differentials of papules on face

papules on face

1. DIFFERENTIAL DIAGNOSIS OF PAPULAR LESIONS ON FACE DR.MIKHIN GEORGE THOMAS

2. CLASSIFICATION INFECTIONS INFLAMMATORY DISORDERS TUMOURS OTHERS

3. INFECTIONS Molluscum contagiosum Tinea faciei Lupus vulgaris Demodicidosis

4. INFLAMMATORY DISORDERS Acne Rosacea Perioral dermatitis Lupus miliaris disseminatus faciei FACE Sarcoidosis Follicular mucinosis Pseudofolliculitis barbae

5. TUMOURS BENIGN EPIDERMAL TUMORS AND CYSTS: DPN Seborrhoeic keratosis Keratoacanthoma Milia

6. Tumors cont… PREMALIGNANT EPITHELIAL LESIONS Actinic keratosis Cutaneous horn MALIGNANT Basal cell carcinoma

7. Tumors of skin appendages Eccrine gland tumors : syringoma , eccrine hidrocystoma Apocrine gland tumors : syringocystadenoma papilliferum Sebaceous gland tumors : sebaceoma , sebaceous adenoma, sebaceous hyperplasia Tumor of hair follicle mesenchyme : trichodiscoma Hair follicle tumors : dilated pore, trichoadenoma External root sheath tumors : trichilemmoma Hamartomas : trichoepithelioma , trichofolliculoma

8. Soft tissue tumors Fibrous tumor : fibrous papule of face Fibrohistiocytic tumors : atypical fibroxanthoma

9. OTHERS Colloid milia Angiofibroma

10. INFECTIONS

11. MOLLUSCUM CONTAGIOSUM Pox virus family MCV 1-4; majority : type 1 Contact with infected persons or contaminated objects, sexual abuse Peak incidence : 2-5 yrs IP: 14 days to 6 mths C/F : shiny, pearly white, hemispherical, umbilicated papule, 5-10 mm Agminate form or giant molluscum Distribution depends on the mode of infection

12. Widespread and refractory mollusca on the face- HIV infection and iatrogenic immunosuppression . Viral entry into the basal layer where an early increase in cell division extends into the supra basal layer. Molluscum bodies

13. Course & treatment : Spontaneous clearance Curettage Cryotherapy Electrosurgery Phenol cantharidin tricholoroacetic acid pot.hydroxide solution topical salicylic acid preparations tretinoin imiquimod cream cidofovir

14. LUPUS VULGARIS Chronic progressive post primary, paucibacillary form of cutaneous tuberculosis Moderate or high degree of immunity Underlying focus- bone, joint or lymph node Haematogenous or lymphatic spread C/F: 80%- head and neck India- buttocks and trunk Initial lesion : small reddish brown plaque, soft, with peripheral extension. 5 types: plaque, ulcerative, vegetating, tumour like, papular and nodular forms. Diascopy : apple jelly nodules

15. Diagnosis Treatment : standard ATT Differential diagnosis : Rosacea leprosy nodules: firmer Nodules of sarcoidosis : resemble grains of sand

16. DEMODICIDOSIS Demodex folliculorum - follicle mite Areas of high sebum production Head down position in the follicle, 2-6 mites, motile Can produce papular and papulopustular lesions in immunosuppressed individuals Pathogenic role: pityriasis folliculorum , rosacea , perioral dermatitis, blepharitis Treatment : topical acaricides

17. TINEA FACIEI Ringworm of glabrous skin of face Trichophyton mentagrophytes , T.rubrum Direct inoculation or secondary spread from other sites Itching, burning & exacerbation with sun exposure Erythema +, Scaling less prominent Simple papular lesions or flat patches of erythema D/D : PMLE and DLE Treatment : antifungals

18. TINEA BARBAE A disease of adult male Ringworm of beard and moustache areas of face Invasion of coarse hairs Commonly farm workers Trichophyton verrucosum , T.mentagrophytes C/F: highly inflammatory pustular folliculitis Hairs surrounded by red inflammatory papules or pustules Loose hairs in affected areas Treatment : antifungals

19. ACNE A chronic inflammatory disease of pilosebaceous units Usually starts in adolescence Seborrhoea , open & closed comedones , erythematous papules & pustules, nodules, pseudocysts , scarring Pathogenesis : 4 factors 99% - lesions on face Early lesions – comedones Grading of acne Acne variants – infantile, occupational, mechanical, tropical, acne excoriee , acne conglobata , acne fulminans fulminans .

