3

Acneiform Eruption
Introduction
Acneiform eruptions are those lesions, which are acne-like lesions and resemble
acne but the distinguishing factor is absence of comedones which are present in
acne and absent in acneiform eruptions.
The other distinguishing factors are as follows:
Presence of acne outside the age of acne
Presence of a similar monotonous morphology
Drug history present
Spontaneous resolution of acne after the stoppage of drug.
Acneiform eruptions can be summarized as:1-5
Nevus comedonicus
Eruptive hair cysts
Tuberous sclerosis
Steroid acne
Chloracne
Acneiform drug eruption
Gram-negative folliculitis
Eosinophilic pustular folliculitis
Pityrosporum folliculitis
Coccidioidomycosis
Secondary syphilis
Sporotrichosis
Rosacea
Perioral dermatitis.

Nevus comedonicus
It is also known as nevus acneiformis unilateralis, is an infrequent developmental
anomaly manifesting as aggregated open comedones.
It consists of dilated follicular or eccrine orifices plugged with keratin. It may
be solitary, congenital.

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Acne and Scars

Treatment of Nevus Comedonicus

If medical therapy is considered then topical retinoids might be of some benefit.
Surgical treatment involves excision or carbon dioxide laser ablation of the
involved skin.

ERUPTIVE VELLUS HAIR CYST6

It presents as flesh-colored papules found usually on the face, chest, neck, axillae,
thighs, groin and buttocks.
It is an anomaly of the vellus hair follicles and might be hereditary.

Treatment of Eruptive Vellus Hair Cyst

There is risk of scarring with incision and drainage of the individual lesion and
other modalities like CO2 laser are difficult to use over large surface areas so
treatment of the cyst is difficult. Ablations are difficult to use over large surface
areas. As far as medical treatment is concerned, topical retinoids and 12% lactic
acid preparations have proven useful in some instances.

STEROID ACNE (Fig. 3.1)7,8

Exposure to steroids, halogenated aromatic hydrocarbons, iodides, bromides and
other halogens can cause acneiform eruption.
It is observed as monomorphous papulopustules located predominantly on
the trunk and extremities, with less involvement of the face.
Characteristically, it appears after the administration of systemic corticoster
oids, including intravenous therapy. Topical or inhaled corticosteroids may cause
an acneiform eruption of the area of skin under which the topical preparation

Fig. 3.1 Steroid acne

Acneiform Eruption

is applied or in around the nose or mouth in the case of inhaled steroids.

The treatment of steroid acne is the usual treatment options which are used
for acne and steroid acne disappears after the stoppage of particular steroid.

Chloracne
It is an entity which also mimics acne caused by exposure to halogenated
aromatic hydrocarbon compounds, such as chlorinated dioxins and dibenzo
furans. Exposure is caused by inhalation, ingestion, or direct contact of contami
nated compounds or foods. Chloracne is seen as lesions similar to acne on the
exposed sites. Xerosis and skin changes in the form of pigmentation might be
other associated findings. These chlorinated dioxins can also be carcinogenic and
might also cause changes in the nervous and hepatic systems.

Treatment of Chloracne
Treatment of chloracne can be difficult as it might persist even years after
exposure has stopped.

ACUTE GENERALIZED PUSTULAR ERUPTION

It is caused mainly by antibiotic, which is mainly a drug reaction and mimics
acne. Acneiform eruption can also be caused by other drugs like isoniazid,
steroids, hydroxychloroquine, naproxen, mercury, itraconazole.9-11
Drugs like olanzapine, lithium are used in chemotherapy, also can cause
acne like eruption.12-18

GRAM-NEGATIVE FOLLICULITIS
It is a complication of long-term of antibiotic therapy in acne or rosacea.
It presents as a persistent papulopustular eruption.
Antibiotic use, such as those of the tetracycline class, can alter the normal
skin flora of the skin allowing for growth of gram-negative organisms in the nares
of the nose. These gram-negative organisms are typically spread to the skin of
the upper lip, chin, and jawline whether they cause a folliculitis. Culture of the
papulopustules grows gram-negative bacilli and gram-negative rods, including
Escherichia coli and Klebsiella, Enterobacter, and Proteus species. Typical history
is a patient with a sudden acne flare despite no change in treatment or a patient
unresponsive to traditional therapies. Oral isotretinoin is considered standard of
care.

