Folliculitis

Folliculitis

Folliculitis is  a group of skin conditions where there are inflamed hair follicles. The result is a tender red spot, often with a surface pustule.

Folliculitis may be superficial or deep.

 It can affect anywhere there are hairs, including chest, back, buttocks, arms and legs.

 Acne and its variants are also types of folliculitis.

can be due to infection, occlusion (blockage) or irritation

Staphylococcus aureus.and Pseudomonas aeruginosa are two of the most common organisms causing bacterial folliculitis

Pityrosporum ovale, also known as Malassezia. Malassezia folliculitis (Pityrosporum folliculitis) is an itchy acne-like condition usually affecting the upper trunk of young adults. 

Candida albicans can also provoke a folliculitis in skin folds (intertrigo) or in the beard area.

both of these could be secondary to antibiotic use.Stop antibiotics and  use  an anti fungal cream.

Tinea capitis,Microsporum canis and Trichophyton tonsurans are some common fungi causing  folliculitis  requiring  oral anti fungal Rx for a few  months.

Herpes simplex ,Herpes zoster and Molluscum contagiosum are the common viral causes.

Colonization by hair follicle mites (demodex) known as demodicosis.is seen in  immuno suppressed patients.

 Infestation by scabies, often leads to folliculitis, as well as non-follicular papules, vesicles and pustules.

Folliculitis may be caused by hairs regrow after shaving, waxing, electrolysis or plucking. these  pustules are sterile.Irritant folliculitis In the beard area is known as pseudofolliculitis barbae. Irritant folliculitis is also common on the lower legs of women (shaving rash). It is frequently very itchy. Treatment is by stopping hair removal, and not beginning again for about three months after the folliculitis has settled. To prevent reoccurring irritant folliculitis, use a gentle hair removal method, such as a lady's electric razor. Avoid soap and apply plenty of shaving gel, if using a blade shaver.

Occlusion/ Paraffin-based ointments, moisturizers, and adhesive plasters may all result in a sterile folliculitis. If a moisturiser is needed, choose an oil-free product, as it is less likely to cause occlusion.

Chemicals/ cutting oils,Coal tar and other chemicals may cause an irritant folliculitis. Avoid contact with the causative product.

Topical steroids/Overuse of topical steroids may produce a folliculitis. Perioral dermatitis is a facial folliculitis provoked by moisturizers and topical steroids. Perioral dermatitis is treated with tetracycline antibiotics for six weeks or so.

Folliculitis due to immunosuppression

Eosinophilic folliculitis is a specific type of folliculitis that may arise in some immune suppressed individuals

Folliculitis due to drugs

Folliculitis may be due to drugs, particularly corticosteroids (steroid acne), androgens (male hormones), ACTH, lithium, isoniazid (INH), phenytoin and B-complex vitamins. Protein kinase inhibitors (epidermal growth factor receptor inhibitors) and targeted therapy for metastatic melanoma (vemurafenib, dabrafenib) nearly always result in folliculitis.

Folliculitis due to inflammatory skin diseases

Certain uncommon inflammatory skin diseases may cause permanent hair loss and scarring because of deep seated sterile folliculitis. These include:

Lichen planus/Discoid lupus erythematosus/Folliculitis decalvans/Folliculitis keloidalis

Treatment depends on the underlying condition and its severity. A skin biopsy is often necessary to establish the diagnosis.

Acne variants 

Acne and acne-like or acneform disorders are also forms of folliculitis. These include:

Acne vulgaris/ Nodulocystic acne/ Rosacea/ Scalp folliculitis/ Chloracne

Follicular occlusion syndrome refers to:

Hidradenitis suppurativa (acne inversa)

Acne conglobata (a severe form of nodulocystic acne)

Dissecting cellulitis (perifolliculitis capitis abscedens et suffodiens)

Pilonidal sinus.

Buttock folliculitis

Folliculitis affecting the buttocks is quite common and is often nonspecific, ie no specific cause is found. Buttock folliculitis is equally common in males and females.Acute buttock folliculitis is usually bacterial in origin (like boils), resulting in red painful papules and pustules. It clears with antibiotics.