20. Treatment : Topicals – retinoids , benzoyl peroxide, topical antibiotics, nicotinamide , azelaic acid Physical modalities Systemic therapy : antibiotics, oral retinoids , hormonal therapy, zinc Acne surgery Differential diagnosis : rosacea , perioral dermatitis, gram negative folliculitis

21. ROSACEA A vascular disorder affecting central face Presence of one or more of the following: flushing, non transient erythema , papules and pustules, telangiectasia Not a disorder of sebaceous glands, absence of comedones Pathogenesis : Damage to dermal connective tissue Abnormal vascular reactivity Sensitivity to noxious stimuli High levels of cathelicidin H.pylori , Demodex folliculorum

22. Cont… Early : episodic flushing, mild telangiectasia , transient edema Progressive : papules, pustules, sustained edema, extensive telangiectasia Late : induration , rhinophyma Lymphoedema , eye involvement, salivary gland involvement Histopathology : Dilated capillaries & lymphatic channels in mid dermis Perivascular lymphohistiocytic infiltrates Solar elastosis Sometimes granulomas Pustules – neutrophilic infiltration

23. Treatment Topical : metronidazole , tretinoin , clindamycin , tacrolimus , azelaic acid Systemic : tetracyclines , metronodazole , isotretinoin Rhinophyma : surgical excision, intense pulsed light lasers, dermabrasion

24. PERIORAL DERMATITIS Persistent erythematous eruption of tiny papules and papulopustules – perioral Periocular dermatitis Pathogenesis : Demodex , candida , fusiform bacteria Irritant and allergic contact factors Atopy Topical steroids, cosmetic products Hormonal factors, sensititvity to sunlight

25. Cont.. Begins in nasolabial areas  perioral areas; sparing lip margins Monomorphic papules & pustules Histopathology – eczematous changes, mononuclear infiltrate; rarely granulomatous inflammation Treatment Discontinue topical steroids Avoid potential contact allergens Oral tetracyclines for 4 weeks Topical tetracycline, metronidazole , erythromycin Pimecrolimus 1% cream

26. ACNE AGMINATA Lupus miliaris disseminatus faciei – historical Acnitis or FIGURE A self limiting variant of granulomatous form of rosacea C/F : Multiple, monomorphic , symmetrical, reddish-brown papules on the chin, forehead, cheeks and eyelids Clustering around mouth or eyelids or eyebrows - ‘ agminata ’ Diascopy – apple jelly nodules Granulomatous histology with large area of caseation D/D : micropapular sarcoidosis Treatment : tetracyclines , dapsone , low dose prednisolone

27. Facial Afro-Caribbean childhood eruption FACE or granulomatous periorificial dermatitis A juvenile form of perioral dermatitis or acne agminata Papular eruption confined to the face – clustering around mouth, eyes and ears Pustules absent, vermilion border involved Histology – nonspecific inflammation with hyperkeratosis or granulomatous mainly perifollicular Complete resolution Treatment – systemic erythromycin or minocycline or topical metronidazole or tacrolimus

28. SARCOIDOSIS A disease characterised by formation in all or several affected organs or tissues of epithelioid cell tubercles, without caseation , proceeding either to resolution or to conversion into hyaline fibrous tissue. Etiology : genetic factors, infectious agents, immunological response

29. Acute and subacute : erythematopapular lesions, scar sarcoidosis , papular and lichenoid variety Sub acute and chronic : erythrodermic , nodular, annular, angiolupoid , subcutaneous Chronic : plaque ( lupus pernio ) Others : ulcerative, psoriasiform , palmoplantar , ungual , mucosal Systemic features : cardiac, respiratory, muscle, CNS, ocular, renal, liver, spleen, lymphnodes Raised ACE levels , hypercalcemia

30. Cont… Histopathology Well defined aggregates of epithelioid cells Few Langhan’s type giant cells Naked tubercle – paucity of lymphocytes MNG cells with asteroid bodies and Schaumann bodies

31. Treatment : Corticosteroids Immunosuppressants Biologics Other drugs – allopurinol , doxycycline , chloroquine , minocycline , levamisole , isotretinoin , fumaric acid esters, thalidomide Topical therapy – high potent topical steroids, ILS, tacrolimus PUVA, cryotherapy , radiotherapy

