Abstract
Acneiform disease includes conditions on the spectrum of acne and folliculitis as well as conditions that may resemble acne clinically, such as rosacea.
1 Acne
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1.
Acne vulgaris
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Common inflammatory skin disease, most often in puberty
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Morphologies include comedonal, papular, pustular, nodulocystic
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Pathophysiology related to:
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1.
Increased sebum production
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2.
Abnormal follicular epidermal turnover/keratinization
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3.
Overgrowth of bacteria (gram positive diptheroid anaerobe Propionobacterium acnes)
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4.
Inflammatory response (to foreign body)
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1.
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Typical therapeutic ladder:
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1.
Benzoyl peroxide in conjunction with topical antibiotic (clindamycin or erythromycin) and topical retinoid (for comedones)
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2.
Systemic antibiotic (tetracyclines)
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3.
Systemic retinoid (isotretinoin)
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1.
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Androgenic hormones have significant influence on acne; with suspected strong hormonal component (e.g. acne flares monthly localizing more on jawline, chin), consider oral contraceptives and spironolactone
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The role of diet in acne is controversial, but no strong evidence for diet connection
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2.
Follicular occlusion tetrad
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These four diseases are thought to be closely related and may co-exist; the primary pathophysiology involves occlusion and rupture of hair follicles with associated inflammation
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This spectrum may be associated with inflammatory bowel disease, pyoderma gangrenosum, acne syndromes
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(a)
Hidradenitis suppurativa
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Aka “acne inversa”
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Clinically may see sinus tracts and nodules, “double comedones”
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Localizes typically to intertriginous areas (axillae, inguinal folds)
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Previously, thought to be a primarily apocrine disease given the typically apocrine gland bearing affected areas, but now thought that apocrine glands are only secondarily inflamed and fibrosed
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Associated with smoking, obesity
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Treatments include intralesional steroids, topical and systemic antibiotics, isotretinoin (often not effective), anti-TNF biologics, surgery
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(b)
Acne conglobata
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Unusually severe nodulocystic acne with sinuses and scarring
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(c)
Dissecting cellulitis
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Aka perifolliculitis capitis abscedens et suffodiens
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Clinically presents as cystic nodules on the scalp
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May have overlap with folliculitis decalvans, which is more typically a flat and boggy scalp plaque
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See also Alopecia:Scarring alopecia
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(d)
Pilonidal sinus
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Involves gluteal cleft
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3.
Acne syndromes
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(a)
Acne fulminans
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Severe nodulocystic acne with variable systemic manifestations (fevers, arthralgias, hepatosplenomegaly), may have osteoclastic lesions, especially of the clavicle
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(b)
SAPHO syndrome
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Syndrome of synovitis, acne conglobata, pustulosis (often palmoplantar), hyperostosis, osteitis
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Can be associated with Sweet’s
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(c)
PAPA syndrome
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Sterile pyogenic arthritis, pyoderma gangrenosum, and acne
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Has been associated with pyrin/nod defects
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(d)
PASH and PAPASH syndromes
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Pyoderma gangrenosum, acne, and suppurative hidradenitis (PASH) and pyogenic arthritis, pyoderma gangrenosum, acne, and suppurative hidradenitis (PAPASH)
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(a)
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4.
Other types of acne
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(a)
Neonatal acne/neonatal cephalic pustulosis
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No open or closed comedones seen
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Onset usually first 2–3 weeks of life, resolves on own with no scarring within weeks, therapy not necessary
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Associated with Malassezia sympodialis
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(b)
Infantile acne
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Usually begins at 3–6 months, may be associated with precocious secretion of gonadal androgens
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Can persist; treated with topical retinoid/benzoyl peroxide
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(c)
Drug-induced acne
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Usually from corticosteroids (“steroid acne”), but also lithium, androgens, phenytoin, ACTH, INH, EGFR inhibitors
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Can see abrupt eruption of monomorphic papules/pustules without comedones
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Would also include halogenoderma (includes iododerma) as a potential drug-induced acneiform eruption
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See also Vascular:Toxic Erythema:Drug Eruptions
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(d)
Chloracne
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Occupational acne caused by exposure to chlorinated aromatic hydrocarbons (dioxins), such as Agent Orange (herbicide/defoliant used in Vietnam War). Famous case: Ukranian president Viktor Yuschenko poisoned.
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Particularly seen behind ears and over the malar crescent
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(e)
Acne excoriée (de jeunes filles)
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Picking at one’s face with history of mild acne
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(f)
Acne aestivalis (Mallorca acne)
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Monomophous eruption of red papules on the face from UVA light (similar to PMLE), no comedones
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(g)
Trichostasis spinulosa
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Small dark follicular papules on the nose; from clusters of vellus hairs embedded within hair follicles; may be variant of comedones
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(h)
Favre–Racouchot syndrome
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Nodular elastosis with cysts and comedones
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Associated with UV and smoking
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(i)
Solid facial edema
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Aka Morbihan disease
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Soft tissue edema associated with acne leading to midline facial distortion
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Has also been associated with rosacea and Melkersson-Rosenthal syndrome
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(j)
Tropical acne
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Acneiform eruption from extreme heat or occupational exposure
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(k)
Acne mechanica
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Caused by repeated rubbing under occlusion
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I.
Fiddler’s neck
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I.