Chronic buttock folliculitis does not often cause significant symptoms but it can be very persistent. Although antiseptics, topical acne treatments, peeling agents such as alphahydroxy acids, long courses of oral antibiotics and isotretinoin can help buttock folliculitis, they are not always effective. Hair removal might be worth trying if the affected area is hairy. As regrowth of hair can make it worse, permanent hair reduction by laser or intense pulsed light (IPL) is best.

Secondary Syphilis

Secondary Syphilis

Patient is very infectious during this stage.

If left untreated or treatment has failed, about 3 weeks to 3 months after the 1st stage, a widespread skin rash occurs.

Rash may be subtle or appear as rough, red or reddish brown papules or patches. Occurs typically on the trunk and frequently affects palms and soles. May be mistaken for other conditions. The rash does not itch. It can appear more obvious with physical activity or heat. It resolves spontaneously within several weeks but can recur during the following 2 years.

Patchy hair loss.

Raw and red mucosal surfaces such as inside the mouth, throat, genital area, vagina and anus (mucous patches).

Unilateral tonsilitis, which may be ulcerated and accompanied by cervical lymph node enlargement. Can be mistaken for common tonsilitis but does not respond to usual oral antibiotics.

Grayish-white moist raised patches in the groin, inner thighs, armpits, or under breasts (condyloma latum).

Other symptoms include fever, tiredness, muscle and joint pains, headache and swollen lymph glands.

Other affected organs may include liver, kidneys, central nervous system (CNS), joints and eyes (resulting in visual impairment).

pyoderma faciale

Pyoderma faciale

This an unusual skin condition occurring usually  in young adult women. It is also called "rosacea fulminan". It can resemble severe acne or rosacea.

Unlike acne, pyoderma faciale:

Starts abruptly

Rarely persists more than a year or so

Is not associated with oily skin

Does not arise from comedones

Is confined to the face

Does not affect males

Affects younger women

Is not associated with flushing

Does not affect eyes

Pyoderma faciale presents as an ugly looking and painful large red bumps (nodules), pustules and sores on very red areas of the cheeks, chin and/or forehead. The lesions may leave scars.

Despite the severity of the inflammation, there are no internal symptoms. No infective organisms are found in bacterial cultures of the affected skin.

Perioral dermatitis

Perioral dermatitis

Periorificial dermatitis

Periorificial dermatitis is a common facial skin problem characterized by groups of itchy or tender small red papules. It is given this name because the papules occur around the eyes, the nostrils, the mouth and occasionally, the genitals.

The more restrictive term, perioral dermatitis, is often used when the eruption is confined to the skin in the lower half of the face, particularly around the mouth. Periocular dermatitis may be used to describe the rash affecting the eyelids.

Periorificial dermatitis and its variants mainly affect adult women aged 15 to 45 years. It is less common in men. It may affect children of any age.People with periorificial dermatitis are often using topical or inhaled corticosteroids.


The exact cause of periorificial is not understood. Periorificial dermatitis may be related to:

Epidermal barrier dysfunction
Activation of the innate immune system
Altered cutaneous microflora
Follicular fusiform bacteria
Unlike seborrhoeic dermatitis, which can affect similar areas of the face, malassezia yeasts are not involved in periorificial dermatitis.This condition  may be induced by:

Topical steroids, whether applied deliberately to facial skin or inadvertently
Nasal steroids, steroid inhalers, and oral steroids
Cosmetic creams, make-ups and sunscreens
Fluorinated toothpaste
Neglecting to wash the face
Hormonal changes and/or oral contraceptives
The characteristics of facial periorificial dermatitis are:

Unilateral or bilateral eruption on chin, upper lip and eyelids in perioral, perinasal and periocular distribution
Sparing of the skin bordering the lips (which then appears pale), eyelids, nostrils
Clusters of 1–2 mm erythematous papules or papulopustules
Dry and flaky skin surface
Burning irritation
In contrast to steroid-induced rosacea, periorificial dermatitis spares the cheeks and forehead.

