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Chapter04:AcneiformEruptions
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Previous:CommonRashes

AcneiformEruptions

Acne
RelatedQuestions
Question49
Question59
Acneisachronicinflammatoryskinconditioncharacterizedbyopenandclosedcomedones(blackheads
andwhiteheads,respectively)andinflammatorylesions,includingpapules,pustules,andnodules
(Figure17).Androgensstimulateincreasedsebumproductionthus,whenacnedevelopsinpatients
outsidethetypicalagerangeorwhentheacneisdifficulttomanage,itisimportanttolookforsignsof
hyperactivityofthehypothalamicpituitaryadrenalorthehypothalamicpituitarygonadalaxis.Examples
includeCushingsyndrome,congenitaladrenalhyperplasia,andpolycysticovarysyndrome.Dependingon
thesuspectedunderlyingdisorder,measurementoffreetestosterone,dehydroepiandrosteronesulfate
(DHEAS),luteinizinghormone(LH),andfolliclestimulatinghormone(FSH)levelsmaybeappropriate.
Figure17.OpeninNewWindow

Extensiveacneinvolvementofupperandmidbackwithpapules,pustules,nodules,granulationtissue,
postinflammatoryerythema,hyperpigmentation,andscarring.

Themicrocomedoneistheprecursortoacnelesionsandiscausedbytheproliferationandaccumulationof
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keratinocytesthatblocktheoutflowofsebum.Ifsebumaccumulationcontinues,anopenorclosed
comedonewillform.TheanaerobicbacteriumPropionibacteriumacnesproliferatesinthecomedoneand
caninciteinflammationifthereisleakageofthecontentsintothedermis.Thismanifestsaspapules,
pustules,andinseverecases,deepcysts,nodules,andinterconnectingsinustracts.Scarringcanoccurand
bedisfiguring.Rarely,severeacnemaybeassociatedwithsystemicinflammation(acnefulminans)or
sterileinflammationofthebonesorjoints(Table9).
Table9.OpeninNewWindowDifferentialDiagnosisofAcneandAcneiformSkinDisorders
Disease

Characteristics

Acne(acne
vulgaris)

Verycommoninadolescents,butalsooccursinpreadolescentsandadults.Womenmay
havepremenstrualflareups.Physicalexamination:coexistingopenandclosedcomedones,
papules,pustules,andnodularlesionslocatedprimarilyonface,neck,anduppertrunk.

Rosacea

Nottrueacneprimarylesionisnotacomedonebutaninflammatorypapulerhinophyma
(bulbous,rednose)isavariant.Physicalexamination:centralfacialerythema,
telangiectasias,papules,andpustules.

Onsetweekstomonthsafterstartofthemedication.Comedonesareabsentinflammatory
papulesandpustulescommonlyappearontheuppertrunkandarmswhenthecauseis
Medication systemic.
induced
Possibletriggersareglucocorticoids,anabolicsteroids,bromides,iodides,isoniazid,
acneiform
phenytoin,azathioprine,cyclosporine,disulfiram,phenobarbital,quinidine,vitaminsB1,
eruption
B2,B6,B12,andD2,testosterone,progesterone,lithium,epidermalgrowthfactor
inhibitors.

Bacterial
folliculitis

Commoninathletes.Physicalexamination:follicularpapules,pustules,occasional
furunclesonanyhairbearingarea,especiallyscalp,buttocks,andthighs.Positiveculture
forpathogenicbacteria.MostcommoncauseisStaphylococcusaureus.

Gram
negative
folliculitis

Causedbyovergrowthofbacteriaduringprolongedsystemicantibiotictreatmentforacne
andpresentsasexacerbationofpreexistingacne.Physicalexamination:manyinflamed
pustules,mostoftenontheface.Positivecultureforgramnegativebacteria,often
Escherichiacoli.

