Download Papulopustular or `pimply` rashes on the face

Forum
Dermatology
Papulopustular or ‘pimply’
rashes on the face
Comedones in
combination with oily
skin and a ‘spotty’ face
is the telltale sign of
acne, however, there
are also other common
papulopustular rashes,
writes David Buckley
Picture 2. Perioral dermatitis
Picture 1. Rosacea
Many patients present to their GP with a spotty face.
Depending on the patient’s age and the distribution of the
spots, the diagnosis may be obvious. For example, the spotty
rash on the face and trunk of a teenager or young adult is
most likely to be acne. This can be confirmed if the patient
has oily skin and comedones (blackheads and whiteheads).
Acne
Comedones are the cardinal sign of acne. If you cannot
see comedones, you should reconsider the diagnosis of
acne. They are a sign of excess oil and follicular plugging
which is the primary disorder in acne. This arises as a result
of the pilosebaceous unit being supersensitive to the normal
fluctuations in hormones that occur in the teens and 20s.
The comedones then become irritated and inflamed as a
result of being colonised by bacteria known as Propionibacterium acnes (P. acnes). The inflammatory reaction results
in papules and pustules in the affected areas. If the inflammation is very severe, nodules and cysts may develop. This
process can be aggravated by a number of factors which
should be discussed with the patient (see Table 1).
The firstline treatment for patients with acne, regardless of its severity, is to deal with the non-inflammatory
components, which is the oily skin and comedones. This
can generally only be achieved with topical agents such as
washes, gels or creams.
Acne is a chronic disease that can last for years. Like with
all chronic diseases, you have to have a treatment phase
to settle down the symptoms and maintenance phase to
prevent relapse. Dealing with the non-inflammatory components of acne (seborrhoea and comedones) is important
at the initial phase to settle things down, and as a maintenance treatment once the obvious papules and pustules
have settled, to prevent relapse.
Various acne washes are available, many of which contain
0.2% to 2% salicylic acid. This can be quite drying and
sometimes irritating and so they should be started slowly
and gradually increased until the patient develops a tolerance to the product. Once the patient is happy with the
Table 1: Factors that aggravate acne
• Oily products such as oily moisturisers or greasy makeup
• Picking and scratching
• Stress eg. before exams
• Poor diet eg. too much sugar, fatty foods or foods processed with steroids or antibiotics such as non-organic
chicken or pork
• Lack of fresh air and exercise
• Premenstrual flare
• Progesterone-only contraceptives (eg. POP, Implanon,
Mirena IUD)
• Smoking
Table 2: Topical retinoids and benzyl peroxide
Advice for using topical retinoids and benzyl peroxide:
• Start off by using them very sparingly
• Introduce new products one at a time and leave at least
three to seven days before starting a second product
• Apply the cream/gel all over the acne-affected areas, not
just onto existing spots
• Continue topical therapies long-term (months or years)
both to clear up existing acne and to prevent relapse
• Expect some dryness of the skin – this is what they are
supposed to do. Avoid moisturisers and greasy makeup
wash (usually after a few days of use) then I usually add
in an anticomedonal topical retinoid or retinoid-like agent
such as adapalene (Differin Gel), isotretinoin (Isotrex Gel)
or azelaic acid (Skinoren Gel), (see Table 2).
Benzoyl peroxide (BPO) (eg. Acnecide 5%) is very effective at clearing the inflammatory components of acne (the
papules and pustules). Unlike other acne treatments, it can
be used safely in children and in pregnancy. It comes in
larger tubes (60g) and is cheaper than topical retinoids, so
can be used safely on large areas such as the back, chest
and neck as well as the face. Bleaching of clothing can be
a problem with BPO and advising patients to wear white
shirts or t-shirts will help. I rarely use topical antibiotics
for acne as resistance develops quickly and their effects
FORUM May 2014 39
Forum
Dermatology
wear off after six to 12 weeks. I usually get the patient to
apply a topical retinoid-like agent at night and after a week
or two add in the BPO in the morning. This combination if
often successful in mild to moderate acne and can be used
for months or years if required to maintain the improvement. For more moderate to severe acne, you may have to
add in an oral anti-acne agent for at least the first three to
six months such as lymecycline or trimethoprim. Once the
acne is controlled, I usually stop the oral therapies but continue the topical treatments indefinitely to prevent relapse.
In women, an alternative approach is an anti-androgen
treatment with an agent such as an oral contraceptive pill
that has ethinylestrodiol and an anti-androgenic progesterone such as cyproterone acetate (Dianette), drospirenone
(Yasmin) or dienogest (Qlaira). These reduce sebum production and like all oral acne treatments, they work best if used
for at least three to six months and in combination with good
topical agents such BPO both during the treatment phase
and after the oral treatments have been stopped to prevent
relapse. Spironolactone (25-200mg daily) can be helpful
in women with polycystic ovarian syndrome and acne, but
pregnancy should be avoided on this drug.