Genital periorificial dermatitis has a similar clinical appearance. It involves the skin on and around labia majora (in females), scrotum (in males) and anus.

Complications of periorificial dermatitis

Granulomatous periorificial dermatitis is a variant of periorificial dermatitis that presents with persistent yellowish papules. It occurs mainly in young children and nearly always follows the use of a corticosteroid. There is a granulomatous perifollicular infiltrate on histopathology.

Steroid rosacea presents with steroid-induced, large facial papules, papulopustules and telangiectasia on the mid-face, including forehead and cheeks.

Rebound flare of severe periorificial dermatitis may occur after abrupt cessation of application of potent topical steroid to facial skin.

How is periorificial dermatitis diagnosed?

The presentation of periorificial dermatitis is usually typical, so clinical diagnosis is usually straightforward. There are no specific tests.

Skin biopsy shows follicular and perivascular chronic inflammation similar to rosacea.

What is the treatment for perioral dermatitis?

Periorificial dermatitis responds well to treatment, although it may take several weeks before there is noticeable improvement.

General measures

Discontinue applying all face creams including topical steroids, cosmetics and sunscreens (zero therapy).
Consider a slower withdrawal from topical steroid/face creams if there is a severe flare after steroid cessation. Temporarily, replace it by a less potent or less occlusive cream or apply it less and less frequently until it is no longer required.
Wash the face with warm water alone while the rash is present. When it has cleared up, use a non-soap bar or liquid cleanser if you wish.
Choose a liquid or gel sunscreen.
Topical therapy

Topical therapy is used to treat mild periorificial dermatitis. Choices include:

Erythromycin
Clindamycin
Metronidazole
Pimecrolimus
Azelaic acid
Oral therapy

In more severe cases, a course of oral antibiotics may be prescribed for 6–12 weeks.

Most often, a tetracycline such as doxycycline is recommended. Sub-antimicrobial dose may be sufficient.
Oral erythromycin is used during pregnancy and in pre-pubertal children.
Oral low-dose isotretinoin may be used if antibiotics are ineffective or contraindicated.
How can periorificial dermatitis be prevented?

Periorificial dermatitis can generally be prevented by the avoidance of topical steroids and occlusive face creams. When topical steroids are necessary to treat an inflammatory facial rash, they should be applied accurately to the affected area, no more than once daily in the lowest effective potency, and discontinued as soon as the rash responds.

What is the outlook for periorificial dermatitis

Periorificial dermatitis sometimes recurs when the antibiotics are discontinued, or at a later date. The same treatment can be used again.

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Naevus Comediconus

Naevus Comediconus

What is a comedo naevus?

A comedo naevus is a hair follicle naevus. It is also known as ‘comedone naevus’ and ‘nevus comedonicus’.

A comedo naevus is an unusual type of epidermal naevus, or birthmark (hamartoma), in which there is a localized collection of dilated follicles filled with keratin. It is more accurately termed follicular keratotic naevus, as there are no true comedones.

What does comedo naevus look like?

Comedo naevus is usually present at birth or develops in early childhood. Males and females are equally likely to be affected. Lesions often grow more quickly at puberty. They can appear anywhere on the body but are most commonly found on the face, trunk, neck and upper extremities.

The lesions appear as closely grouped slightly elevated papules with central keratinous plugs so they look like comedones. They may be distributed in a linear, interrupted, unilateral or bilateral pattern and sometimes follow the lines of Blaschko.(Blaschko's lines, also called the lines of Blaschko, named after Alfred Blaschko, are lines of normal cell development in the skin. These lines are invisible under normal conditions. They become apparent when some diseases of the skin or mucosa manifest themselves according to these patterns.)

The exact cause of comedo naevus is unknown, but it is thought to be due to cutaneous mosaicism, i.e. a line of cells with a genetic error. If this error occurs early in development of the embryo, the cells may spread out to cause multiple comedo naevi.

