Hyperpigmented Macules and Patches on the Face: Exogenous Ochronosis or Lichen Planus Pigmentosus?

We present a case of a patient with a 10-year history of blue-black macules and patches on the face and an associated history of skin-lightening cream usage. The skin lightening cream contained hydroquinone, which is often associated with exogenous ochronosis (EO). Interestingly, the biopsy did not show characteristic findings of ochronosis, confusing the final diagnosis, however discontinuing the skin-lightening creams halted the progression of the patient's skin lesions supporting a diagnosis of EO. EO presents as asymptomatic hyperpigmentation after using products containing hydroquinone. This condition is most common in Black populations, likely due to the increased use of skin care products and bleaching cream containing hydroquinone in these populations. Topical hydroquinone is FDA-approved to treat melasma, chloasma, freckles, senile lentigines, and hyperpigmentation and is available by prescription only in the US and Canada. However, with the increased use of skin-lightening creams in certain populations, it is important for dermatologists to accurately recognize the clinical features of exogenous ochronosis to differentiate it from similar dermatoses. An earlier diagnosis can prevent the progression to severe presentations with papules and nodules. We summarize the clinical presentations diagnostic features, and treatment pearls, concluding with a discussion of the differential diagnoses.  J Drugs Dermatol. 2024;23(7):567-568.     doi:10.36849/JDD.8248.

Idiopathic aseptic facial granuloma: A retrospective study of 43 cases.

BACKGROUND: Idiopathic aseptic facial granuloma (IAFG) is an underrecognized pediatric skin disease, currently considered within the spectrum of rosacea. It usually manifests as a solitary, reddish, asymptomatic nodule on the cheek that resolves spontaneously. METHODS: Retrospective and descriptive observational study of 43 pediatric patients with a clinical diagnosis of IAFG, followed between 2004 and 2022, at two general hospitals in Argentina. RESULTS: IAFG predominated in girls (65%) and the average age of onset was about 6 years. A single asymptomatic nodule was seen in 79% of patients. The most common localization was the cheek (58%) followed by lower eyelids (41%). Family history of rosacea was present in 16% of patients. A concomitant diagnosis of rosacea and periorificial dermatitis was made in 14% and 9% of our population, respectively. Past or present history of chalazia was detected in 42% of the children. IAFG diagnosis was mainly clinical (88% of cases). Oral antibiotics were the most common indicated treatment (84%). Complete healing was achieved by the majority, but 18% of those with eyelid compromise healed with scars. CONCLUSIONS: IAFG is a benign pediatric condition that physicians should recognize in order to manage correctly. We herein refer to a particular morphologic aspect of IAFG lesions affecting the lower eyelids, where nodules adopt a linear distribution and have a higher probability of involute leaving a scar. Also, we consider that the concomitant findings of rosacea, periorificial dermatitis and chalazia in our patients, reinforce the consideration of IAFG within the spectrum of rosacea.

[Ulcerative colitis diagnosed with facial pyoderma gangrenosum: a case report].

Pyoderma gangrenosum (PG) is a sterile inflammatory skin condition that is frequently associated with immune-related diseases, including inflammatory bowel disease (IBD). PG causes noninfectious ulcers. Facial PG is uncommon while PG usually occurs on the trunk and lower limbs. Herein, we report a case of a male teenager with fever, pustules, ulcers, and necrosis on both cheeks. He was initially diagnosed with complicated acne with bacterial infection, but the condition progressed to subcutaneous ulcers despite treatment. Biopsy revealed inflammatory lesions in dermal and subcutaneous tissue with neutrophil infiltration, consistent with PG. Although lacking typical IBD symptoms, blood tests revealed anemia and positive fecal occult blood. Sigmoidoscopy revealed inflammation, ulcers, and pseudopolyps in the colon and rectum, thereby diagnosing ulcerative colitis (UC). After treating PG and UC with prednisolone and skin grafts, golimumab was prescribed. The patient is now in remission. Necrotic tissue buildup can complicate closure in PG cases;this emphasizes the need for effective IBD treatment to facilitate procedures such as skin grafts.

