folliculitis?
Presents with follicular papulopustules mainly on back, chest, and shoulders
Dx of malassezia folliculitis?
KOH prep of follicular contents
Clinical of candida folliculitis?
Presents with pruritic satellite pustules surrounding areas of intertriginous candidiasis
A population that is susceptible to HSV 1/2 folliculitis?
Men w/ history of recurrent herpes infxn who shave w/ blade razor (consider VZV in immunocompromised)
Clinical of demodex folliculitis?
Associated with immunosuppression and rosacea; p/w erythematous papulopustules on the face within a background of diffuse erythema
The population at risk for drug-induced folliculitis?
Most common in acne-prone pts and age groups
When does drug-induced folliculitis start after having used a drug?
Within 2 wks of starting drug
Is risk of drug-induced folliculitis related to dose?
Yes, risk is proportional to dose and duration of therapy
Clinical of drug-induced folliculitis?
Presents with monomorphic erythematous follicular papules and pustules (trunk, shoulders, upper arms), no true comedones
Most common medications to cause drug-induced folliculitis?
Steroids, androgenic hormones, EGFR inhibitors, iodides, lithium, isoniazid, anticonvulsants
What are the 3 variants of eosinophilic folliculitis?
- Eosinophilic pustular folliculitis (Ofuji’s disease)
- Immunosuppression-associated eosinophilic pustular folliculitis
- Eosinophilic pustular folliculitis of infancy
Where is eosinophilic pustular folliculitis reported most commonly?
Japan
Is eosinophilic pustular folliculitis associated with systemic disease?
No
Clinical of eosinophilic pustular folliculitis?
Presents with recurrent episodes of PRURITIC follicular papulopustules → erythematous patches and plaques with superimposed coalescent pustules → central clearing (figurate lesions) - lesions last 7-10 d and course is spontaneous resolution with relapses as the norm
What lab abnormalities can be seen in eosinophilic pustular folliculitis?
Blood eosinophilia
Treatment for eosinophilic pustular folliculitis?
Indomethacin 50mg/day
Epidemiology of Immunosuppression-associated eosinophilic pustular folliculitis?
Disease activity correlates with low CD4 count (<300), also a/w iatrogenic immunosuppression and leukemia/lymphoma/hSCT pts, can be a part of immune reconstitution syndrome
Clinical of Immunosuppression-associated eosinophilic pustular folliculitis?
Presents with chronic, pruritic follicular papules, less pustular than Ofuji’s, favor face, scalp, upper trunk
Treatment for Immunosuppression-associated eosinophilic pustular folliculitis?
Tx HIV/AIDS, improvement with an elevation of CD4 count, UVB phototherapy for pruritus, topical tacrolimus, permethrin, oral abx
What is Eosinophilic pustular folliculitis of infancy?
Unusual self-limiting d/o mainly on scalp and brow region, secondary crusting often seen - self-limited course
What are the hallmark findings in keratosis pilaris atrophicans?
Abnormal follicular keratinization + atrophy + scarring alopecia
What are the main treatments for keratosis pilaris atrophicans?
Combination of keratolytics, topical or oral retinoids, topical or intralesional steroids, IPL
Mode of inheritance for keratosis pilaris atrophicans faciai (ulerythema aphryogenes)
AD
Age of onset for keratosis pilaris atrophicans faciai?
Infancy
Distribution for keratosis pilaris atrophicans faciai?
Eyebrows, particularly the lateral third (alopecia), temples, cheeks, forehead.
Cutaneous features of keratosis pilaris atrophicans faciai?
Erythematous follicular papules w/ central keratotic plugs, eventuating in follicular atrophy. Scarring alopecia of the lateral eyebrows
What syndromes/diseases is keratosis pilaris atrophicans faciai associated with?
Noonan syndrome, cardio-facio-cutaneous syndrome, wooly hair, and Cornelia de Lange syndrome
Age of onset for atrophoderma vermiculatum?
Childhood (usually 5-12 years)
What is the distribution of atrophoderma vermiculatum?
Cheeks, preauricular area, upper lip
Cutaneous lesions in atrophoderma vermiculatum?
Associated with ipsilateral congenital cataract, Loeys-Dietz, Rombo, and Nicolau-Balus syndrome
Genetics of keratosis folicularis spinulosa decalvans (x-linked)?
XR
Age of onset for keratosis folicularis spinulosa decalvans (x-linked)?
Childhood (inflammation often remits at puberty
Distribution for keratosis folicularis spinulosa decalvans (x-linked)?
Face, scalp, limbs, trunk
Cutaneous features of keratosis folicularis spinulosa decalvans (x-linked)?
Erythematous follicualr papules with central keratotic plugs, eventuating in follicular atrophy, scarring alopecia of the scalp, eyebrows and eyelashes
What other features is keratosis folicularis spinulosa decalvans (x-linked) associated with?
Variable facial erythema, nail dystrophy and palmoplantar keratoderma, keratitis, blepharitis, photophobia
Genetics for keratosis follicularis spinulosa decalvans (folliuclitis spinulosa decalvans)?
