pediatric dermatology Series Editor: Camila K. Janniger, MD, Newark, New Jersey Acneiform Eruptions Julianne H. Kuflik, MD, Newark, New Jersey Robert A. Schwartz, MD, MPH, Newark, New Jersey Acne-like eruptions represent a variety of disorders. These include gram-negative folliculitis, nevus come- donicus, steroid acne, acneiform drug eruptions, rosacea, amineptine acne, chloracne, perioral der- matitis, eruptive vellus hair cysts, sporotrichosis, coc- cidioidomycosis, secondary syphilis, and even tuberous sclerosis. The comedone is not exclusive to acne vul- garis, nor is the acneiform papule. The acne papule is really a special perifollicular papulopustule. Suppura- tion begins at a deep level and is linked with an in- flammatory exudate. Other disorders may resemble it. Nevus Comedonicus Comedones may occur alone, congenitally, or later in life as a result of occupational exposure.1,2 Nevus comedonicus is an infrequently occurring develop- mental anomaly that resembles a deformed piloseba- ceous apparatus. It is evident clinically as confluent FIGURE 1. Steroid acne on the shoulder. clusters of dilated follicular orifices plugged with ker- atin, giving the appearance of aggregated open come- dones.3,4 It is also known as comedone nevus and ne- the cyst’s epithelial lining with resultant foreign-body vus acneiformis unilateralis. It is evident at birth in granulomatous formation. Similar lesions in family about 50% of cases. The differential diagnosis of ne- members suggest a hereditary component. vus comedonicus includes familial dyskeratotic come- dones, and linear comedone formations usually linked Tuberous Sclerosis with acne vulgaris or chronically sun-damaged skin Angiofibromas are connective tissue hamartomas (Favre-Racouchot disease). Infrequently, multiple that can appear as multiple flesh-colored papules on comedones in other unusual contexts may raise ne- the face.6 They are a common skin presentation in vus comedonicus as a possible consideration. tuberous sclerosis, along with hypopigmented mac- ules, shagreen patches, café-au-lait macules, mollus- Eruptive Vellus Hair Cysts cum fibrosum pendulum, forehead fibrous plaque, Eruptive vellus hair cysts, which are developmental periungual fibromas, and confetti-like macules. Treat- anomalies of vellus hair follicles, appear as multiple ment is difficult, and has included laser ablation, sur- comedo-like flesh-colored papules on the face, chest, gical excision, curettage, cryosurgery, chemical peel, neck, thighs, groin, buttocks, and axillae.5 Histo- dermabrasion, and isotretinoin.6,7 pathology reveals a mid-dermal epithelial cyst that contains keratinous material and vellus hairs. Lesions Amineptine Acne may regress spontaneously, form an open pore to the Certain drugs have also been shown as a cause of surface of the epidermis, or undergo degradation of papules and pustules. Amineptine, a tricyclic antide- pressant, at high doses can induce a severe facial acne From Dermatology and Pediatrics, New Jersey Medical School, that may also appear on the thorax, extremities, or Newark, New Jersey. 8,9 REPRINT REQUESTS to Dermatology, New Jersey Medical perineal regions. The eruption usually clears after School, 185 South Orange Avenue, Newark, New Jersey 07103- stopping the drug and has responded in some cases to 2714 (Dr. Kuflik). isotretinoin. VOLUME 66, AUGUST 2000 97 ACNEIFORM ERUPTIONS FIGURE 2. Chloracne on the face. Other Acneiform Drug Eruptions duce an acneiform eruption similar to that of steroid Generalized pustular eruptions of aseptic pustules fol- acne; however, the iodide-induced eruption may be low administration of oral medications, most com- more marked. monly antibiotics.10 They usually develop in febrile patients with leukocytosis. Other less frequent of- Folliculitis fenders include subcutaneously injected dexametha- Infections may also display an acneiform pattern. sone,11 the oral antifungal nystatin,12 and the antipsy- Gram-negative folliculitis may be a complication in chotic olanzapine.13 Lithium is also an antipsychotic patients receiving prolonged antibiotic treatment that may induce a follicular acneiform eruption.14 for acne vulgaris or rosacea. It appears as persist- ent papulopustules resistant to usual acne therapy.19 Steroid Acne The papulopustules contain gram-negative bacilli Steroid acne may occur after the administration of and gram-negative rods, including Escherichia coli, topical or systemic corticosteroids.15 It is character- Klebsiella, Enterobacter, and Proteus species. It has ized by monomorphous papulopustules with greater been shown to resolve with appropriate antibiotic involvement of the trunk and extremities than the coverage. Isotretinoin is also an effective alterna- face and usually resolves upon discontinuation