In vivo evaluation of facial papule dermatoses with reflectance confocal microscopy in children.

BACKGROUND: Molluscum contagiosum (MC), milia, keratosis pilaris (KP), verruca plana (VP), seborrheic keratosis (SK), and juvenile xanthogranuloma (JXG) are common papule dermatoses on the face of children that have a similar appearance. In vivo evaluation of facial papule dermatoses with reflectance confocal microscopy (RCM) is helpful in the diagnosis of these ambiguous lesions in children. The purpose of this study was to clarify the RCM characteristics of MC, milia, KP, VP, SK, and JXG and explore the clinical application value of RCM for these common facial papule dermatoses. METHODS: We recruited 113 patients referred for unequivocal facial papule dermatosis, including 21 patients with MC, 17 patients with milia, 19 patients with KP, 36 patients with VP, 8 patients with SK, and 12 patients with JXG. We evaluated the characteristics and distinguishing features of the six kinds of facial papule dermatoses using RCM. RESULTS: The main RCM features of the six dermatoses included a well-demarcated border of the lesion area. MC, milia and KP all manifested cyst-like structures, and their distinguishing features were the location of the cystic structures and the refractive index of the contents. Although VP, SK, and JXG did not have obvious cystoid structures, VP was typically characterized by uniformly distributed petal-like structures with a medium-to-high refractive index in the epidermis. With regard to SK, the characteristic features were an obviously thickened epidermis and cobblestone-like structures. JXG was mainly characterized by multiple large round and ovoid cells with a foamy cytoplasm, and discoid-shaped multinucleated large cells were diffusely distributed in the dermis. CONCLUSION: RCM allows the real-time visualization of major key diagnostic and distinguishing features of common facial papule dermatoses in children, including MC, milia, KP, VP, SK, and JXG.

Tinea incognito "mask"erading as allergic contact dermatitis due to COVID-19 facial covering in children.

We present three children with tinea incognito initially misdiagnosed as allergic contact dermatitis to face masks. All three patients presented with pruritic erythematous patches and plaques across the malar cheek and nose. This case series suggests that clinicians should keep a broad differential when evaluating mask-related facial dermatoses in children.

Tacrolimus 0.1% versus ciclopiroxolamine 1% for maintenance therapy in patients with severe facial seborrheic dermatitis: A multicenter, double-blind, randomized controlled study.

BACKGROUND: No long-term maintenance therapy has been tested in patients with seborrheic dermatitis (SD). OBJECTIVE: We sought to compare the efficacy and tolerance of tacrolimus 0.1% ointment versus ciclopiroxolamine 1% cream as maintenance therapy for severe SD. METHODS: This double-blind randomized controlled study was conducted from 2014 to 2017 in 5 Dermatology Departments and 15 dermatology practices in France. Consecutive patients with severe and chronic facial SD were included. Patients were initially treated with desonide 0.05% cream twice daily for 7 days. Patients cleared after this open phase were randomized to receive tacrolimus 0.1% or ciclopiroxolamine 1% cream 2 times a week 24 weeks. The primary endpoint was disease-free-duration, defined as the time from randomization to first relapse. RESULTS: One hundred fourteen patients were randomized (tacrolimus, n = 57; ciclopiroxolamine, n = 57). Twelve patients relapsed in the tacrolimus group after a median delay of 91.5 days (range 15-195 days) versus 23 patients in the ciclopiroxolamine group (median delay, 27 days [range 13-201 days]). Comparison of disease-free duration curves showed that patients in the tacrolimus group had a longer duration of complete remission than those in the ciclopiroxolamine group (P = .018), corresponding to a hazard ratio of relapse of 0.44 (95% confidence interval 0.22-0.89; P = .022). LIMITATIONS: The theoretical sample size was not reached. CONCLUSION: Tacrolimus 0.1% is more effective than ciclopiroxolamine 1% as maintenance therapy for patients with facial SD.

Facial and neck erythema associated with dupilumab treatment: A systematic review.