Mutations in FGFR2 have been detected in the naevi of some patients. This is the same gene that has found to be abnormal in a more serious generalized genetic condition, Apert syndrome, so the comedo naevus may be a ‘mosaic’ of Apert syndrome (some cells have the abnormal gene, and other cells have the normal gene). Apert syndrome causes craniofacial dysostosis (abnormalities of the bone structure of skull and face) and other skeletal abnormalities. Patients with Apert syndrome often suffer from severe acne, which also arises within a comedo naevus.

What is comedo naevus syndrome

Comedo naevus syndrome is when comedo naevus is associated with other medical conditions. Like other epidermal naevi, comedo naevus is rarely associated with other abnormalities of the cell of origin, the embryonic ectoderm. These may include:

Cataracts

Skeletal anomalies especially affecting fingers and toes or the spine

Developmental delay

What is the treatment for comedo naevus?

There is no specific treatment for comedo naevus. Lesions are usually symptom less and treatment is usually sought for cosmetic purposes. Some improvement of lesions may be seen with the use of topical tretinoin, salicylic acid or ammonium lactate lotion.

Surgery and laser treatment may be used if lesions are particularly disfiguring.

What are the complications of comedo naevus?

Rarely, at puberty or later, a comedo naevus may develop inflammatory acne-like lesions within it. These can lead to cysts, recurrent bacterial infections, abscesses, and scarring. then treatment with antibiotics or surgical drainage may be required  Topical and oral treatment for acne may improve the appearance.

Herpes gladiatorum

Herpes gladiatorum

• The name implies association with martial arts. In association with rugby it is called 'scrum pox'.
• Transmission is primarily by direct skin-to-skin contact and abrasions may facilitate a portal of entry. The majority of lesions occur on the head or face, followed by the trunk and extremities.
• A prodromal itching or burning sensation is followed by clustered vesicles on an erythematous base which heal with crusts over about one to two weeks. Less often, headache, malaise, sore throat and fever may be reported.
• Recurrent episodes may follow the initial infection.
• Because of its unusual location, herpes gladiatorum any be confused with impetigo, varicella, staphylococcal furunculosis, or allergic or irritant contact dermatitis.
• Accurate diagnosis requires viral immunofluorescence and cultures should be obtained by gently breaking an intact vesicle and firmly rubbing the swab tip across the base of the erosion.
• Treatment of herpes gladiatorum is with oral aciclovir or similar agents and is most effective if commenced at the first symptoms of an outbreak. Topical aciclovir is probably less effective. Any secondary infection should also be treated.
• The virus can survive for hours to days outside the host if conditions are appropriate. Hence, all contaminated surfaces should be cleaned with antiseptic solution. In the vesicular phase and until the crusts have separated, patients should avoid sports which could involve physical contact.
• Herpes simplex acquired in sport is often associated with constitutional symptoms.
• Prophylactic use of valacyclovir has been shown to be efficacious in lowering the incidence of outbreaks of herpes gladiatorum among adolescents at a 28-day wrestling camp
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Acne aestivalis

Acne aestivalis

Acne Aestivalis

Acne aestivalis is also known as mallorca acne. Acne aestivalis is a form of light-sensitive acne. That is to say, it is triggered by sun exposure. Acne aestivalis is characterized by multiple tightly-clustered eruptions of simple red papules forming on the skin after exposure to sunlight. It should be noted that only sun exposure and its relevant ultraviolet rays will cause acne aestivalis; merely bright lights or lights from any other source will not. Acne aestivalis is frequently associated with various skin cancers, but in truth, this is because both share a common root in sun overexposure. Acne aestivalis could nearly be thought of as a warning mechanism to indicate that the individual is spending too much time in the sun.

Acne aestivalis is very distinctive from other forms of acne due to the uniform nature of its breakout, as well as the distinctly red coloration of the papules.

