CME
`
`Acneiform facial eruptions
`A problem for young women
`
`Melody J. Cheung, MD Muba Taher, MD, FRCPC Gilles J. Lauzon, MD, PHD, FRCPC
`
`ABSTRACT
`OBJECTIVE To summarize clinical recognition and current management strategies for four types of acneiform facial
`eruptions common in young women: acne vulgaris, rosacea, folliculitis, and perioral dermatitis.
`QUALITY OF EVIDENCE Many randomized controlled trials (level I evidence) have studied treatments for acne vulgaris
`over the years. Treatment recommendations for rosacea, folliculitis, and perioral dermatitis are based predominantly
`on comparison and open-label studies (level II evidence) as well as expert opinion and consensus statements (level III
`evidence).
`MAIN MESSAGE Young women with acneiform facial eruptions often present in primary care. Diff erentiating between
`morphologically similar conditions is often diffi cult. Accurate diagnosis is important because treatment approaches
`are diff erent for each disease.
`CONCLUSION Careful visual assessment with an appreciation for subtle morphologic diff erences and associated clinical
`factors will help with diagnosis of these common acneiform facial eruptions and lead to appropriate management.
`
`RÉSUMÉ
`OBJECTIF Faire le point sur le diagnostic clinique et les modalités thérapeutiques actuelles de quatre types
`d’éruptions faciales acnéiformes chez la femme jeune: l’acné vulgaire, l’acné rosacée, la folliculite et la dermatite
`périorale.
`QUALITÉ DES PREUVES Le traitement de l’acné vulgaire a fait l’objet de plusieurs essais randomisés ces dernières
`années. Les recommandations pour le traitement de l’acné rosacée, de la folliculite et de la dermatite périorale
`reposent surtout sur des essais comparatifs ou ouverts (preuves de niveau II), mais aussi sur des opinions d’experts et
`des déclarations de consensus (preuves de niveau III).
`PRINCIPAL MESSAGE Les femmes jeunes consultent fréquemment les établissements de soins primaires pour des
`éruptions faciales acnéiformes. Il est souvent diffi cile de distinguer des conditions morphologiquement semblables. Il
`importe toutefois de poser un diagnostic précis car les modalités thérapeutiques diff èrent d’une maladie à l’autre.
`CONCLUSION Le diagnostic et le traitement des éruptions faciales communes sont plus faciles si l’on fait une
`évaluation visuelle attentive et si on tient compte des diff érences morphologiques subtiles et des facteurs cliniques
`associés.
`
`This article has been peer reviewed.
`Cet article a fait l’objet d’une évaluation externe.
`Can Fam Physician 2005;51:527-533.
`
`➛
`
`FOR PRESCRIBING INFORMATION SEE PAGE 567
`
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`CME Acneiform facial eruptions
`
`A
`
`
`cneiform eruptions, such as acne vulgaris, cneiform eruptions, such as acne vulgaris,
`
`rosacea, folliculitis, and perioral dermatitis, are rosacea, folliculitis, and perioral dermatitis, are
`routinely encountered in primary care. Acne
`routinely encountered in primary care. Acne
`vulgaris alone aff ects up to 80% of adolescents and con-
`vulgaris alone aff ects up to 80% of adolescents and con-
`tinues to aff ect 40% to 50% of adult women.1 An esti-
`mated 13 million Americans are aff ected by rosacea.2
`Th ese conditions often have psychosocial sequelae.3
`These four eruptions are challenging to diag-
`nose because they all resemble acne. Th is article
`describes these eruptions, highlighting the salient
`distinguishing characteristics, and summarizes
`current management recommendations from the
`medical literature.
`
`Quality of evidence
`PubMed was searched from January 1966 to
`December 2003 using the names of each of the acne-
`iform conditions combined with “treatment.” Several
`randomized controlled trials (level I evidence) on
`treatment of acne vulgaris were found, but there was
`little level I evidence for treating the other condi-
`tions. Recommendations for treating these condi-
`tions are based mainly on comparison or open-label
`studies (level II evidence) and expert opinion and
`consensus guidelines (level III evidence).
`
`Acne vulgaris
`Acne vulgaris is a disease of the sebaceous follicles
`that primarily affects adolescents but not uncom-
`monly persists through the third decade and beyond,
`particularly in women. Pathogenesis is multifacto-
`rial and involves an interplay between abnormal
`follicular keratinization or desquamation, exces-
`sive sebum production, proliferation of follicular
`Propionibacterium acnes, and hormonal factors.