BACKGROUND: Neither dupilumab-associated facial erythema nor neck erythema was reported in phase 3 clinical trials for the treatment of atopic dermatitis, but there have been a number of reports of patients developing this adverse event in clinical practice. OBJECTIVE: To outline all cases of reported dupilumab-associated facial or neck erythema to better characterize this adverse event, and identify potential etiologies and management strategies. METHODS: A search was conducted on EMBASE and PubMed databases. Two independent reviewers identified relevant studies for inclusion and performed data extraction. RESULTS: A total of 101 patients from 16 studies were reported to have dupilumab-associated facial or neck erythema. A total of 52 of 101 patients (52%) had baseline atopic dermatitis facial or neck involvement and 45 of 101 (45%) reported different cutaneous symptoms from preexisting atopic dermatitis, possibly suggesting a different etiology. Suggested etiologies included rosacea, allergic contact dermatitis, and head and neck dermatitis. Most commonly used treatments included topical corticosteroids, topical calcineurin inhibitors, and antifungal agents. In the 57 patients with data on the course of the adverse events, improvement was observed in 29, clearance in 4, no response in 16, and worsening in 8. A total of 11 of 101 patients (11%) discontinued dupilumab owing to this adverse event. LIMITATIONS: Limited diagnostic testing, nonstandardized data collection and reporting across studies, and reliance on retrospective case reports and case series. CONCLUSION: Some patients receiving dupilumab develop facial or neck erythema that differs from their usual atopic dermatitis symptoms. Prompt identification and empiric treatment may minimize distress and potential discontinuation of dupilumab owing to this adverse event.

Occupational dermatitis to facial personal protective equipment in health care workers: A systematic review.

BACKGROUND: Prolonged wear of facial protective equipment can lead to occupational dermatoses. OBJECTIVE: To identify important causes of occupational dermatoses from facial protective equipment. METHODS: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using PubMed and Embase databases. Articles were included if they reported occupational dermatoses caused by surgical/procedure masks or N95 respirators, or both. RESULTS: We identified 344 articles, and 16 were suitable for inclusion in this review. Selected articles focused on facial occupational dermatoses in health care workers. Allergic contact dermatitis to the elastic straps, glue, and formaldehyde released from the mask fabric was reported. Irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. Irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (>6 hours). Acneiform eruption was reported due to prolonged wear and occlusion. Contact urticaria was rare. LIMITATIONS: Only publications listed in PubMed or Embase were included. Most publications were case reports and retrospective studies. CONCLUSION: This systematic review from members of the American Contact Dermatitis Society highlights cases of occupational dermatitis to facial protective equipment, including potential offending allergens. This work may help in the diagnosis and treatment of health care workers with facial occupational dermatitis.

Childhood rosacea and related disorders.

Rosacea is a chronic inflammatory condition that affects the skin and the eyes. The pathogenesis of rosacea is complex and includes the interaction between genetic and environmental factors, dysregulation of the innate immune system, neurovascular modifications and the interaction with skin commensals. Clinical manifestations in children include the telangiectatic form, papulopustular rosacea, ocular rosacea, periorificial dermatitis, granulomatous rosacea and idiopathic facial aseptic granuloma. Management is aimed at identifying and avoiding triggers. Topical therapy is used for mild cases with topical antibiotics and anti-inflammatory agents. Oral agents are indicated, in combination with topical therapy, for moderate to severe cases. Prolonged therapy may be required.

Novel Facial Treatment Regimen Improves Aging Skin Appearance.

BACKGROUND: Skin care regimens with multiple active ingredients offer a multimodal approach to anti-aging treatments. OBJECTIVE: The objective of this research was to investigate the efficacy of a multimodal skincare regimen on facial skin appearance after 12 weeks of twice daily use as compared to baseline. METHOD: 35 healthy female subjects 35–65 years of age of Fitzpatrick skin types I–III with mild to moderate facial photoaging characterized by hyperpigmentation were enrolled. Subjects were seen at baseline, week 6, and week 12, and underwent subject and investigator assessments along with noninvasive evaluations (elasticity, corneometry, dermaspectrophotometer) and photography. RESULTS: Most notable at week 12 was a 60% improvement in smoothness, 82% improvement in dryness, 30% improvement in fine lines, and 24% improvement in crow’s feet. There was an 8% reduction in macule hyperpigmentation (P<0.001) at week 12, supporting excellent pigment lightening qualities for the regimen. There was a statistically significant increase in skin firmness (decrease in elasticity) as early as week 6 of 6% with further improvement observed at week 12 of 16% (P=0.002). SUMMARY: A multimodal skincare regimen with antioxidants, retinol, hydrolyzed pearl, caviar extract, peptides, and growth factors including EGF and TGF-β results in an improvement in the appearance of photoaged skin after 12 weeks of twice daily use. J Drugs Dermatol. 2021;20(3):274-278. doi:10.36849/JDD.5791.

