Friday, November 02, 2012

Atypical Acneiforn Eruption

Abstract: 18 yo man with two month history of papules and pustules on chin

HPI:  The patient describes mild acne before leaving for college in late August 2012.  He did being a new electric razor with him.  Shortly after arriving at school, he developed an inflammatory process on his chin.  He was treated with Keflex for > one month without relief.

O/E:  Papules + pustules on the chin.  Rest of exam unremarkable.

Photos:  11/2/12

Lab:  Culture grew "Few Serratia marsencens"  plus Staph epidermitis and alpha hemolytic strep

Diagnosis: Gram Negative Acne is favored over Pyoderma faciale

Discussion:  This young man had acne which had been treated with cephalexin for one to two months.  It has not improved and the presentation with pustules suggested gram negative acne.  His college health center's provider wisely performed a bacterial culture which grew Serratia.  Initially, I was thinking of prescribing ciprofloxicillin, but the literature suggests that isotretinoin may be the treatment of choice.

Followup after five months isotretinoin:

1. James WD, Leyden JJ. Treatment of gram-negative folliculitis with isotretinoin: positive clinical and microbiologic response. J Am Acad Dermatol. 1985 Feb;12(2 Pt 1):319-24
Abstract: Thirty-two patients with gram-negative folliculitis were treated with 0.47 to 1.0 mg/kg/day of isotretinoin. Serial microbiologic evaluations demonstrated rapid clearing of the face and nasal mucosa of gram-negative rods. The clinical response was rapid, complete, and induced prolonged remissions. Twenty-six of thirty-two patients developed Staphylococcus aureus nasal carriage by the end of the 20-week treatment course. Isotretinoin has decided advantages over previously reported therapies for gram-negative folliculitis.
Photo from James and Leyden's article, above
2.  Böni R, Nehrhoff B.  Treatment of gram-negative folliculitis in patients with acne.  Am J Clin Dermatol. 2003;4(4):273-6.
Department of Dermatology, University Hospital, Zürich, Switzerland.
Abstract:  Gram-negative folliculitis may be the result of long-term antibacterial treatment in acne patients. It is caused by bacterial interference and replacement of the Gram-positive flora of the facial skin and the mucous membranes of the nose and infestation with Gram-negative bacteria. These Gram-negative bacteria include Escherischia coli, Pseudomonas aeruginosa, Serratia marescens, Klebsiella and Proteus mirabilis. The occurrence of Gram-negative folliculitis should be considered in acne patients in whom oral treatment with tetracyclines has not resulted in a significant improvement of acne lesions after 3-6 months' treatment. The occurrence of Gram-negative folliculitis in acne patients is believed to be generally underestimated, since correct sampling and bacteriology is rarely performed by clinicians. Gram-negative folliculitis in acne and rosacea patients is best treated with isotretinoin (0.5-1 mg/kg daily for 4-5 months).

3.  Massa MC, Su WP.  Pyoderma faciale: a clinical study of twenty-nine patients.  J Am Acad Dermatol. 1982 Jan;6(1):84-91.
Abstract:  Pyoderma faciale is a distinctive entity. Twenty-nine patients with this process were seen in the Mayo Clinic from 1969 to 1980. Twenty-seven patients had follow-up that ranged from 1 month to 11 years, and twenty-two had follow-up of 3 years or more. Clinical features that characterize the patients were (1) female predominance, (2) onset later than teenage acne vulgaris, generally at 19 to 40 years of age, (3) rapid onset and progression, (4) facial involvement with sparing of the back and chest, (5) cysts, swelling, and purulent drainage with a lack of comedones, and (6) paucity of systemic complaints. Patients were treated with multiple forms of therapy simultaneously, often including Vleminckx packs, oral antibiotics, incision and drainage, ultraviolet B, and intralesional steroids. Of twenty-five patients available for follow-up at 1 year, twenty-three had achieved remission, though fifteen patients required ongoing treatment to maintain optimal control. Twenty-three patients had scarring as a sequela. Patients with pyoderma faciale represent a subset of patients with acne in whom the outlook is favorable with appropriate therapy.

1 comment:

  1. The occurrence of Gram-negative folliculitis in acne patients is believed to be generally underestimated, since correct sampling and bacteriology is rarely performed by clinicians.

    How very true! Most of us clinicians treat empirically and hope for the best. Most times we are rewarded and the patient gets better. In recalcitrant cases such as the one described in the vignette, it's good to keep in mind that the culprit may be a gram negative bug. Certainly patients who don't respond to several months of tetracycline or minocycline should have cultures done. As it turns out, isotretinoin can be a useful drug in these cases.

    Brian T. Maurer


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