`Diagnosis is often clear, and laboratory inves-
`tigations are unnecessary, except where signs and
`symptoms suggest hyperandrogenism.4,5 Acne is
`
`Dr Cheung is a dermatology resident, Dr Taher has
`completed dermatology residency, and Dr Lauzon is
`an Associate Professor and Director in the Division
`of Dermatology, all at the University of Alberta in
`Edmonton.
`
`characterized by a variety of lesions that indicate
`varying degrees of disease severity.
`Mild or noninfl ammatory acne is characterized
`by comedones. Closed comedones appear as pale
`white, slightly elevated, dome-shaped, 1- to 2-mm
`papules with no clinically visible follicular orifi ce
`(Figure 1). Open comedones are flat or slightly
`raised lesions with a visible central orifi ce fi lled with
`a brown-black substance (Figure 1). Infl ammatory
`acne has a range of lesions. Papules (Figure 1) are
`often encircled by an infl ammatory halo, and pus-
`tules can be identifi ed by a central core of purulent
`material. Nodules are rounder and deeper to palpa-
`tion than papules and are often tender. Cysts have a
`propensity to scar and essentially feel like fl uctuant
`nodules. Acne scars (Figure 1) usually appear as
`sharply punched out pits.
`
`Figure 1. Acne vulgaris in various stages: A) Several closed
`comedones (1-mm to 2-mm pale white, dome-shaped papules); B) Several
`open comedones, papules with a central orifi ce fi lled with a brown-black
`substance; C) Acne papule; D) Several punched-out depressions marking
`acne scars.
`
`Before commencing therapy and in the interest
`of establishing a therapeutic alliance, it is impor-
`tant to explain to patients the causes of acne and
`the rationale for therapy as well as the expected
`duration of therapy (weeks to months). Th e litera-
`ture suggests that therapy be based on the severity
`or the predominant morphologic variant of disease.
`Mild comedonal acne should be treated with
`topical antimicrobials,1,6-8 such as benzoyl perox-
`ide (available in 2.5/5/10% cream, gel, or wash) or
`
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`Acneiform facial eruptions CME
`
`topical comedolytics,1,6-8 such as tretinoin (available
`in 0.025/0.05/0.1% cream, 0.01/0.025% gel, and 0.05%
`liquid) (Table 19-24). Benzoyl peroxide is preferred
`for patients with infl ammation8; tretinoin is eff ective
`for cases with a predominance of comedones. Th e
`recently developed topical retinoid, adapalene, is only
`marginally more eff ective than tretinoin, but is bet-
`ter tolerated.7 Choice of treatment depends largely on
`patients’ tolerance and preference.6 Gels and creams
`with water bases are less drying than gels in alcohol or
`glycol bases. Exfoliants, such as salicylic acid, remain
`an option for acne treatment, but are ineff ective for
`deep comedones and can be irritating.1
`Papular and pustular acne can be treated with
`topical or oral antibiotics (Table 19-24). Both topical
`erythromycin (available as solution, gel, or pled-
`gets) and clindamycin (available as solution, gel,
`lotion, or pledgets) are reported to be equally eff ec-
`tive.9,25 Topical erythromycin is considered safest
`during pregnancy.1
`Combination topical products, such as
`Clindoxyl (clindamycin and benzoyl peroxide) and
`Benzamycin (benzoyl peroxide and erythromycin),
`have recently come on the market and are quite use-
`ful.6 Tetracycline (1000 mg/d in two or four divided
`doses), because of its eff ectiveness and low cost, is
`the fi rst-choice oral antibiotic followed by minocy-
`cline (50 to 100 mg/d) or doxycycline (100 mg/d).
`Th ese drugs are often prescribed, along with topical
`retinoids, combination products, or antimicrobials,
`to improve efficacy and prevent resistance from
`developing. Trimethoprim-sulfamethoxazole is
`best reserved for severe, recalcitrant cases.1 Other
`oral antibiotics mentioned in the literature include
`erythromycin, clindamycin, ampicillin, and amoxi-
`cillin in no particular order. Most of these drugs
`should be used for at least 2 months before they
`are deemed ineff ective.6
`Cases of treatment-resistant, nodulocystic, or
`scarring acne should be referred to a dermatolo-
`gist for isotretinoin treatment, steroid injection, or
`hormone therapy (Table 19-24). Isotretinoin is noto-
`rious for its drying side eff ects and teratogenicity,
`but is a very eff ective medication with a response
`rate as high as 90%.1 It is administered at 0.5 to 1.0
`mg/kg daily and titrated to obtain an optimal and
`
`Table 1. Recommendations for treating acne vulgaris
`NONINFLAMMATORY
`First line: Benzoyl peroxide (I)10 or topical tretinoin (I)11
`Second line: Adapalene (I)11
`PAPULAR OR PUSTULAR
`First line: Topical erythromycin (I),10,12 clindamycin (I),9,13 clindoxyl (I),14 or
`benzamycin (I)15
`Second line: Oral tetracycline (I),16 minocycline (I),17 doxycycline (I),18
`erythromycin (I),16 clindamycin (I),19 ampicillin (III), or amoxicillin (III)
`Third line: Oral antibiotics plus topical retinoids (I),20 clindoxyl or
`benzamycin (III), or antimicrobials (III)
`Fourth line: Trimethoprim-sulfamethoxazole (III)
`NODULOCYSTIC OR TREATMENT-RESISTANT ACNE OR SCARRING
`First line: Steroid injection, if sparse (I),21 isotretinoin, if diff use (I)22
`Second line: Antiandrogens, for example, oral contraceptives (I)23 or
`spironolactone (I)24
`Roman numerals indicate level of evidence.