Calcium pantothenate is present in cosmetics and may cause allergic contact dermatitis.

Calcium pantothenate (CAS no. 137-08-6) is the calcium salt of pantothenic acid (vitamin B5). It is used in cosmetics due to its anti-static and hair conditioning properties. A 53-year-old female nurse's aide presented with intermittent facial eruptions (Figure S1). Patch tests were positive to calcium pantothenate, an ingredient of two of her products (a cleansing milk and a facial tonic). To our knowledge, no previous cases of sensitization from calcium pantothenate have been reported except for one case of systemic dermatitis from a nutritional supplement in a dexpanthenol-sensitized patient.

Facial contact dermatitis caused by cosmetic-relevant allergens.

BACKGROUND: Facial allergic contact dermatitis caused by cosmetic products is common. New allergens in cosmetics continuously emerge. OBJECTIVES: To investigate characteristics of patients with facial dermatitis (FD) between 2010 and 2019 including patch test results from cosmetic-related allergens and a new test series with cosmetic-relevant natural ingredients (CRNIs). METHODS: This is a retrospective study analysing demographics, clinical characteristics according to MOAHLFA index (male; occupation; atopic dermatitis; hand; leg; face; age ≥ 40 years), and patch test results to 27 cosmetic-relevant allergens in FD patients. A prospective study evaluating a screening test series with CRNIs in consecutive FD patients for 1 year was also conducted. These patients received a questionnaire for collecting extra characteristics (eg, concerning quality of life). RESULTS: Of 8740 tested patients, 2292 (26.2%) had FD. Of these, 30.6% had cosmetic-induced FD. The most common cosmetic-related allergens were fragrances and preservatives. The most common patch test-positive CRNIs were hydroperoxides of limonene and linalool, and propolis. Potato and peanut were rare, but the most common prick test-positive CRNIs, however, without any relation to the use of cosmetic products. FD affected nearly all patients' quality of life and caused limitations to their daily life. CONCLUSIONS: Updated management and quick diagnosis of FD is important to avoid negative impact on patients' quality of life.

Superficial Granulomatous Pyoderma Gangrenosum Involving the Face: A Case Series of Five Patients and a Review of the Literature [Formula: see text].

BACKGROUND: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful and ulcerating lesions on the skin. It rarely involves the face and is often difficult to diagnose. There are few cases reported in the literature of PG involving the face. AIM: To share our experience with 5 patients in whom the final diagnosis was PG involving the face, and to review the literature. METHODS: We report a series of 5 patients with a final diagnosis of PG involving the face and reviewed relevant literature. We searched through PubMed andEMBASE using keywords such as "face" and "pyoderma gangrenosum," "blastomycosis-like pyoderma gangrenosum, vegetative pyoderma gangrenosum and granulomatous pyoderma gangrenosum." RESULTS: We report 5 patients (4 females) with pyoderma gangrenosum involving the face. All 5 had a final diagnosis of superficial granulomatous PG. All cases presented with nonhealing facial ulcer most commonly on cheeks and a common histopathology of mixed inflammatory infiltrates, multinucleated giant cells, and plasma cells with some granulomatous inflammation. CONCLUSIONS: PG can involve the face, and all 5 of our patients had the superficial granulomatous as the most common form.

Lupus miliaris disseminatus faciei with complete response to isotretinoin.