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(a)
2 Rosacea
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Aka acne rosacea; rosacea is considered a distinct entity from acne with different pathophysiology, though may respond to similar therapeutics
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Rosacea is classically recognized by central erythema of the face with stinging/burning sensations; however, different types may have different clinical morphologies
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Classic triggers include sunlight, alcohol, caffeine, spicy foods, emotions, hot drinks
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Pathophysiology of rosacea is unclear, but it is thought to reflect a vascular dysregulation
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Has been associated with increased levels of toll-like receptor 2, and increased expression of cathelicidin, LL-37, and kallikrein 5
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Demodex folliculorum has been implicated in etiology (but circumstantial evidence)
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Treated topically with metronidazole, azelaic acid, sodium sulfacetamide, even retinoids, permethrin, ivermectin; systemically with oral antibiotics (since etiology unclear, why these work is also unclear), ivermectin; also pulsed dye laser
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1.
Classic types of rosacea
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(a)
Erythematotelangiectatic
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(b)
Papulopustular
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(c)
Phymatous (including rhinophyma)
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(d)
Ocular (including blepharoconjunctivitis)
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(a)
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2.
Pyoderma faciale/rosacea fulminans
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A more severe inflammatory form of rosacea
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Some use former term to mean more localized, latter term for whole face
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Presents as eruption of inflamed papules and yellow pustules in the centrofacial region
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3.
Perioral/periorificial dermatitis
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May be within rosacea spectrum, but also can be caused by topical steroid use; classically spares vermillion border of lips
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Includes periorificial dermatitis of childhood
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4.
Granulomatous rosacea
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Clinically consistent with rosacea, but with lesions with granulomatous clinical morphology (red-brown/orange papules) and pathology
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See also Dermal:Inflammatory:Granulomatous/histiocytic
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5.
Lupus miliaris disseminatus faciei
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Aka acne agminata
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Granulomatous eruption on face; some consider a form of rosacea
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Previously thought to be a tuberculid reaction
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1.
3 Folliculitis
3.1 Superficial Folliculitis
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(a)
Bacterial
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I.
Impetigo of Bockhart (Staph)
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II.
Gram negative folliculitis
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III.
Hot tub folliculitis (Pseudomonas)
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I.
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(b)
Fungal
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I.
Dermatophytes
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1.
Tinea barbae (T. mentagrophytes and T. verrucosum)
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2.
Tinea capitis (especially T. tonsurans and M. canis)
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1.
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II.
Candida
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III.
Pityrosporum
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I.
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(c)
Viral
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I.
Herpes simplex (HSV)
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I.
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(d)
Eosinophilic pustular folliculitis (EPF)
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Three types
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I.
HIV-associated EPF
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Presents as pruritic papules on chest/back/face; can mimic acne
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II.
Ofuji’s disease
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Seen primarily in Asians/Japanese
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III.
Eosinophilic pustulosis of infancy
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Ddx erythema toxicum neonatorum
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I.
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(e)
Demodex folliculitis
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(f)
Other non-infectious
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I.
Disseminate and recurrent infundibulofolliculitis (DRIF)
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Aka Hitch and Lund disease
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Numerous monomorphic follicular papules on chest
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Can appear like lichen spinulosus
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Ddx juxtaclavicular beaded lines, an entity perhaps related to sebaceous hyperplasia
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II.
Irritant/frictional
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I.
3.2 Deep Folliculitis
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(a)
Infectious
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I.
Furunculosis
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Aka boils or follicular abscesses
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From Staph and Strep primarily
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Primary treatment is incision and drainage; may also use systemic antibiotics
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See also Infectious Diseases: Bacterial: Staph and Strep
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II.
Sycosis barbae (Staph/mycotic/herpetic)
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Homophone with “psychosis”
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Localizes to the beard area
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III.
Majocchi’s granuloma (deep dermatophyte folliculitis)
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T. rubrum
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Often on legs, with topical steroid use
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I.
3.3 Pseudofolliculitis
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From in-grown hairs
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(a)
Pseudofolliculitis barbae (PFB)
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Often treated with topical antibiotics for presumed associated folliculitis; also treated with decreased shaving frequency
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(b)
Acne keloidalis/Acne keloidalis nuchae (AKN)
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May represent a scarring reaction to pseudofolliculitis
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See also Alopecia:Scarring alopecia
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(a)
4 Follicular Cysts
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See also Neoplastic:Cysts
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1.
Milia
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Benign, keratin-filled cysts (small epidermoid cysts); do not confuse with miliaria (from obstruction of sweat gland ducts)
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(a)
Primary milia
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From vellus hair follicles
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(b)
Secondary milia
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From damage to pilosebaceous unit (as in subepidermal blistering diseases)
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(a)
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2.
Epidermal inclusion cysts
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Aka epidermoid cysts or sebaceous cyst (misnomer) or infundibular cyst (from the infundibulum)
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Associated with Gardner syndome/FAP
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Has granular layer
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3.
Pilar cysts
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Aka trichilemmal cysts, sometimes autosomal dominant
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Derived from the outer root sheath trichilemma of the hair follicle
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Lacks granular layer
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4.
Foreign body granulomatous reaction to ruptured follicular cyst (ruptured cyst/keratin granuloma)
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5.
Eruptive vellus hair cysts
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Small bluish papules typically on mid chest/sternum, rarely extremities
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See also Neoplastic:Cysts
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6.
Steatocystoma/steatocystoma multiplex
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Cystic papules with oily, yellow liquid
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See also Neoplastic:Cysts
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1.
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Lipoff, J. (2016). Acneiform Diseases. In: Dermatology Simplified. Springer, Cham. https://doi.org/10.1007/978-3-319-19731-9_8
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