Periorificial
Morecommoninwomen.Physicalexamination:small(<2mm)papulesandpustules
dermatitis,
aroundmouthoreyelids.Similartoacnebutwithoutcomedones.
idiopathic
Periorificial
Frequentcausesareprolongedtopicalglucocorticoidtherapyforatopicdermatitisand
dermatitis,
inappropriateuseoftheseagentstotreatacne.Similarinappearancetoidiopathictype.
iatrogenic

Cutaneous
proliferations

Adenomasebaceum:numerouspinkorskincoloredpapulesclusteredaroundthenoseand
chin,associatedwithtuberoussclerosis.Patientswithouttuberoussclerosismayhaveone
oruptoseveralfibrouspapulesonthenoseandcentralface.
Folliculartumors(fibrofolliculomasandtrichodiscomas):numerousskincoloredpapules
onthefaceandears,associatedwithBirtHoggDubsyndrome(kidneycancerrisk).

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Treatmentbeginsbyconsideringthetypesanddistributionoflesions,aswellasthepregnancystatusof
thefemalepatient(Figure18andTable10).Interventionsareselectedwiththegoalofmodifyingthe
maincausalfactors,suchasfollicularocclusion,sebumproduction,P.acnesproliferation,and
inflammation.Itisimportanttoeducatepatientsabouttheexpectationsoftherapytreatmentsoftentake6
to8weekstodemonstrateaneffect,needtobeusedregularlyduringthistime,andarenotcapableof
completeclearanceinallpatients.Inaddition,patientscanbecounseledthatneitherdietaryrestrictionnor
excessivefacewashinghasbeenshowntobebeneficial.
Figure18.OpeninNewWindow

Firstandsecondlinetreatmentformild,moderate,andsevereacne.

TMPSMZ=trimethoprimsulfamethoxazole.
aConsideroralcontraceptives/antiandrogensinfemalepatients.Ifrefractorytotreatment,consider
gramnegativefolliculitis.
Table10.OpeninNewWindowTreatmentofAcne

Medicationa

Indication

FDA
Pregnancy
Categoryb

SideEffectsandComments

Topicalretinoids Mildcomedonal
(tretinoin,
acneusesinglyor Localirritationsuperficialdesquamationmay
adapalene,
incombinationwith becombinedwithtopicalantibiotics
tazarotene)
othertreatments

Tazaroteneis
pregnancy
categoryXand
requires
pregnancy
testingpriorto
prescription

Mildcomedonal
Topicalsalicylic acneusesinglyor
Mainlyinpatientswithretinoidintolerantskin
acid
incombinationwith
othertreatments

Adjunctivetherapy
Topicalazelaic
formildtomoderate Localirritation
acid
acne

Firstlinetherapyfor
mildtomoderate
Topicalbenzoyl acneusesinglyor
Localirritationand,rarely,contactsensitivity
peroxide
incombinationwith
othertreatments

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Topical
antibiotics
(clindamycin,
erythromycin)

Therapyformildto Localirritationpromotionofantibioticresistant
moderate
bacteriawhenusedsingly,thereforecombination B
inflammatoryacne therapywithbenzoylperoxideissuggested

Moderatetosevere
inflammatoryacne
Topicaldapsone canbepartofa
LocalirritationG6PDtestingisnotnecessary
regimenwithother
treatments

Oral
doxycycline

Moderatetosevere
Doserelatedphototoxicity,vaginalyeast
inflammatoryacne
infection,dyspepsianotforuseinchildren<12
canbecombined
yearsofageorpregnantwomen
withtopicalagents

Oral
minocycline

Moderatetosevere
inflammatoryacne
canbecombined
withtopicalagents

Dizziness,vertigo,discoloredteeth,bluegray
skinstaining,rarehepatotoxicityandlupuslike
syndrome,mildphototoxicitynotforusein
children<12yearsofageorpregnantwomen

Oral
erythromycin

Moderatetosevere
inflammatoryacne Gastricupset,diarrheacanbeusedinchildren
canbecombined
<12yearsofage
withtopicalagents

