Acneiform Lesions

Acne vulgaris usually begins at puberty and involves several mechanisms, including hyperkeratinization of follicles, increased sebum production secondary to increased androgenic hormone levels, proliferation of Propionibacterium acnes, and resulting inflammation. Topical and systemic glucocorticoid therapy, hormone therapy, use of anabolic steroids, hyperandrogenism, and polycystic ovary syndrome may contribute to acneiform eruptions. Acne-prone sites include the face, neck, chest, upper back, and shoulders. In most cases, the history and physical examination are sufficient to diagnose acne. Acne is classified as either noninflammatory or inflammatory and by degree of severity. Noninflammatory acne involves open and closed comedones (occluded hair follicles); inflammatory acne consists of erythematous papules; pustules; and, occasionally, nodules. Topical retinoids and benzoyl peroxide are effective treatments for noninflammatory acne. Treatment of inflammatory acne requires an antibacterial agent (topical clindamycin or erythromycin) in addition to a comedolytic or keratolytic agent. Moderate to severe inflammatory acne often requires both topical treatment and an oral antibiotic (doxycycline, minocycline, erythromycin). Treatment with oral contraceptives and spironolactone, in addition to topical acne therapy, is effective for female patients with androgen excess. Isotretinoin (an oral retinoid) is used in patients with severe nodular acne that is unresponsive to oral antibiotic therapy and may result in prolonged remissions; however, because of teratogenicity, isotretinoin should be administered only by physicians who are trained in its use and registered with the Food and Drug Administration.

Acne rosacea (rosacea) is a chronic inflammatory skin disorder affecting the face, typically the cheeks and nose. The cause is unknown. Rosacea is characterized by erythema with telangiectasia, pustules, and papules; comedones are absent (Plate 23). In the early stages, rosacea can present as only facial erythema and resemble the butterfly rash of systemic lupus erythematosus (SLE); however, the rash of SLE typically spares the nasolabial folds and areas under the nose and lower lip. Rhinophyma (large, irregular hyperplastic nose) can develop in some patients with rosacea. Treatment may consist of topical agents (metronidazole gel, benzoyl peroxide, tretinoin) or oral antibiotics (tetracycline, erythromycin).

Perioral dermatitis is characterized by discrete papules and pustules on an erythematous base centered around the mouth (Plate 24). The eruption often follows the use of topical or inhaled glucocorticoids. Treatment consists of discontinuing the glucocorticoid or protecting the skin from the inhaled product. Initial treatment includes topical antibiotics and sulfur preparations.