Red face revisited: Disorders of hair growth and the pilosebaceous unit
Introduction
Several illnesses may turn the face red; among them, there are some disorders of hair and pilosebaceous follicle. We discuss the diseases related to the hair that may cause a red face, and we present an update on their epidemiology, clinicals, pathogenesis, and therapy. Most of them are causes of cicatricial alopecia of the scalp, but they can affect also the face, especially the area of the beard.
The conditions presented in this paper are lichen planopilaris with its variants, classic lichen planopilaris, Lassueur Graham-Little Piccardi syndrome, and frontal fibrosing alopecia, as well as fibrosing alopecia in a pattern distribution, which may be a fourth form of lichen planopilaris; discoid lupus erythematosus; folliculitis decalvans; dissecting folliculitis; acne keloidalis nuchae; pseudofolliculitis barbae; tinea capitis; tinea barbae; folliculitis of diverse causative factors and inflammatory follicular keratotic syndromes, including erythromelanosis follicularis faciei et colli; ulerythema ophryogenes; atrophoderma vermiculatum; keratosis follicularis spinulosa decalvans; and folliculitis spinulosa decalvans.
Section snippets
Lichen planopilaris
Lichen planopilaris, a follicular form of lichen planus, is a rare inflammatory lymphocyte-mediated disorder that selectively involves hair follicles. Lichen planopilaris leads to follicular destruction and, consequently, cicatricial alopecia. Three forms of lichen planopilaris are described: classical lichen planopilaris, Lassueur Graham-Little Piccardi syndrome, and frontal fibrosing alopecia. Fibrosing alopecia in a pattern distribution could be added as a fourth variant.[1], [2]
Epidemiology
Discoid lupus erythematosus typically starts between the ages of 20 and 40 years and has a female predominance.[5], [20] Less than 5% of adults with discoid lupus erythematosus will experience development of systemic lupus erythematosus. Such progression, however, seems to be more common in children (26%).[20], [21]
Pathogenesis
Manifestation of discoid lupus erythematosus results from an intricate interaction among genetic, environmental, and host factors. In predisposed patients, ultraviolet radiation
Epidemiology
Patients with folliculitis decalvans represent 11% of all primary cicatricial alopecia cases, being the most common type of neutrophilic scarring alopecia. Folliculitis decalvans is a disease of young and middle-aged adults and seems to be more common in African-American and male patients.[4], [25]
Pathogenesis
The pathogenesis of folliculitis decalvans remains poorly understood. Staphylococcus aureus is frequently cultured from lesions and has been implicated as a causative agent.[4], [25], [26] It has been
Epidemiology
Dissecting folliculitis is reported to occur mainly in young black men, and it represented approximately 1% of all cases of cicatricial alopecia in one study.26
Pathogenesis
Dissecting folliculitis is part of the follicular occlusion tetrad, together with hidradenitis suppurativa, acne conglobata, and pilonidal cysts. These disorders are characterized by follicular hyperkeratosis resulting in follicular occlusion, secondary bacterial infection, and follicular rupture. Foreign-body reaction and scarring ensue.
Epidemiology
Acne keloidalis nuchae predominantly affects young black male individuals,5 representing 1.3% of all skin conditions seen in a dermatologic clinic of an African country.37 There are case reports of drug-induced acne keloidalis nuchae in patients using ciclosporin after organ transplantation,38 and diphenylhydantoin and carbamazepine in one case.39
Pathogenesis
The pathogenesis of acne keloidalis nuchae is poorly understood. Acne keloidalis is a misnomer, because the disease is not a variant of acne vulgaris
Epidemiology
Pseudofolliculitis barbae is primarily seen in the beard area of individuals with tightly curled hairs who shave; mainly men of African American and Hispanic origins [40], [44]; pseudofolliculitis barbae also occurs in women from tweezing or plucking facial hair. Other areas of hair removal, such as axilla and groin, may also be involved.45 Male individuals are mostly affected from 14 to 25 years old and women in their perimenopausal period, because of changes in hormone levels. Hirsute women
Epidemiology
Tinea capitis is a dermatophytosis of the scalp and associated hair. It is the most common fungal infection in children, being uncommon in adults. Pathogenic organisms vary from country to country. In a Brazilian study, Microsporum canis (70,5%) and Trichophytum tonsurans (23,2%) represented the most common agents, followed by T mentagrophytes (3.6%), M gypseum (1.8%), and T rubrum (0.9%).52
Pathogenesis
There are three patterns of hair infection: endothrix, ectothrix, and favus (endothrix favosa). Endothrix
Epidemiology
Tinea barbae is a rare dermatophytic infection of the bearded areas of the face and neck with invasion of coarse hairs. Tinea barbae is by definition seen only in male individuals. When present at the chin and upper lip in female adults and children, it is considered tinea faciei.[61], [62]
Pathogenesis
Although there are only a few studies about tinea barbae, the available clinical data point to a pathogenesis similar to tinea capitis.62 In the past, the main way of transmission relied on the fact that
Folliculitis and inflammatory follicular keratotic syndromes
Folliculitis is characterized by the presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule arising on an erythematous base.65 Folliculitis has many causes, such as bacteria, viruses, fungi, and parasites, as well as noninfectious causes, and classification is controversial. In this section, we mainly consider the causes in which “red face” is a clinical feature. A group of disorders characterized by abnormal follicular keratinization
Conclusions
Red face is a common manifestation of many cutaneous and systemic diseases. Dermatologists should be aware of these illnesses to make an accurate diagnosis. Among them, the various diseases of the hair and pilosebaceous unit are included, and the differential diagnosis between them is frequently very difficult to make. The therapy is equally frustrating.
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Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology
2020, Anais Brasileiros de DermatologiaCitation Excerpt :Doses of 10 mg/day to 1 mg/kg/day, duration, maintenance doses, and varying associations have been reported in the literature. Despite the small number of reports, frequent relapses, and few studies with long follow-up, a SR concluded that, even without evidence, oral isotretinoin is considered the treatment of choice for DC.204 Quinquaud folliculitis decalvans is a rare, chronic, and recurrent neutrophilic scarring alopecia that affects young adults of both sexes.
Trichoscopy Tips
2018, Dermatologic ClinicsCitation Excerpt :In these cases, follicular openings may not be clearly visible, misleading one’s diagnosis. Another clue for potentially scarring conditions is the presence of inflammatory signs, such as erythema and scaling or the presence of exudative lesions.18,22 Even though this is not a strict rule, overt inflammation is usually part of the trichoscopic picture of potentially scarring conditions, whereas nonscarring conditions, such as AGA, AA, and telogen effluvium do not present obvious inflammatory features.
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2018, Dermatologic ClinicsCitation Excerpt :Seborrheic dermatitis presents with macular erythema and greasy scales involving the scalp, eyebrows, or retroauricular region.70 Atopic dermatitis is characterized by pruritic papules and plaques, xerosis, keratosis pilaris, and hyperlinearity of the plantar and palmar surfaces.70 Facial erythema, often involving the malar or seborrheic regions, is common in dermatomyositis and lupus erythematosus (LE) and may precede systemic symptoms by years.
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