Oral
contraceptives
(norethindrone
acetateethinyl
estradiol,
norgestimate
ethinyl
estradiol)

Firstlinetreatment
ofmoderateto
severeacneinadult Requiresanaverageof5cyclestoachieve50%
womenorwith
improvementadjunctivetopicaltherapyis
laboratoryevidence usuallyneeded
of
hyperandrogenism

Usefulformoderate
Spironolactone tosevereacnein
Concurrentoralcontraceptivesrecommended
adultwomen

Isotretinoin

Treatmentofchoice
forsevere,
recalcitrantnodular
acneprolonged
remissions(13
years)in40%of
patients

Allprescribers,patients,wholesalers,and
dispensingpharmaciesmustberegisteredinthe
FDAapprovediPLEDGEprogramcheilitis,dry
skinandmucousmembranes,
X
hypertriglyceridemiapossibleincreased
incidenceofinflammatoryboweldisease
depression

G6PD=glucose6phosphatedehydrogenase.
aForspecificindicationsandprecautions,pleaserefertothelabelinginformationofthemedications
listed.
bSeeMKSAP17GeneralInternalMedicinefordescriptionofFDAPregnancyCategories.
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Treatmentofacneisimportant,notonlytoavoidcomplicationsbutalsobecauseacnehasbeenshownto
significantlyreducequalityoflifemeasuresforthoseaffected.Patientswithmoderateacnereportmore
mentalhealthandsocialproblemsthanthosewithasthma,epilepsy,ordiabetesmellitus.Complications
fromacnearepostinflammatoryhyperpigmentationandscarringincludinghypertrophicscarsandkeloids.
Treatmentofacnescarringcanbeperformedbydermatologistsorplasticsurgeonshowever,mitigating
scardevelopmentbyearlyandappropriatetreatmentispreferred.
Firstlinetreatmentformostpatientsistopicalretinoidandtopicalantimicrobialtherapy.Benzoyl
peroxideisavailableoverthecounterandisanexcellentcomplementtotreatmentwithanoralortopical
antibiotic,asitreducesthedevelopmentofbacterialresistance.Salicylicacidisalsoavailableoverthe
counterandprimarilyworksbyremovingandpreventingcomedones.Themostfrequentadverseeffectof
topicalacnetreatmentsisirritation.Lowerconcentrationsofbenzoylperoxide(2.5%)aretherefore
recommended,astheefficacyissimilarirritationislessthanwhenformulationswithbenzoylperoxide
10%concentrationareused.
Topicalretinoidsareeffectiveforcomedonalaswellasinflammatoryacne.Topicalretinoidscanprevent
acnebyreducingfollicularpluggingandmayalsohaveantiinflammatoryeffects.Becauseretinoidsare
preventive,theyneedtobeappliedtotheentireacneproneareaandnotusedasaspottreatment.The
mostcommonadverseeffectsaredrynessandirritation.
Antibioticshavebeenusedfordecadestotreatacnevulgaris.Numerousstudieshavedemonstratedthe
efficacyoforalantibiotics.Guidelinesrecommendthatthedurationoforalantibiotictherapybelimited,
specificallythatoralantibioticsbeusedfor3monthsandthendiscontinuedforpatientswithgoodclinical
improvement.Thesameantibioticcanbeusedagainforpatientswithgoodclinicalimprovementwho
haveasubsequentrelapse.
Isotretinoinisanoralretinoid.Itisusedasafirstlinetreatmentforsevere,nodulocysticacne(Figure19)
andforinflammatoryacnethatisrecalcitranttomultimodalitytherapywithtopicalretinoidsandoral
antibiotics.TheiPLEDGEprogramisanFDAapprovedregulatoryprogramtopreventbirthdefectsfrom
isotretinoin.Providers,patients,andpharmaciesmustberegisteredintheiPLEDGEprogramand
completemonthlyreports.
Figure19.OpeninNewWindow

Severenodulocysticacneontheface.