of the tive treatment. causative agent (Figure 1). Steroid acne may occur Pityrosporum folliculitis, another type of folliculi- from oral, topical, intravenous, or inhaled therapy.16,17 tis, is caused by the yeast Malassezia furfur, previously named Pityrosporum ovale, and it can appear prima- Chloracne rily on the trunk and upper extremities as an ac- Chloracne is an acneiform reaction from exposure neiform eruption.20 Unlike acne vulgaris, Pityrospo- to halogenated aromatic hydrocarbon compounds rum folliculitis has no comedones and does not such as chlorinated dioxins and dibenzofuranes.18 It respond to systemic antibiotic therapy. mainly appears on the skin as polymorphous come- dones and cysts (Figure 2) and may also involve Other Infections changes in the ophthalmic, nervous, and hepatic Secondary syphilis may become evident as an ac- systems. Some chloracnegens can be oncogenic. neiform skin eruption. It occurs on the face, trunk, Associated skin findings include xerosis and pig- and extremities as nodules and crusted papulopus- mentary changes. Contact may be through direct tules.21,22 Skin biopsy specimens, serologic tests, and exposure or by inhalation or ingestion of contami- the presence of spirochetes from lesions on darkfield nated compounds or foods. Treatment is difficult. microscopy reveal the diagnosis. Once present, chloracne may persist for years, even Mycotic infections, such as sporotrichosis or coc- without further exposure. Chemicals that contain cidioidomycosis, may also manifest cutaneously with iodides, bromides, and other halogens can also in- papules and nodules, which may ulcerate and crust. 98 CUTIS® ACNEIFORM ERUPTIONS FIGURE 3. Perioral dermatitis. Although most sporotrichosis infections consist of REFERENCES the lymphocutaneous type, there is also a persistent 1. Adams PB, Cherry VB, Mutasin DF: Periorbital comedones and fixed localized cutaneous papulonodular eruption their relationship to pitch tar: a cross-sectional analysis and a that may involve the face.23,24 The causative organ- review of the literature. J Am Acad Dermatol 42: 624-627, 2000. ism, Sporothrix schenckii, can be demonstrated by skin 2. del Río E: Peculiar distribution of comedones: a report of biopsy, peripheral blood smear, and fungal culture. three cases. Dermatology (Basel) 195: 162-163, 1997. Cutaneous coccidioidomycosis is an infection 3. Lefkowitz A, Schwartz RA, Lambert WC: Nevus come- caused by Coccidioides immitis from soil and dust that donicus. Dermatology (Basel) 199: 204-207, 1999. usually results from dissemination from the lungs and 4. Bogdanowski T, Rubisz-Brzezinska J: Naevus comedonicus rarely from primary inoculation. It usually appears as giganteus. Przegl Dermatol 75: 305-307, 1998. papulonodules, pustules, or plaques that can eventu- 5. Held JL, Andrew JE, Toback AC: Eruptive vellus hair cysts. ally ulcerate and crust.25 Cutis 40: 259-260, 1987. 6. Jozwiak S, Schwartz RA, Janniger CK, et al: Skin lesions Rosacea in children with tuberous sclerosis complex: their preva- Rosacea appears on the face with acneiform papules lence, natural course, and diagnostic significance. Int J Der- and pustules. In addition, patients with rosacea may matol 37: 911-917, 1998. have facial flushing, telangiectases, and cysts with a 7. Song MG, Park KB, Lee ES: Resurfacing of facial angiofi- risk for chronic sebaceous and connective tissue hy- bromas in tuberous sclerosis patients using CO2 laser with perplasia of the nose (rhinophyma).26 Although the flashscanner. Dermatol Surg 25: 970-973, 1999. definitive etiology is unknown, triggers and exacer- 8. Grimalt R, Mascaro-Galy JM, Ferrando J, et al: Guess what? bators include hot spicy foods and alcohol. Acne Macronodular iatrogenic acne due to amineptine. Eur J rosacea has also been associated with the ingestion Dermatol 9: 491-492, 1999. of a high-dose vitamin B supplement.27 9. Vexiau P, Gourmel B, Castot A, et al: Severe acne due to chronic amineptine overdose. Arch Dermatol Res 282: 103- Perioral Dermatitis 107, 1990. Perioral dermatitis, mostly seen in the young female 10. Roujeau JC, Bioulac-Sage P, Bourseau C, et al: Acute gen- white population, also appears as papulopustules with eralized exanthematous pustulosis: analysis of 63 cases. erythematous bases28(Figure 3). Located predominantly Arch Dermatol 127: 1333-1338, 1991. periorally, the eruption may also include the perinasal 11. Demitsu T, Kosuge A, Yamada T, et al: Acute generalized and periorbital areas and characteristically spares the exanthematous pustulosis induced by dexamethasone in- vermilion border of the lip. Although the etiology is jection. Dermatology (Basel) 193: 56-58, 1996. unknown, suggested causative agents include topical or 12. 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