Pityrosporum Folliculitis
It is another infectious folliculitis that is presumably caused by a host reaction
to the yeast Malassezia furfur, previously named Pityrosporum ovale, a normal
human skin commensal organism. It appears primarily on the trunk and upper
extremities of late adolescents and young adults. Unlike acne vulgaris, it is pruritic,
does not contain comedones, and responds to empiric antifungal therapy rather
than antibiotics. Diagnosis is typically made clinically, although the yeast and
hyphae can be observed in biopsy specimens in the widened follicular ostia

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Acne and Scars

along with keratinous material, and occasionally, rupture of the follicular wall
may occur. Patients may be treated with topical leave-on, wash-off, or systemic
antifungal therapy.
Eosinophilic pustular folliculitis (EPF) is a disease of unclear etiology, thought
to be an allergic hypersensitivity. It appears as a recurrent pruritic papulopus
tular eruption on the face, trunk, and extremities. Histopathology reveals a
predominantly perifollicular infiltration of eosinophils with some mononuclear
cells and subcorneal pustules composed of eosinophils. Three main types exist,
1. Infantile form
2. HIV associated
3. Classic Ofuji disease in immunocompetent patients, typically Japanese
patients.
Patients may also demonstrate blood eosinophilia and leukocytosis. Treatment
modalities and results vary greatly. Options include topical and systemic
corticosteroids, oral antibiotics, dapsone, isotretinoin, and pulsed ultraviolet
phototherapy (PUVA). Indomethacin is the treatment of choice for classic Ofuji
disease.
Several infectious diseases may result in acneiform eruptions:
In secondary syphilis, acne like lesions, like papulopustules and nodules, may
occur on the face, trunk, and extremities. The causative agent, the spirochete
Treponema pallidum, may be easily observed in biopsy specimens with
the Warthin-Starry stain. In addition, serologic tests and the presence of
spirochetes on dark field microscopy may reveal the diagnosis.
Papules and nodules mimicking acne may occur in mycotic infections also
and may ulcerate and crust.
Sporotrichosis caused by Sporothrix schenckii, also causes papulonodular
eruption but commonly induces a lymphocutaneous reaction. It presents as a
persistent fixed localized cutaneous papulonodular eruption that may involve
the face. The organism can be demonstrated histologically, by peripheral
blood smear, and by fungal culture.
Cutaneous coccidioidomycosis usually caused by inhalation and dissemina
tion of Coccidioides immitis, may rarely occur by primary inoculation and
appear as papulopustules, nodules, or plaques that can eventually ulcerate
and crust.

Rosacea
It is a condition which manifests mainly as facial flushing and telangeictasias
but appears similarly to acne vulgaris with papulopustular lesions also (Fig. 3.2).
Patients with rosacea, however, lack comedones. Four subtypes of rosacea exist:
1. Erythematotelangiectatic
2. Papulopustular
3. Phymatous
4. Ocular.
The incidence of rosacea is mostly seen in whites.
Mainly women are affected. The age group affected is mostly the third and
fourth decades of life.
Rhinophyma, which is due to sebaceous hyperplasia of nose, develops mainly
in men.

Acneiform Eruption

Fig. 3.2 Rosacea and papulopustular lesions

Rosacea can also have eye findings also. They are blepharitis, conjunctivitis,
iritis, iridocyclitis, and hypopyon. In severe cases, keratitis may also occur.
The etiology is still unclear but the factors which affect are extremes of weather,
hot and spicy food and alcohol. Sometimes the mite Demodex folliculorum can
also trigger or exacerbate rosacea.
It was also seen that taking of high dose vitamin B6 supplement also caused
rosacea.19
Granulomatous inflammation is seen in the histopathology. The treatment
includes antibiotics like metronidazole and systemic antibiotics like oral tetra
cycline. Avoidance of sun exposure and use of sunscreens should be advised.

Perioral Dermatitis
It is a disorder in which papulopustules with erythematous base are seen
periorally sparing the vermilion border. It might include perinasal and periorbital
areas. Although the etiology is not clear, the disease is mainly seen in young and
white females.
A variant known as periocular dermatitis affects the skin around the eyes. The
eruption is thought to be a variant of rosacea, as biopsies show changes similar to
those of rosacea.
Causative agents are theorized to be prior use of topical corticosteroids, but
neither duration of use nor steroid strength have been shown to be clearly related.
Demodex mites,20 moisturizers, fluorinatced compounds, and contact irritants or
allergens have also been implicated as causes of eruption.
Therapy typically includes cessation of topical steroids or other offending
agents and topical anti-inflammatory treatments such as topical metronidazole,
topical pimecrolimus cream, azelaic acid, as well as oral anti-inflammatory dose
of antibiotics such as doxycycline.

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