Individuals that sunbathe with or without skin protection are more prone to acne aestivalis than anyone else. While casual sun exposure can cause a breakout of acne aestivalis, prolonged sun exposure is far more likely to spark a case. The use of sunscreen does not assay the risk of an acne aestivalis outbreak; sun exposure writ large is the culprit in acne aestivalis’ cause. Individuals that use sunscreen are only very mildly protected with regards to acne aestivalis.

Individuals such as manual laborers who must spend multiple hours each day outdoors may be at risk as well, although this generally involves more oblique sun exposure. The more direct the sun exposure suffered, the greater the chance of an outbreak. Risk can be reduced by covering the skin with clothing, or with wide-brimmed hats for those that it would not be a safety risk for (gardeners, for instance, could wear a wide-brimmed hat to shade themselves almost entirely from the sun, while a construction worker could not do so safely).

Acne aestivalis is not a common condition. While it is not rare or unheard of, most simply don’t need to deal with it at any point in their lives. Further, individuals of darker complexions are fairly insulated against acne aestivalis; the paler the skin, the greater the risk, and vice-versa.

Individuals that are generally resistant to sunburn and other such skin conditions will not necessarily be immune or resistant in any way to acne aestivalis. Some individuals develop acne aestivalis at the same time as they burn in the sun, others develop acne aestivalis after burning. Still others develop acne aestivalis as a result of sun exposure without burning at all. In any case, acne aestivalis indicates that the individual has spent too much time in the sun and needs to extricate themselves from sun exposure as soon as possible.

Acne aestivalis is caused by sun exposure. There are no other causes known for acne aestivalis, and no contributing factors that lead to acne aestivalis specifically. Other conditions that may exacerbate other forms acne may also exacerbate acne aestivalis, but they cannot cause acne aestivalis; acne aestivalis is a stand-alone condition brought about by sunlight.

Acne aestivalis is, in general, less of a nuisance than most cases of acne. It is unsightly and can be uncomfortable, but the pustules rarely swell in the same manner as in other forms of acne, so the risk of scarring and infection is much lower. Acne aestivalis does still carry the standard suite of potential secondary effects, however: acne aestivalis breakouts are more susceptible to excoriation and subsequent infection than the rest of the skin, and if an acne aestivalis breakout is scratched or otherwise mechanically abused, permanent scarring can occur.

Acne aestivalis in and of itself is not dangerous. It is quite unsightly and a nuisance, but it is not life-threatening, nor does it pose a long-term risk to greater bodily health. That said, acne aestivalis incidence indicates a sensitivity to the sun in excess of what the body can stand. Some individuals sunburn very easily, and others do not; likewise, some individuals contract acne aestivalis very quickly, and others do not. Whether or not the rest of the skin is sunburned, an acne aestivalis breakout indicates that the afflicted has been spending too much time in direct sunlight, which can cause many more difficult health and cosmetic problems in the future, including wrinkles and rough skin. Further sun exposure may cause skin cancer. Thus, any case of acne aestivalis should be taken as a hint that the afflicted needs to change their outdoor behavior.

Acne aestivalis treatment is the standard regimen for environmental acne breakouts. First and foremost, the individual must be removed from the source of the acne. In this case, the source is the sun. While the individual does not need to begin spending all of their hours indoors, they do need to pull themselves away from sunbathing. Sunbathing more carefully with sunscreens, or stronger variations thereof will not be sufficient. They must stop sunbathing and, as best as possible, limit sunlight contact with the afflicted areas. Further treatments are symptomatic for the breakout itself, and include antibiotic regimens. These regimens vary depending upon the patient’s own tolerance and allergies for antibiotics, but are generally a very low dose.

If you have suffered a distinctive acne outbreak after sun exposure, it is entirely likely that you are suffering from acne aestivalis. If you have been spending regular time in the sun, it is more likely that you have suffered from a breakout of acne aestivalis. Furthermore, if you are Caucasian, you are at greater risk. Acne aestivalis is difficult to mistake for other forms of acne due to the nature of its red lesions. If this breakout coincides with sun exposure, cease sunbathing immediately and contact your physician as soon as possible.