Acnecanoccurinadulthood,althoughtheprevalencedecreaseswithincreasingage.Adultacneismore
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commoninwomenandmostcommonlyaffectsthelowerhalfofthefaceorjawline.Androgensare
believedtoplayasignificantroleinadultfemaleacnehowever,mostwomenhavenormalandrogen
levels.Combinationoralcontraceptivesandantiandrogens(suchasspironolactone)canbeusefultherapies
foradolescentaswellasadultwomen,especiallythosewithperimenstrualacneflares.

KeyPoints
Acnemanifestsaspapules,pustules,andinseverecases,deepcysts,nodules,andinterconnecting
sinustracts.
Firstlinetreatmentformostpatientswithacneincludestopicalretinoidandtopicalantimicrobial
therapy.

Rosacea
RelatedQuestion
Question3
Rosaceaisacommonchronicconditionofthefacialskincharacterizedbypinkpapules,pustules,
erythema,andtelangiectasias.Itistypicallyfoundinabilaterallysymmetricdistributiononthe
convexitiesoftheface,namelytheforehead,cheeks,nose,andchin.Rosaceaissometimescalledadult
acne.Bothacneandrosaceahaveinflammatorypapulesandpustules,butcomedonesarenotseenin
rosacea.Rosaceamorecommonlyaffectswomen,especiallythose30to60yearsold.
Thepathogenesisofrosaceaisunknown.Multiplestudieshavedemonstratedcutaneousinflammation
however,thetriggerishighlydebated.Alcohol,sunexposure,andothertriggerscancauseatransient
increaseinfacialerythemabutdonotcauserosacea.
Therearethreecutaneousformsofrosacea(erythrotelangiectatic,papulopustular,andphymatous)andan
ocularform.Allthreetypesofcutaneousrosaceacausesomeerythemaandtelangiectasiahowever,they
differintheamountandseverityofpapulopustularlesionsandphymatouschanges.Thereisconsiderable
overlapamongthethreemaintypes,andwhileprogressionfromoneformtoanotherispossible,itis
uncommonandoftenslow.
Erythrotelangiectaticrosaceacausesflushingandpersistenterythemaonthecentralportionofthefaceand
fewinflammatorypapules(Figure20).Patientsmayhaveswelling,stinging,burning,roughness,scaling,
andahistoryofflushing.Flushingcanbetriggeredbysun,stress,hotweather,alcohol,andwarmorspicy
foods.Caffeinehasnotbeenshowntobeaconsistenttrigger.
Figure20.OpeninNewWindow

Erythrotelangiectaticrosaceapresentspredominantlywithpatchesoferythemaandtelangiectasia.

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Papulopustularrosaceacausescentralfacialerythemawithmorefrequentandnumerouspapulesor
pustulesburningandstingingmaybepresent(Figure21).
Figure21.OpeninNewWindow

Papulopustularrosaceacauseserythemaandpinkpapulesoftheconvexitiesoftheface,namely,the
forehead,nose,cheeks,andchin.

Phymatousrosaceaischaracterizedbyoilythickenedskinwithprominentporesandtelangiectasias,and
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nodulesofthickenedskincanaccumulateoveryears.Thenoseismostcommonlyaffected(rhinophyma)
(Figure22),butphymatousrosaceacanalsooccuronthecheeks,forehead,chin,andears.
Figure22.OpeninNewWindow

Rhinophyma,characterizedbyhyperplasticsebaceousglandsandenlargementofthenose,inapatient
withlongstanding,uncontrolledrosacea.