Lupus miliaris disseminatus faciei is an uncommon type of granulomatous rosacea characterized by a papular eruption in the central regions of the face. A 43-year-old woman presented with an asymptomatic papular eruption on the face that had developed over a period of five months. Physical examination revealed multiple, small, reddish-brown papules, distributed symmetrically on the central area of the face. A biopsy was taken, showing dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells. No foreign bodies were found in granulomas and no mycobacterial or fungal components were detected. On the basis of these findings, the diagnosis of lupus miliaris disseminatus faciei was made. The patient was given oral isotretinoin 20mg/day with initial slow response. After 6 months' treatment the lesions completely disappeared. Many authors consider this entity to be a variant of granulomatous rosacea. It is a chronic condition that primarily affects young adults. Treatment is usually unsatisfactory. Therapies with corticosterois, tetracyclines, retinoids, clofazimine or topical tacrolimus have been described but there is a lack of controlled studies and convincing results. Our success with a 6-month course of low dose isotretinoin suggests consideration of a longer trial prior to abandoning this as treatment.

The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time.

BACKGROUND: As a result of concerns about hypertriglyceridemia, liver enzyme abnormalities, and leukopenia during isotretinoin therapy for acne, patients are often monitored closely with routine laboratory assessments, although the value of this practice has been questioned. METHODS: We conducted a cohort study of patients receiving isotretinoin for acne between January 1, 2008, and June 30, 2017, using the OptumInsights Electronic Health Record Database (Optum, Eden Prairie, MN) to evaluate the frequency of laboratory abnormalities. Poisson regression was used to evaluate for changes to the frequency of routine laboratory monitoring over time. RESULTS: Among 1863 patients treated with isotretinoin, grade 3 or greater triglyceride and liver function testing abnormalities were noted in fewer than 1% and 0.5% of patients screened, respectively. No grade 3 or greater cholesterol or complete blood count abnormalities were observed. There were no meaningful changes in the frequency of laboratory monitoring over time. LIMITATIONS: Limitations include that we are unable to evaluate the clinical notes to understand the exact clinical decision making when clinicians encountered abnormal laboratory values. CONCLUSION: Although laboratory abnormalities are rare and often do not influence management, frequent laboratory monitoring remains a common practice. There are opportunities to improve the quality of care among patients being treated with isotretinoin for acne by reducing the frequency of lipid and liver function monitoring and by eliminating complete blood count monitoring.

An alternative diagnostic method of eruptive vellus hair cysts: Report of a familial case with pruritus.

Eruptive vellus hair cysts (EVHC) represent a developmental abnormality of vellus hair follicles. Up till now more than 150 cases of EVHC have been published in the literature, but it appears to be more common than recognized. The diagnostic hallmark is the presence of vellus hair shafts within the cystic space. Firstly to evaluate the potential benefit of new diagnostic method of EVHC using a dermatoscope and secondly to report a familial case of EVHC where females were only affected. Five women from the same family with a clinical diagnosis of EVHC were included in the study. The diagnosis of EVHC was confirmed by skin biopsy with histologic examination in four patients. New diagnostic approach of the cyst contents examination with using a handheld dermatoscope was performed in all patients. Numerous vellus hair shafts were detected on the images of the cysts content taken with dermatoscope and applying the above-mentioned method in all patients. We suggest that it seems possible to differentiate EVHC by using the dermatoscope, which appears to be simple, quick, and less time consuming.

Evaluation of skin problems and dermatology life quality index in health care workers who use personal protection measures during COVID-19 pandemic.

The aim of this study was to evaluate the skin problems and dermatological life quality of the health care workers (HCWs) due to personal protection equipment (PPE) use, who are at high risk for COVID-19 infection. A questionnaire about HCWs' PPE use, their skin symptoms, and prevention, management methods and Dermatology Life Quality Index (DLQI) was fulfilled. The median age of 440 participants was 33.5 (21.0-65.0) years old. Skin problems were found to be 90.2%, the most common were dryness, itching, cracking, burning, flaking, peeling and lichenification. The presence of skin problems (P < .001) was higher in those who did not use moisturizers. Of all, 22.3% (n = 98) stated that the use of PPE increased the severity of their previously diagnosed skin diseases and allergies (P < .01). Only 28.0% (n = 123) stated that they know the skin symptoms that may develop by using PPE. The proper hand washing rate was higher as education level increased (P < .001). Skin problems were higher in those using mask with metal nose bridge (P: .02 and P: .003, respectively). As the mask using period prolonged, acne was more common (P: .02). DLQI was significantly affected in women (P = .003), and with increased skin problems related to PPE (P < .001). It is important to organize trainings on prevention and management of possible skin symptoms due to PPE use according to guidelines.