32. FOLLICULAR MUCINOSIS Alopecia mucinosa 2 distinct forms: associated with MF and benign inflammatory form C/F are identical : follicular papules and boggy cutaneous plaques Severe pruritus and prediliction for face and scalp Prominent giant comedones and alopecia Pathology : degeneration of involved hair follicles with a prominent pilotropic atypical T cell infiltrate, inter follicular epidermotropism CD3+ve, CD4+ve and CD8 – ve Treatment : dapsone for inflammatory forms Associated with MF: bexarotene , radiotherapy, total skin electron beam therapy

33. PSEUDOFOLLICULITIS BARBAE Inflammation due to penetration into the skin of sharp tips of shaved hairs If shaven too long – the hair may curve backwards after emerging from the follicle to penetrate the adjacent skin If cut very short – it retracts into the follicle; may directly penetrate the follicle wall Curly hair – more prone Male beard – commonest area Complications – keloid , hyperpigmentation

34. Treatment Stop shaving for 4-6 weeks Lifting out of reentrant hairs Hair maintained at 1 mm length Steroid-antibiotic combination creams and emollients Hair removal with chemical depilatories or topical eflornithine hydrochloride cream Laser

35. TUMOURS

36. Benign epidermal tumors and cysts DPN Seborrhoeic keratosis Milia

37. Dermatosis papulosa nigra Pigmented papular eruption of face and neck Nevoid developmental defects of pilosebaceous follicles Histology resembling seborrhoeic keratoses C/F: black or dark brown, flattened or cupuliform papules 1-5 mm Malar regions and forehead Also on neck, chest and back Treatment : electrosurgery

38. SEBORRHOEIC KERATOSIS Benign tumor of epidermal keratinocytes Increasing age ; 5 th decade ; M=F Most frequent on face and upper trunk Classical, DPN, stucco keratosis Hyperpigmented papules or plaques Sign of Leser-Trelat Histopathological types : clonal , hyperkeratotic , acanthotic , irritated, reticulate, melanoacanthoma Treatment : curettage, electrosurgery , cryotherapy

39. KERATOACANTHOMA Molluscum sebaceum Rapidly evolving tumor of the skin composed of keratinizing squamous cells originating in pilosebaceous follicles M>F; middle aged ; white races Etiology : sunexposure , tar and mineral oil, sorafenib C/F: firm, rounded, flesh colored or reddish papule rapid growth phase- 10- 20mm Telangiectasias , central horny plug or crust concealing a keratin filled crater

40. Central part of face – nose, cheeks, eyelids and lips Usually solitary Histopathology : epidermis normal or acanthotic , composed of mass of rapidly multiplying squamous cells, hyperchromaticity , atypical mitotic figures, dyskeratosis and loss of polarity D/D : SCC Treatment : curettage and coagulation of base, excision and suture, radiotherapy, 5-FU.

41. MILIA Small subepidermal keratin cyst All ages ; from infancy onwards Due to pilosebaceous or eccrine sweat duct plugging Primary or secondary Subepidermal blistering diseases(BP , EB, PCT), burns, dermabrasion , radiotherapy Firm white or yellowish 1-2mm dome shaped papules, on cheeks and eyelids of adults Eruptive milia - rare Milia en plaque

42. Histopathology : small cysts lined by stratified epithelium few cell layers thick and contain concentric lamellae of keratin D/D : milia are whiter and more translucent than syringomas Spontaneous clearance Treatment : incision and squeezing of contents, chemical cautery , electrosurgery .

43. Tumors cont… PREMALIGNANT EPITHELIAL LESIONS Actinic keratosis Cutaneous horn MALIGNANT Basal cell carcinoma

44. ACTINIC KERATOSIS Or solar keratosis Premalignant epithelial lesion Hyperkeratotic lesions on chronically light exposed skin Low risk of progression to invasive SCC Middle aged or elderly; fair skinned Relapsing or remitting lesions Face, scalp and dorsa of hands C/F : multiple macules or papules with a rough scaly surface, 1mm to 2 cms , aymptomatic Hyperemic base with punctate bleeding points

45. Histopathology : Treatment : curettage and cautery , cryotherapy , topical 5-FU, imiquimod , photodynamic therapy, dermabrasion and chemical peels