`
`early response with minimal side eff ects. Average
`duration of therapy is 4 months; a second course
`might be necessary. Triamcinolone acetonide intra-
`lesional injections are feasible for sparser nodu-
`locystic lesions, but care must be taken to avoid
`steroid atrophy. Finally, for women unresponsive to
`conventional therapy, hormonal therapy (biphasic
`or triphasic contraceptive pills or spironolactone,
`which has strong antiandrogenic activity) is recom-
`mended in conjunction with topical treatment.1,8
`
`Rosacea
`Rosacea is a chronic vascular acneiform facial
`disorder that aff ects primarily 20- to 60-year-old
`people of northern and eastern European descent.
`Although the condition is equally prevalent in men
`and women, it is usually more severe in men and
`can progress to tissue hyperplasia. Pathogenesis
`remains unknown, although many factors including
`bacteria, Demodex mites, vasomotor and connec-
`tive tissue dysfunction, and topical corticosteroids
`have been implicated.
`Rosacea is characterized by a triad of symmetrical
`erythema, papules and pustules, and telangiectasia
`on the cheeks, forehead, and nose (Figures 2 and 3).
`The absence of comedones is an important fac-
`tor that diff erentiates rosacea from acne vulgaris.
`Rosacea follows a course of exacerbations and
`remissions and is often aggravated by sun, wind,
`
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`CME Acneiform facial eruptions
`
`Figure 2. Rosacea: A young woman has persistent erythema and red
`papules on both cheeks. No comedones are visible.
`
`Figure 3. Rosacea: Rosacea can persist into later decades. This older
`woman has deep symmetrical erythema and many red papules on her
`cheeks, forehead, and chin.
`
`Table 2. Recommendations for treating rosacea
`
`First line: Topical metronidazole (I)30 plus oral tetracycline (I)31 or minocycline (III)
`Second line: Sulfacetamide (III) plus oral antibiotics as above
`Third line: Topical retinoid (II)32 plus vitamin C (II)29
`Fourth line: Isotretinoin (II)33
`Roman numerals indicate level of evidence.
`
`and hot drinks. Frequent fl ushing, mild telangiec-
`tasia, increased telangiectasia with acneiform erup-
`tions, and tissue hyperplasia are the four sequential
`stages of the condition. Rosacea can also be asso-
`ciated with ocular symptoms of burning, redness,
`itching, sensation of a foreign body, tearing, dry-
`ness, photophobia, and eyelid fullness or swelling.26
`Begin treatment by discussing potential triggers
`and how to avoid them. Concomitant topical met-
`ronidazole and oral tetracycline are recommended
`as first-line therapy for early-stage rosacea27,28
`(Table 229-33). Th is combination lowers the poten-
`tial for relapse once the oral medication is with-
`drawn.27,28 Oral minocycline (100 to 200 mg/d) is
`considered an acceptable alternative.28 Doxycycline,
`clindamycin, erythromycin, clarithromycin, ampi-
`cillin, and metronidazole have also been shown to
`be eff ective (Table 229-33). Oral therapy should be
`prolonged in those with ocular symptoms, although
`some sources recommend deferring oral antibiotics
`until there are ocular complaints.34
`There is no significant difference in efficacy
`between twice-daily treatment with 0.75% topi-
`cal metronidazole and once-daily treatment with
`1.0% metronidazole.27 Topical sulfacetamide is an
`alternative if metronidazole is not tolerated or if
`patients want concealment (sulfacetamide is avail-
`able in a fl esh-coloured preparation) (Table 229-33).