Ocularrosaceareportedlyaffects6%to18%ofpatientswithcutaneousrosacea.Symptomsofocular
rosaceaarewateryeyes,foreignbodysensations,burning,anddryness.Conjunctivitisandstyesare
common.
Thedifferentialdiagnosisforrosaceaincludesdisordersthatcausecentralfacialerythemaor
inflammatorypapules,suchasperiorificialdermatitis,cutaneouslupuserythematosus,sarcoidosis,contact
dermatitis(eczema),seborrheicdermatitis,actinicdamage,andfolliculitisduetoPityrosporumor
Demodexspp.Flushingisacommoncharacteristicofrosaceathedifferentialdiagnosisofthisincludes
carcinoidsyndrome,mastocytosis,andpheochromocytoma.
Aswithmostchronicskindiseases,rosacearequireslongtermtreatment.Treatmentisoftentailoredto
targetthemostprominentmanifestationsineachpatient(Table11).Topicalagentsareoftenthefirststep
intreatment.Themostfrequentsideeffectofanymedicationisdrynessorirritation.Oralantibioticsare
especiallyeffectiveforocularrosaceaandthepapulesandpustulesofpapulopustularrosacea.Oral
doxycyclineisrecommendedadoseof40mgtwicedailyisaseffectiveas100mgtwicedailybuthas
feweradverseeffects.Topicalororaltherapiesarelesseffectiveforfacialerythemaandtelangiectasia
laserandintensepulsedlightaremoreeffective.Laserandsurgicaldebulkingcanbeusedtoremove
excesstissueforthosewithphymatousrosacea.
Table11.OpeninNewWindowManagementofRosacea
FDAPregnancy
Category

Interventions

Sunprotection(sunscreenorsunprotectiveclothing)
Avoidance
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N/A
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Triggers:Foods(spicy,warm),alcohol,warm
environments
Metronidazole,0.75%or1%
Sodiumsulfacetamide/sulfur
Topical

Azelaicacid,15%20%
Topicalcalcineurininhibitors(pimecrolimus,
tacrolimus)
Permethrin
Tetracyclineantibiotics(doxycycline,40mg)

Systemic

Macrolideantibiotics
Erythromycin,azithromycin
Clarithromycin

N/A

B
C
B
C
B

D
B
C

Lasers(PDL,Nd:YAG,CO2,andothers)
Laser,light,and
surgical

Intensepulsedlight

Avoided

Electrosurgery
Nd:YAG=neodymiumdopedyttriumaluminiumgarnetPDL=pulseddyelaser.

KeyPoints
Rosaceaisacommonchronicconditionofthefacialskincharacterizedbypinkpapules,pustules,
erythema,andtelangiectasiasandistypicallyfoundontheforehead,cheeks,nose,andchin.
Firstlinetreatmentsforrosaceaincludeavoidanceoftriggers(sunexposure,spicyorwarmfoods,
hotdrinks,andalcohol),topicalmetronidazole,topicalsodiumsulfacetamide/sulfur,topicalazelaic
acidandforpapulopustularrosaceaoralantibiotics.

HidradenitisSuppurativa
RelatedQuestion
Question16
Hidradenitissuppurativa(HS)oracneinversaisachronicinflammatorydiseasethatpredominantly
affectstheapocrineglandbearingareasoftheskin.Thecommonsitesaretheaxillae,breastsand
inframammarycreases,inguinalfolds,andglutealcleft(Figure23).Itischaracterizedbycomedones,
inflammatorypapules,nodules,cysts,andscarring.Thelesionsarepainful,andthedrainageisoftenfoul
smelling.Thedistributionandseverityofdiseasecanrangefromminortodebilitating.
Figure23.OpeninNewWindow

Hidradenitissuppurativaintheaxillademonstratingcomedonesandscars.