Severe nodular cystic acne, scarring acne or acne that
fails to respond to at least two long courses of appropriate
topical and systemic acne treatments should be considered
for a course of isotretinoin (Roaccutane).
Rosacea
The second most common papulopustular rash on the
face is rosacea (see Picture 1). As the name implies the
face is rosy red as a result of flushing and telangiectasia.
There is also an absence of comedones. Rosacea usually occurs in a slightly older age group (30-60 years old)
and is aggravated by ultraviolet light and topical steroids
(steroid rosacea). Most cases respond to a combination of
topical metronidazole or azelaic acid and an oral acne treatment such as a low dose of doxycycline (Efracea) 40mg
or lymecycline for one to three months. Lifelong photo
protection with sun blocks everyday and a broad-brimmed
hat is important. Avoiding topical steroids on the face will
help to prevent relapse. Flushing and telangiectasia will
not respond to standard rosacea treatments and this may
require laser treatment with a pulse dye laser or IPL to control it. Roaccutane can help some patients with more severe
resistant rosacea.
Red acne
Some patients with acne may also develop rosacea as they
get older and may for a time have features of both conditions
(red acne). Fortunately, some treatment can help both conditions such as azelaic acid 15% and oral tetracyclines (eg.
lymecycline). Although the sun usually helps acne it should
be avoided in patients who have features of rosacea.
Perioral dermatitis
Perioral dermatitis (see Picture 2) causes micropapules
around the mouth but leaving a clear area of skin between
the rash and the vermilion border of the lips. It usually
occurs in young women and girls. Although it is called dermatitis, it is considered a variant of rosacea and there are
no comedones. Most patients have used a topical steroid in
an attempt to clear the rash. Sometimes, steroid eye drops,
steroid nasal sprays or steroid inhalers may be responsible.
While topical steroids may help initially, in the long-term
40 FORUM May 2014
they usually aggravate perioral dermatitis and result in a
severe flare-up of the rash once stopped. However, if the
patient is treated with an oral anti-acne treatment such
as lymecycline for six to 12 weeks (or erythromycin if the
patient is pregnant or a child) then they are less likely to
flare up when the topical steroid is stopped. Milder cases
may respond to topical erythromycin, topical metronidazole
gel or azelaic acid gel.
Occasionally, perioral dermatitis can occur on the outer
aspect of the lower eyelid (periocular dermatitis) instead of,
or at the same time as, around the mouth. Treatment in this
area is the same as the more classical perioral dermatitis.
Folliculitis
Folliculitis in the beard area in men can also cause papules
and pustules. These can be difficult to treat. It may respond
to growing a beard. Swabs should be taken for culture and
sensitivity. If bacteria are grown, the patient may respond to
a long course of low-dose oral and topical antibiotics such as
flucloxacillin, 250mg three times a day, for one to two months
and Fucidin cream for two weeks. Nasal swabs may reveal
a source of the chronic infections and this can be treated
with nasal antiseptics such as Naseptin or Bactroban nasal
ointment for at least two weeks. Washing and shaving with
an antibacterial wash such as Hibiscrub may also helpful.
Gram-negative folliculitis
This may occur in acne sufferers on long-term oral tetracyclines. It may present as a worsening of the acne in a
patient on oral tetracyclines. The papules are usually worse
on the upper lip, under the nose, on the cheeks and chin.
Swabs may help to identify the offending gram-negative
organism. The tetracycline should be stopped and the
patient should be treated with amoxacillin, trimethoprim
or Roaccutane.
Fungal infection
Fungal infection of the beard area in men can cause papules and pustules so if there is any doubt hair should be
blocked or skin scrapings should be taken from the infected
areas for fungal stain and culture. Treatment is usually for
four to six-week course of an oral anti fungal agent such as
terbinafine tablets (Lamisil).
Pseudofolliculitis barber
This is a common cause of papules and pustules, especially in the beard area of men on the side of the neck. It is
caused by ingrown hair as a result of the hair shaft growing
out of the skin at an acute angle instead of growing out at
right angles. Growing a beard may help. Alternatively, shaving in the opposite direction to the angle the hair emerges
from the skin with a ‘sensitive’ shaving foam and a new
sharp blade may help. Getting the hair to stand up before
shaving using a ‘Buf Puf’ facial sponge may also help. Weak
topical steroids combined with an antibacterial agent such
as Fucidin H cream used twice a day for two weeks in the
affected areas once every three months may also help. More
frequent application may result in antibiotic resistant. Very
severe cases may respond to laser or IPL permanent hair
reduction in the affected areas.
David Buckley is in practice in Tralee, Co Kerry
Note: Acne and Roaccutane were discussed in detail in dermatology articles in Forum in May and July 2012