Contact dermatitis due to masks and respirators during COVID-19 pandemic: What we should know and what we should do.

Given the current lack of a therapeutic vaccine for coronavirus disease 2019 (COVID-19), preventive measures including mask wearing are crucial in slowing the transmission of cases. However, prolonged wearing of protective respirators, medical and fabric masks can easily generate excessive sweating, moisture and friction. Closed and warm environments heighten the skin's permeability and sensitivity to physical or chemical irritants, leading to chronic cumulative irritant contact dermatitis or, rarely, even allergic contact dermatitis. Although not representing a life-threatening condition, contact dermatitis can have a significant impact on emergency management, as it is potentially able to reduce work performance and create emotional discomfort due to the involvement of evident body areas. To minimize the skin breakdown, adherence to standards on wearing protective and safe equipments and avoidance of overprotection should be performed. At the same time, some measures of skin care are recommended. Here, we offer some tips on how to prevent and manage contact dermatitis due to masks not only in health care workers, but also in the general population during this COVID-19 outbreak.

Face Mask-induced Itch: A Self-questionnaire Study of 2,315 Responders During the COVID-19 Pandemic.

Little is known about itch related to the use of face masks. This internet survey study investigated the prevalence, intensity and clinical characteristics of itch related to the use of face masks by the general public during the COVID-19 pandemic. A total of 2,315 replies were received, of which 2,307 were included in the final analysis. Of the respondents, 1,393 (60.4%) reported using face masks during the previous week, and, of these, 273 (19.6%) participants reported having itch. Subjects who reported sensitive skin and atopic predisposition, and those with facial dermatoses (acne, atopic dermatitis or seborrhoeic dermatitis) were at significantly higher risk of itch development. The high-est rating of itch for the whole group on the Itch Numeral Rating Scale was 4.07 ± 2.06 (itch of moderate intensity). Responders who wore masks for longer periods more frequently reported itch. Almost 30% of itchy subjects reported scratching their face without removing the mask, or after removing the mask and then scratching. Wearing face masks is linked to development of itch, and scratching can lead to incorrect use of face masks, resulting in reduced protection.

Efficacy and Safety of Intense Pulsed Light With a KTP/PDLlike Filter for the Treatment of Facial Telangiectasias.

BACKGROUND: An intense pulsed light (IPL) narrowband "KTP/PDL-like" filter (525–585 nm) may combine the tolerability of the IPL with the precision of KTP and PDL lasers. This study evaluated the impact of IPL with a KTP/PDL-like filter on telangiectasias. METHODS: This was a single-center, prospective study of 17 subjects with facial telangiectasias and skin types I–III. Three monthly treatments were performed using this specific filter, with follow-up visits at 1, 3, and 6 months. Telangiectasia improvement was assessed by the investigator and subjects using a 5-point scale. Facial photographs and safety assessments were obtained at each visit. Subject discomfort was evaluated using a visual analog scale (VAS) immediately posttreatment, and subject downtime was recorded at each subsequent visit. RESULTS: All facial telangiectasias significantly improved. At 1-month follow-up, >50% lesion clearance was noted in 97.1% of facial (n=36) and 85.7% of non-facial (n=7) lesions, with 73% of subjects satisfied or very satisfied. An increase in mean social downtime (0, 2.3, and 3 days) and VAS scores (3.5, 4.5, and 4.8) with treatments 1, 2, and 3, respectively, mirrored a stepwise increase in fluence with subsequent sessions. CONCLUSIONS: The use of a novel IPL narrowband KTP/PDL-like filter can significantly improve facial and non-facial telangiectasias with minimal downtime. J Drugs Dermatol. 2020;19(9):844-850. doi:10.36849/JDD.2020.4834.