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HSisestimatedtoaffect1%to4%ofthegeneralpopulationandfrequentlybeginsinthesecondtothird
decade.Itismorecommoninwomen.Almost40%ofHSpatientsreportafamilyhistoryofthedisease.
AbouthalfofpatientswithHShavebreastandarmpitinvolvementandhypertrophicscars.Somealso
haveahighincidenceofacne,cysts,andfolliculitis.Smoking,depression,obesity,andmetabolic
syndromearemorecommoninpatientswithHSthaninthegeneralpopulation.Itisthereforeimportantto
performacompletehistoryandphysicalexaminationtoidentifythesefactorsandtodeterminethefull
extentandseverityofdisease.
AcneinversaisanaptnamebecausethepathogenesisofHSbeginswithfollicularocclusionbutnot
infectionorinflammationoftheapocrineglands.Followingocclusion,secretionsbuildupinthefollicular
ductandresultinruptureandasubsequentinflammatoryreactionthatresemblesabacterialabscess.
Followingthis,anacuteinflammatoryreactionistriggeredinthesurroundingtissue.Theroleofbacteria
iscontroversialandislikelyasecondarycolonizationsincelesionsareinitiallysterileandantibioticsare
notentirelyeffectiveinpreventingnewlesions.Inadditiontotheireffectsonbacteria,antibioticsmay
alsoexertantiinflammatoryeffects.
Thedifferentialdiagnosisincludesfolliculitis,abscessorcarbuncle,rupturedepidermalinclusioncyst,
cutaneousmanifestationsofCrohndisease,andsexuallytransmittedinfectionssuchasgranuloma
inguinaleorlymphogranulomavenereum.HScanbedistinguishedbythepresenceofopencomedones
(blackheads),chronicrelapses,predispositionforthefoldsofthebody,andrecurrenceafterboth
antibioticandsurgicaltherapy.
Manyoptionsareavailablefortherapy,althoughthereislittlescientificevidencetosupporttheir
effectiveness,andnotreatmentiseffectiveforallpatients(Table12).Topicalandoralantibiotics,topical
andoralretinoids,intralesionalglucocorticoids,incisionanddrainage,surgicalexcision,radiation,laser
therapy,andTNFinhibitorsarealltreatmentoptions.Clindamycinrifampincombinationantibiotics,
infliximab,andsurgicalexcisionhavethegreatestevidenceofeffectiveness.Manypatientsrequire
combinationtherapy.PotentialcomplicationsofHSincludescarringandcontractionresultingin
functionallimitation,secondaryinfection,malignantdegenerationintosquamouscellcarcinoma,
lymphedemaduetochronicinflammationandscarring,andrectalorurethralfistulas.
Table12.OpeninNewWindowTreatmentOptionsforHidradenitisSuppurativa
DiseaseSeverity

TreatmentOptions/Considerations

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Mild

Antibacterialwashes,topicalantibiotics,analgesics,warm
Predominantlycomedones,small
compresses,smokingcessation,weightloss
papulesorpustules,solitarynodules
Moderate

Oralantibioticswithantibacterialwashesand/ortopicalantibiotics,
analgesics,widelocalexcision

Multiplenodules,abscessesorcysts,
scarring
Women:Oralcontraceptives,spironolactone
Severe
Multiplenodules,sinustracts,
scarring

Referraltodermatologistorsurgeonforconsiderationofwidelocal
excision,tumornecrosisfactorinhibitors,orclinicaltrial

Bibliography
AlikhanA,LynchPJ,EisenDB.Hidradenitissuppurativa:acomprehensivereview.JAmAcad
Dermatol.2009Apr60(4):53961.PMID:19293006
KennedyCarneyC,CantrellW,ElewskiBE.Rosacea:areviewofcurrenttopical,systemicand
lightbasedtherapies.GItalDermatolVenereol.2009Dec144(6):67388.PMID:19907406
RambhatlaPV,LimHW,HamzaviI.Asystematicreviewoftreatmentsforhidradenitissuppurativa.
ArchDermatol.2012Apr148(4):43946.PMID:22184715
StoneDU,ChodoshJ.Ocularrosacea:anupdateonpathogenesisandtherapy.CurrOpin
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StraussJS,KrowchukDP,LeydenJJ,etalAmericanAcademyofDermatology/American
AcademyofDermatologyAssociation.Guidelinesofcareforacnevulgarismanagement.JAm
AcadDermatol.2007Apr56(4):65163.PMID:17276540
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ThiscontentwaslastupdatedinAugust2015.

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