`Oral tetracycline is usually started at 1000 mg/d,
`tapered, and fi nally discontinued. Various sources
`recommend various tapering protocols and dura-
`tion of therapy. Some recommend tapering to 500
`mg/d over 6 weeks followed by a slow mainte-
`nance taper to 250 mg/d over 3 months if patients
`respond; otherwise, a 6-week course of full-dose
`tetracycline should be repeated.2 Others recom-
`mend therapy at full dose until clearance or for 12
`weeks’ duration.28 Recently, topical retinoid and
`vitamin C preparations have been shown to have a
`benefi cial eff ect29,32 (Table 229-33).
`For recalcitrant rosacea, a 4- to 5-month course
`of oral isotretinoin at either low dose (10 mg/d) or
`the dose used for acne vulgaris has been shown
`to reduce symptoms.35 Patients with rosacea with
`fi brotic changes should be referred to a cosmetic
`surgeon.
`
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`
`Folliculitis
`Folliculitis is an inflammation of the hair fol-
`licle as a result of mechanical trauma (eg, shav-
`ing, friction), irritation (certain topical agents, such
`as oils), or infection. Mechanical trauma, occlu-
`sion, and immunocompromise predispose patients
`to infection. The usual infectious organism is
`Staphylococcus aureus, although Gram-negative
`folliculitis can result from prolonged use of anti-
`biotics for acne. Pityrosporum, a saprophytic yeast,
`has also been implicated.
`Diagnosis is clinical. Th ere is usually an abrupt
`eruption of small, well circumscribed, globu-
`lar, dome-shaped, often monomorphic pustules in
`clusters on hair-bearing areas of the body and face
`(Figure 4). Deeper follicular infections, or sycosis,
`although rare, are more erythematous and painful.
`Initially, potassium hydroxide testing of the
`hair and any surrounding scale should be con-
`sidered to exclude Pityrosporum. Otherwise,
`an identifying culture should always be taken
`before initiating therapy.34 In confirmed cases,
`topical therapy with econazole cream, sele-
`nium sulfide shampoo, or 50% propylene gly-
`col36 has been recommended for a duration of 3
`to 4 weeks (Table 337-41). Subsequent additional
`
`Figure 4. Folliculitis: A cluster of small monomorphic pustules
`appears on a woman’s forehead.
`
`Acneiform facial eruptions CME
`
`Table 3. Recommendations for treating folliculitis
`PITYROSPORUM
`First line: Topical econazole (III), selenium sulfi de shampoo (III), or 50%
`propylene glycol (III)
`Second line: Oral fl uconazole (II),37 itraconazole (I),38 or ketoconazole (II)37
`Third line: Oral antifungal plus topical agents (II)37
`BACTERIAL
`First line: Topical mupirocin (I),39 erythromycin (III), clindamycin (III), or
`benzoyl peroxide (III)
`Second line: Oral antistaphylococcal antibiotics, such as fl uoroquinolones (I),40
`fi rst-generation cephalosporins (III), or macrolides (III)
`GRAM NEGATIVE
`First line: Isotretinoin (II)41
`Second line: Ampicillin (III) or trimethoprim-sulfamethoxazole (III)
`Roman numerals indicate level of evidence.
`
`intermittent maintenance doses once to twice
`a week42 have been found helpful for avoid-
`ing recurrence, which is common in folliculi-
`tis. Oral antifungals (fluconazole, ketoconazole,
`or itraconanzole) have been deemed effective
`when used for 10 to 14 days43 (Table 337-41). One
`clinical trial demonstrated the superiority of
`combined topical and oral therapy as compared
`with either alone.37
`Topical therapy for superfi cial S aureus includes
`erythromycin, clindamycin, mupirocin, or ben-
`zoyl peroxide44 (Table 337-41). Oral antistaphylo-
`coccal antibiotics (fi rst-generation cephalosporins,
`penicillinase-resistant penicillins, macrolides,
`or fluoroquinolones) are indicated for extensive
`disease or for the deep involvement of sycosis44
`(Table 337-41). Treatment is continued until lesions
`completely resolve.45 Gram-negative folliculitis
`can be treated as severe acne with isotretinoin at
`a dose of 0.5 to 1.0 mg/kg daily for 4 to 5 months46
`(Table 337-41). Alternatives are ampicillin at 250 mg
`or trimethoprim-sulfamethoxazole at 600 mg four
`times daily, but response to antibiotic treatment is
`slow, and relapse is common.
`
`Perioral dermatitis
`Perioral dermatitis is an acneiform eruption
`of unknown etiology, although many contribut-
`ing factors have been implicated: fluorinated
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`CME Acneiform facial eruptions
`
`Figure 5. Perioral dermatitis: Pinpoint erythematous papules, some
`confl uent, are distributed in a perioral array distinctly sparing the vermilion
`border of the lip.
