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Home , Comedo, Keratosis pilaris, Perioral dermatitis, Rosacea

Sometimes the run-of-the-mill case of vulgaris is more than it seems. Here’s how to spot and treat common acne foolers.

By Julie C. Harper, MD

ne of the most common diagnoses made by a conversation about the need to follow the prescribed regimen, dermatologist, acne is easily recognizable by you move in closer for a visual inspection and notice that both physician and patient. In fact, the patient things look different than they did from across the room. The most often has made the diagnosis prior to diagnosis is not acne vulgaris at all. scheduling an appointment. So, a very busy dermatologistO picks up a chart that says, “Chief complaint: Finding the Clues acne vulgaris,” and walks into the exam room. From the door There are several simulators of acne vulgaris that can confound a the doctor can appreciate bumps on the and maybe even clinician. Though these “imposters” can present with a clinical on the neck and chest. This patient is straightforward! The appearance similar to that of acne, closer inspection often reveals presentation is so clear that a diagnosis is made without close subtle (and sometimes not too subtle) clues that will point to the examination of the skin. Treatment is initiated and the patient true diagnosis. Some deserve special consideration: is scheduled for follow-up in eight weeks. Perioral . may certainly be The patient returns for follow-up in eight weeks with mistaken for acne vulgaris. It is seen most commonly in young absolutely no improvement. Of course, compliance is always to middle-aged females, a group that is also susceptible to acne an issue! As you visit with the patient, preparing to ease into a vulgaris. It may be associated with inflammatory acne-like

26 Practical August 2006

be seen together. Often the patient presents with an acne con- globata-like appearance. Alternatively, they may have been treated with or even with what is con- sidered only a partial response. Some dermatologists might be tempted to prescribe additional courses of isotretion aimed at these resistant acne “.” True epidermoid cysts will not show significant improvement with oral antibiotics or isotretinoin. They are best treated with surgical excision. fulminans. Not to be confused with acne fulmi- nans, rosacea fulminans presents in young to middle-aged adult females with a history of minimal acne. Seemingly out- that involve the of-the-blue, these individuals go from having clear skin to chin, jawline and nasolabial folds. As the name being disfigured with large inflammatory nodules and pustules. implies, perioral dermatitis is also a dermatitis and therefore is Again the , the hallmark of acne vulgaris, is absent. As associated with redness, dryness and itching. Remember that in , systemic symptoms may be present. the area immediately adjacent to the vermillion border will be Treatment includes systemic alone for weeks to months spared. Acne vulgaris may also affect the perioral skin, particu- followed by a combination of systemic steroids and larly in adult females. What helps to differentiate perioral der- isotretinoin. Once the appears to be well con- matitis from acne vulgaris is the absence of the comedo. trolled the steroids may be discontinued and isotretinoin con- Unless there is an overlap between perioral dermatitis and tinued appropriately. acne vulgaris, comedones should be absent. Fortunately, treat- Syringomas. Occasionally an appendageal tumor will mask ment is similar for both with antibiotics often lead- as acne vulgaris. Eruptive syringomas present around puberty ing to resolution of perioral dermatitis within eight weeks. and may be seen on the face, upper chest and upper back, all However, the typical topical treatments for acne vulgaris areas prone to acne vulgaris. Treating eruptive syringomas is dif- including topical and may con- ficult. Ablative lasers may offer some cosmetic improvement. tribute to the dryness and irritation associated with perioral Pityrosporum . Pityrosporum folliculitis is prob- dermatitis. ably mistaken for acne more often than any of us know. It is Verruca plana. Numerous flat can also be mistaken seen most commonly on the trunk in the same distribution as for acne vulgaris. They are small, skin-colored, non-inflamed . It is characterized by erythematous, follicular papules that may occur anywhere on the body. When they are papules and small pustules and is notoriously itchy. Treatment localized to the face or upper trunk they may mimic come- includes systemic antiyeast , including itraconazole donal acne. However, on close inspection, the are not or fluconazole. centered around a follicle and no comedones are visible. Flat folliculitis. Demodex folliculorum is a warts may respond to topical retinoids but may require addi- present in the sebaceous follicles on the face. Whether or not tional treatments, including cryotherapy, imiquimod, and/or Demodex incites inflammation is controversial. However, it is immunotherapy. worth considering Demodex folliculitis in individuals with an Multiple epidermoid cysts. Epidermoid cysts are some- asymmetric, itchy papular eruption on the face. Demodex fol- times confused with nodulocystic acne. The two entities may liculitis has also been reported in patients with HIV. Treatment

August 2006 Practical Dermatology 27

Acne Imposters

Don’t Be Fooled By Acne Imposters

Imposter Clues Treatment Options

Perioral dermatitis Area immediately adjacent to the ver- ; Typical topical million border will be spared; No treatments for acne vulgaris (retinoids comedones visible and benzoyl peroxide) may contribute to dryness and irritation. Verruca plana Lesions not centered around a follicle; Topical retinoids; Additional treat- No comedones visible ments include: cryotherapy, imiquimod, and/or immunotherapy Multiple epidermoid cysts Non-response to oral antibiotics or Surgical excision isotretinoin Rosacea fulminans Absent comdedo; Possible systemic Systemic steroids + oral isotretinoin symptoms; No or minimal history of acne Syringomas Skin-colored papules not centered Ablative lasers around a follicle; no comedones visible Pityrosporum folliculitis Notoriously itchy Systemic antiyeast medications, incl. itraconazole or fluconazole Demodex folliculitis Asymmetric, itchy papular eruption Topical permethrin; Topical or oral on the face ; orally for resistant cases Gram–negative folliculitis Initial therapeutic response followed Oral isotretinoin by acne flares; Large inflamed crusted papules around nose and mouth Tinea faceii and tinea Annular, erythematous or pustular Antifungals; For deep-seated pustules, barbae eruption systemic therapy likely necessary