46. CUTANEOUS HORN Horny plugs or outgrowths due to various epidermal changes Infection : molluscum , viral wart Benign: keratoacanthoma , seborrhoeic keratosis , trichilemmal and epidermoid cyst Malignant : BCC, SCC C/F : hard yellowish brown horn, curved, circumferential ridges, surrounded by normal epidermis or acanthotic collarette Upper face and ears Inflammation and induration beneath : malignant transformation Histology : absent granular layer, no atypicality Treatment : excision

47. BASAL CELL CARCINOMA Basalioma or rodent ulcer Most common malignant tumour of skin ; rarely metastasizes Composed of cells similar to basal cells an appendages M>F Etiology: UV exposure, arsenic, ionizing radiations and burns, mutations in PTCH1 gene, immunosuppression C/F : small, translucent or pearly papule, raised and rounded areas covered by thin epidermis, dilated superficial vessels, nodule or plaque Erosions & crusting common, sometimes ulcerate Types

48. Pathology -Tumor cells resemble basal cells of epidermis -Peripheral palisading of nuclei - Stroma - Clefting artefact - Atypia

49. Treatment Surgical excision Non-surgical approaches: curettage and cautery , cryotherapy , laser, topical imiquimod , topical 5FU, PDT, systemic retinoids

50. Tumors of skin appendages Eccrine gland tumors : syringoma , eccrine hidrocystoma Apocrine gland tumors : syringocystadenoma papilliferum Sebaceous gland tumors : sebaceoma , sebaceous adenoma, sebaceous hyperplasia Tumor of hair follicle mesenchyme : trichodiscoma Hair follicle tumors : dilated pore, trichoadenoma External root sheath tumors : trichilemmoma Hamartomas : trichoepithelioma , trichofolliculoma

51. SYRINGOMA Benign tumor with differentiation towards eccrine acrosyringium F>M C/F : numerous small, firm, smooth skin colored or yellowish papules, <3 mm Outline – angular or crenated Face esp lower eyelids Other sites: neck, chest, trunk, axillae , vulva,ventral trunk. Eruptive syringomas : familial in adolescent girls

52. Histopathology : collections of convoluted and cystic duct spaces in upper dermis Lined by double layer of cells Tail like strand of cells into the stroma - ‘tadpole or comma appearance’ Treatment : electrosurgery , cryotherapy , dermabrasion , laser resurfacing

53. ECCRINE HIDROCYSTOMA Tumour by mature deformed eccrine sweat units; secretions dilate the ducts Rare; middle aged women; exposure to heat Confined to cheeks and eyelids Cystic, blue, increase in size on exposure to heat and flattens with exposure to cold Multiple, pigmented lesions on face Pathology : uni or multilocular dermal cystic lesion lined by 2 layers of cells Inner layer- columnar , outer layer- myoepithelial cells Treatment : electrodessication, CO2 laser, pulse dye laser, excision

54. SYRINGOCYSTADENOMA PAPILLIFERUM Exuberant proliferating lesion with apocrine differentiation Birth or childhood C/F : Multiple warty papules, translucent and pigmented Majority on face and scalp Pathology Papillomatosis with invaginations Cystic structures – apocrine pattern Dermis – plasma cells Sometimes sebaceous, eccrine , follicular differentiation Treatment – surgical excision

55. SEBACEOUS TUMOURS Sebaceous adenomas and sebaceomas Benign tumors composed of incompletely differentiated sebaceous cells Rare; elderly C/F : rounded, raised, sessile or pedunculated , <10 mm,waxy or yellowish, plaques or ulceration Face and scalp Multiple - Muir Torre syndrome

56. Pathology Sebaceoma – irregular cell masses of mostly undifferentiated basaloid cells Sebaceous adenoma – sharply demarcated lesion with peripheral basaloid cells and central mature sebaceous cells Treatment – surgical excision

57. SEBACEOUS HYPERPLASIA Benign proliferation in middle aged and elderly Yellowish-pink papules 1-3 mm Forehead and temples Renal transplant patients on CsA Treatment – cautery , cryotherapy , TCA, laser

58. TRICHODISCOMA Hamartomatous proliferation of mesodermal component of the Haarscheibe Haarscheibe – a slowly reacting mechanoceptor associated with hair follicle C/F : multiple, discrete, flat topped papules 2-3 mm Central face Birt – Hogg- Dube syndrome Pathology : non encapsulated area of myxoid , poorly cellular stroma wirh focal collagen deposition in dermis, proliferation of vessels