`
`Table 4. Recommendations for treating perioral dermatitis
`First line: Oral tetracycline (II)50
`Second line: Oral erythromycin (III)
`Third line: Topical metronidazole (I)51 with or without oral antibiotics as
`above
`Roman numerals indicate level of evidence.
`
`topical corticosteroids, subclinical irritant contact
`dermatitis, and overmoisturization of skin. Women
`are aff ected more than men.47
`Clinically, the condition appears as an eruption
`of discrete, symmetrical pinpoint papules and pus-
`tules in clusters periorally (on the chin or nasolabial
`folds, but not on the vermilion border of the lips)
`that might have an erythematous base (Figure 5).
`Similar and concomitant lesions are sometimes
`found at the lateral borders of the eyes.
`Despite an unclear etiology, treatment is sim-
`ple and effective. Perioral dematitis resolves with
`tetracycline (250 mg two to three times daily for
`several weeks)48 or erythromycin49 (Table 450,51).
`Topical antibiotics are less well tolerated and less
`effective, but remain an option for those who
`cannot take systemic antibiotics.27 Topical flu-
`orinated corticosteroids should be discontin-
`ued. Gradually weaker topical corticosteroids
`for weaning and prevention of rebound erup-
`tions have been used either as monotherapy or
`as additional agents to topical metronidazole and
`oral erythromycin.52
`
`EDITOR’S KEY POINTS
`• Acneiform facial eruptions, including acne vulgaris, rosacea, fol-
`liculitis, and perioral dermatitis, are common in young women and
`cause much medical and psychological distress.
`• Treatment for acne vulgaris varies with severity, beginning with
`antimicrobials (benzoyl peroxide), comedolytics (tretinoin), and
`topical or oral antibiotics (tetracycline, clindamycin, erythromycin).
`Resistant cases or nodular or scarring acne should be referred to
`dermatologists for isotretinoin or steroid injection.
`• Rosacea aff ects primarily women in their 20s and 30s and requires
`long-term management including avoiding triggers and using top-
`ical metronidazole or oral tetracycline-minocycline. Topical retinoids
`or isotretinoin are used for severe cases.
`• Perioral dermatitis has a classic presentation but unknown etiology.
`Removing fl uorinated topical steroids and taking oral tetracycline
`are eff ective measures.
`
`POINTS DE REPÈRE DU RÉDACTEUR
`• Les éruptions acnéiformes du visage comme l’acné vulgaire, l’acné
`rosacée, la folliculite et la dermatite périorale sont fréquentes chez
`la femme jeune et sont une source de préoccupation médicale et
`psychologique.
`• Le traitement de l’acné vulgaire est fonction de sa sévérité; on utilise
`d’abord les antimicrobiens (peroxyde de benzoyle), les comédolyti-
`ques (trétinoïne) et les antibiotiques topiques ou oraux (tétracycline,
`clindamycine, érythromycine). Les cas résistants de même que l’acné
`nodulaire ou cicatrisant devraient être dirigés en dermatologie pour
`un traitement par l’isotrétinoïne ou par injections de stéroïdes.
`• L’acné rosacée aff ecte principalement les femmes de 20 à 40 ans
`et elle exige un traitement prolongé qui comprend l’évitement des
`facteurs déclencheurs et l’usage de métronidazole topique et de
`tétracycline-minocycline orale. Les rétinoïdes et l’isotrétinoïne topi-
`ques sont réservés aux cas sévères.
`• La dermatite périorale a une présentation classique, mais son étio-
`logie est obscure. Elle répond bien à l’arrêt des stéroïdes fl uorinés
`topiques et à la tétracycline orale.
`
`Conclusion
`Acneiform facial eruptions are common in young
`women. Diff erential diagnosis of the four conditions
`discussed above should be kept in mind when assess-
`ing patients. Although there is some overlap in how
`these conditions present, careful attention to distribu-
`tion of lesions, morphology, and exacerbating factors
`can lead to accurate diagnosis and optimal therapy.
`
`Acknowledgment
`We thank Dr Thomas G. Salopek and Dr Benjamin
`Barankin for supplying some fi gures for this article.
`
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`Acneiform facial eruptions CME
`
`Competing interests
`None declared
`
`Correspondence to: Dr M.J. Cheung, Dermatology
`Resident, Division of Dermatology, 2-104 Clinical
`Sciences Bldg, University of Alberta, Edmonton, AB
`T6G 2G3; telephone (780) 407-1555; fax (780) 407-3003;
`e-mail melody@ualberta.ca
`
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