AD
Age of onset forkeratosis follicularis spinulosa decalvans (folliuclitis spinulosa decalvans)?
Puberty (onset or worsening)
Distribution of keratosis follicularis spinulosa decalvans (folliuclitis spinulosa decalvans)?
Scalp
Cutaneous presentation of keratosis follicularis spinulosa decalvans (folliuclitis spinulosa decalvans)?
Follicular pustules, features of keratosis follicularis spinulsa decalvans, x-linked
What other features may be seen with keratosis follicularis spinulosa decalvans (folliuclitis spinulosa decalvans)?
Variable facial erythema and nail dystrophy, blepharitis, conjunctivitis, keratitis, photophobia
Presentation of lichen spinulosus?
Grouped, skin-colored follicular papule on the extensor surface of the arm. You can also see central keratitis plugs.
What are the 4 types of sycosis?
Barbae, lupoid, mycotic, and herpetic
What is sycosis barbae?
Bacterial folliculitis of the beard or mustache areas, usually caused by Staph aureus. appears deep-seated, edematous, perifollicular papule and pustules that may coalesce to form plaques student w/ pustules and crusts
What is lupoid sycosis?
Scarring from deep folliculitis that is more prominent in the beard areas.
- May be caused by S. Aureus.
- The name comes from the peripheral extension of perifollicular papule and pustules w/ central atopic scarring/cicatricial alopecia; granulomatous inflammation can lead to appearance reminiscent of lupus vulgarisms.
What is mycotic syncosis?
Dermatophyte folliculitis of the beard area, most often the chin which is usually caused by zoophilic organisms. - Presents with inflammatory perifollicular papule and pustules coalescing to form nodules and plaques w/ purulent discharge from patulous follicles, crusting and loose hairs that can be painlessly removed.
What is the treatment for pseudofolliculitis barbae?
Cure is laser hair removal with 1064 nm ND:YAG laser with long pulse duration or modified 810 nm super-long-pulsed diode laser
What is the genetic predisposition for pseudofolliculitis barbae?
Mutation in 1A alpha-helical subdomain of hair follicle companion layer-specific keratin K6hf (K75).
What is acne keloidalis nuchae?
Begins as chronic folliculitis of posterior neck and occipital scalp but then evolves into keloidal papule and plaques.
Epidemiology of acne keloidalis nuchae?
Seen in darker prototypes, almost exlusively in black men
Treatments for acne keloidalis nuchae?
- Tretinoin gel and potent CS get twice daily (for non-inflamed papule and plaques
- Hair removal for papule
- Excision w/ punch or surgical depending on size
- Imiquimod
What is hidradenitis suppurativa?
Pathology of the apocrine gland bearing skin sites (axilla/groin/etc)
Epidemiology of hidradenitis suppurativa?
Black F>>M, onset puberty
clinical of hidradenitis suppurativa?
Stage pt according to hurley stages. clinically see recurrent furuncles and draining sinus tracts → scarring
Morbdities of hidradenitis suppurativa?
anemia of chronic disease, secondary amyloidosis, lymphedema, fistulas, arthropathy, SCC within chronic scars
General treatment of HS for all patients?
- Weight reduction if obese or overweight
- Measures to reduce friction and moistures like loose undergarments, absorbent powders, antiseptic soaps, topical aluminum chloride
- Warm compresses
- Stopping smoking
What is Hurley stage I disease for HS?
Solitary or multiple isolated abscesses, no scarring or sinus tracts
Treatment for Hurley stage I disease in HS?
ILK, topical clindamycin, eradicate S aureus, oral antibiotic therapy (tetracycline, doxycycline, clindamycin, rifampin + clindamycin, dapsone, Bactrim)
What is Hurley stage II disease in HS?
Recurrent abscesses, sinus tract formation, early scarring
Treatment for Hurley stage II disease?
Systemic adjuvant or maintenance therapy (acitretin, infliximab, cyclosporin)
- Surgical treatment
What is Hurley stage III disease?
Diffuse or broad involvement with multiple interconnected abscesses and sinus tracts.
- More extensive scarring
Tx for Hurley stage II dz?
Early wide surgical excision to involved areas -CO2 laser ablation w/ secondary intention healing.
What is trichostasis spinulosa?
Asymptomatic comedo-like lesions containing keratin and multiple vellus hairs mainly on face (mid to lower central portion)
What is the typical scenario of a patient with viral -associated trichodysplasia?
Seen in drug-induced immunosuppression with cyclosporine
What is the clinical of viral -associated trichodysplasia?
Presents with skin-colored to pink follicular papules and follicular spines (central face → loss of eyebrows and eyelashes)
What virus is viral-associated trichodysplasia associated with?
Polyomavirus
Treatment for viral -associated trichodysplasia?
Reduced immunosuppression if possible, otherwise topical cidofovir or tazarotene or oral valganciclovir
Important components of Pityrosporum folliculitis histologically?
- Pityrosporum can be seen normally in the follicular infundibulum
- Pityrosporum should be deeper, and there needs to be eosinophils associated with the folliculitis