59. DILATED PORE Wiener’s pore or infundibuloma Area of expanded follicular infundibulum Dilated poral opening into subcutaneous tissue C/F : comedo like lesion on head and neck in elderly Pathology : wide crater like cavity, from which acanthotic areas of follicular epithelium radiate; follicle lined by outer root sheath epithelium

60. TRICHOADENOMA Rare benign tumor, with multiple cystic structures closely resembling infundibular portion of hair follicle Differentiates towards follicular infundibulum C/F : Papule or nodule on the face Pathology : lesions in upper dermis, cluster of cysts

61. TRICHILEMMOMA Proliferation of external root sheath of hair follicle Infundibular keratinisation C/F : small non specific papules on facial skin in young adults Multiple : Cowden’s syndrome Pathology Lobular tumors extending from epidermis Clear cytoplasm – glycogen Peripheral palisading Sometimes prominent epidermal changes Variant – desmoplastic trichilemmoma

62. TRICHOEPITHELIOMA Hamartoma of the hair germ composed of immature islands of basaloid cells Focal primitive follicular differentiation and induction of a cellular stroma 3 forms : solitary, multiple and desmoplastic Solitary- skin colored papules, 5-8 mm, on face esp around nose, upper lips, cheeks Brooke spiegler syndrome – trichoepitheliomas , cylindromas and spiradenomas

63. Pathology Well circumscribed lesion in superficial dermis Horn cysts and basaloid cells Tumor islands show peripheral palisading Treatment – surgical excision, curettage, electrosurgery , cryotherapy , dermabrasion

64. TRICHOFOLLICULOMA Hamartoma of pilosebaceous follicle Several hairs form within the follicular opening , protruding onto the epidermal surface Young adults Prediliction for face C/F : small raised nodules, 2-3 hairs protruding in a small tuft Pathology Cystic cavity lined by squamous epithelium Keratinised material & fragments of hair shafts Several pilosebaceous structures opening into the canal Treatment : excision

65. Soft tissue tumors Fibrous tumor : fibrous papule of face Fibrohistiocytic tumors : atypical fibroxanthoma

66. FIBROUS PAPULE OF FACE Benign tumor Small facial papule with distinctive fibrovascular component C/F: slowly developing dome shaped skin colored or red or pigmented papule, sessile, Nose, forehead, cheeks, chin or neck Pathology : normal epidermis, clear cells overlying the lesion, increased collagen in the dermis, dilated vascular channels, increased cellularity Treatment : excision or surgical paring

67. ATYPICAL FIBROXANTHOMA Fibrohistiocytic tumor Sun damaged skin of elderly ; M>F UV induced p53 mutations C/F : papules or nodules with ulceration , red fleshy appearance On ears, cheeks, bald scalp of elderly males Local recurrence, metastasis to lymphnodes and internal organs Pathology : large spindle shaped and histiocytic cells, multinucleated in dermis, mitotic figures, atypical forms Resembles a highly malignant soft tissue sarcoma histologically Treatment : mohs micrographic surgery

68. COLLOID MILIA Degenerative change on light exposed skin Nonfamilial occurring in later life UV, trauma, hydroquinone C/F : small dermal papules, 1-2 mm, yellowish brown , irregular groups Face esp around orbits, sides of neck, ears, dorsa of hands and back. Rare juvenile and nodular form Histopathology : colloid globules at tips of dermal papillae Treatment : electrosurgery , dermabrasion , Er:YAG laser, topical retinoids

69. Small flesh colored to brownish red papules – usually on central face Multiple lesions – Tuberous Sclerosis Complex Composed of hyperplastic blood vessels, sebaceous glands, immature hair follicles Treatment – electrosurgery , laser ANGIOFIBROMA

70. HOW TO APPROACH??

71. Onset Duration Evolution Mucosal lesions Systemic Complaints Treatment history ? Symptomatic Triggering factors Photosensitivity Past history HISTORY

72. Morphology of predominant lesion Number of lesions, symmetry Size, colour and surface ? Flat topped ? Translucent Umbilication ? Erythema ? Telangiectasia Annular lesions Diascopy Other types of lesions ? Scarring ? Ulceration Distribution over face Nasolabial fold, perioral & periocular regions Involvement of other areas Other systems Investigations EXAMINATION…

73. GOECKERMAN REGIMEN

74. INGRAM REGIMEN

75. BATH PUVA

76. BATH PUVA