Sarcoidosis Apple jelly color lesions; Comedones Topical, intralesional or systemic absent; Systemic symptoms in patients steroids, hydroxycholoroquine, with systemic sarcoidosis. pilaris Red, follicular, hyperkeratotic papules Topical retinoids, alpha-hydroxy acids, on the cheeks; Similar changes on the or topical ; Low-potency upper extensor arms, , or topical Rosacea Comedo absent; Papules not always Physician preferred regimen for centered around follicle; rosacea. Telangiectases and facial ; History of , triggers (esp. sun- light) Pseudofolliculitis barbae Ingrown evident; Comedones diminish inflammation; absent Topical retinoids (fordesquamation, to lighten PIH)

Eosinophilic folliculitis Often pruritic; May be intermittent, UV therapy; Antipruritics; Systemic alternating periods of flaring and steroids clearing

28 Practical Dermatology August 2006

includes topical permethrin and/or topical or oral metronida- Acne rosacea. Is it acne vulgaris or is it rosacea? Making this zole. Resistant cases may benefit from ivermectin orally. distinction can be more challenging than it initially appears at Gram–negative folliculitis. Gram-negative folliculitis is first blush (no pun intended). Remember that the primary seen in individuals who have known acne vulgaris. These indi- of acne is the comedo. This lesion should be readily viduals have been on numerous antibiotics for relatively long apparent in acne vulgaris and absent in rosacea. Rosacea periods of time. They may have had an initial excellent papules are also not always centered around the follicle and response, but as the lesions become infected with gram nega- telangiectases and facial erythema may be promininent. tive organisms, the acne flares with large inflamed crusted History may also offer some clues to the correct diagnosis. Ask papules around the nose and mouth. Although the name about a tendency to blush easily and ask what effect sunlight would imply that additional antibiotics are required for clear- has on the condition. Sunlight is the most frequently implicat- ing, the treatment of choice is oral isotretinoin. ed exacerbating factor in rosacea. Patients with acne vulgaris Tinea faceii and tinea barbae. Tinea faceii or tinea barbae often report that their acne improves with sunlight exposure. may be very subtle. It may present in any age Pseudofolliculitis barbae. PFB is not acne but group as an annular, erythematous or pustu- Always certainly does look like it. Inflammatory lar eruption. If the patient already has a papules and pustules surround involved background of facial erythema or closely inspect the follicles within the beard area. On close acne vulgaris, these additional inspection, numerous ingrown hairs pustules may be difficult to skin of individuals who are evident and comedones are differentiate. Tinea faceii is absent. Fortunately, many of the most commonly caused by present with “acne” to confirm same topical and systemic med- Trichophyton rubrum while ications improve both condi- the causative organism in the diagnosis and ensure that tions. Namely, tetracycline tinea barbae is more com- antibiotics help diminish the monly Trichophyton verruco- another subtle process is not inflammation associated with sum. If tinea faceii presents PFB while topical retinoids help with deep-seated pustules, present. Additionally, if an acne to normalize desquamation and systemic therapy will likely be lighten any associated post- necessary to achieve a cure. patient is not responding to inflammatory . Sarcoidosis. Sarcoidosis is a Eosinophilic folliculitis great fooler. In its papular form it treatment, question the (Ofuji’s). Eosinophilic folliculitis is a may mimic acne vulgaris. papular eruption most commonly Differentiating these two may be partic- diagnosis. involving the face. Eosinophilic folliculitis ulary difficult in darker skin types is often quite pruritic and may be intermittent, (Fitzpatrick IV-VI) where the inflammation of with alternating periods of flaring and clearing. Most acne may be hard to appreciate. Cutaneous sarcoidosis often affected individuals have no associated systemic symptoms but involves the periorificial areas of the face and may have a char- may have a peripheral eosinophilia. A similar eruption may be acteristic apple jelly color to the lesions. Of course, comedones seen in the HIV population. Eosinophilic folliculitis may be should be absent. Systemic symptoms may also be present in a differentiated from acne based on the absence of the comedo patient with systemic sarcoidosis. and by the presence of both itching and a history of waxing . Keratosis pilaris is almost as common as and waning. Treatment may include therapy, acne vulgaris. It often presents as red, follicular, hyperkeratotic antipruritics, and systemic steroids. papules on the cheeks. Individuals with keratosis pilaris on the face may also have similar changes on the upper extensor arms, Closer Inspection buttocks or thighs. There may be a history of Many common skin conditions can mimic acne vulgaris. Always and allergies. Treatment is challenging. Topical retinoids, closely inspect the skin of individuals who present with “acne” to alpha-hydroxy acids, or topical salicylic acid may help to confirm the diagnosis and ensure that another subtle process is smooth the hyperkeratotic papules while a low-potency topical not present. Additionally, if an acne patient is not responding to steroid may help to reduce erythema. Of course, these patients treatment, question the diagnosis. Could there be pityrosporum, often have “sensitive skin” and at least some of these topical demodex, or an appendageal tumor? Look care- agents may cause facial irritation. fully, be thorough, and don’t be fooled by an acne imposter.

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