Cystic Acne vs. Filler Reaction

Presented by Dr. Kaare Nordqvist
Grand Forks, North Dakota

The patient is a 35 y.o. television news reporter in a Midwestern state.  For the past two yeas she has had inflammatory facial cysts.  She had acne when younger, but it was not like this.  Recently she’s been treated with intralesional triamcinalone, spironolactone (100 mg/d) and doxycycline 100 mg bid.  She has relocated to her family home in North Dakota due to Covid-19.

History: Anamnesis reveals that she had been receiving Restylane and Juvederm for the past two years for old acne scars.

It’s not clear that this pauci cystic diathesis was typical of her earlier acne.

O.E:  Deep cysts, 1.5 – 3 cm in diameter in cheeks, chin and nasolabial folds.  At any time there are no more than two to three lesions.  No other evidence of acne.

Clinical Images:

Diagnosis:  Are we dealing with pauci cystic acne or a reaction to HA fillers? It is known that injected material can migrate and the literature suggests that HA reactions may be more common after viral infections.

This young woman was on the television news nightly.  She is understandably concerned about these lesions and subsequent scarring once she in back in the public's eye.

References

1.Ofir Artzi  et. al. Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm. Clin Cosmet Investig Dermatol. 2020 May 18;13:371-378. PMC

2. Katie Beleznay et al.  Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management. Dermatol Surg. 2015 Aug;41(8):929-39.

Herpes Simplex Neuralgia

History: A 48-year-old woman was seen because of her concern about a lesion on the left buttock.  She is worried that she had gotten a spider bite six months prior.  It healed but she has had two similar episodes since then.  

The patient is in her usual state of health.  Her only medication is sertraline.  She says she is not under any stress but I know that she has a 20-year-old daughter with psychiatric disease who is a great concern for her.   She has one sexual partner who is asymptomatic.   

O/E:  On examination, the patient has a cluster of resolving vesicular lesions on the left buttock. 

Images: (Photos taken by patient and two weeks after acyclovir)

Further history reveals that she has seen a neurologist for sciatic symptoms down the left leg extending to the foot and has been diagnosed with sciatica, meralgia paresthetica and small fiber neuropathy.  She was prescribed gabapentin for this (which she discontinued).

IMPRESSION:  I believe she has recurrent sacral herpes simplex.  This has also called been called "herpes buttockalis" in Iraq, and "herpes okolealis" in Hawaii. Some of these patients have secodary neurological symptoms.

I discussed this with her and prescribed acyclovir 400 mg t.i.d. which she will take for a month or so and then the dose will be lowered depending on symptoms.

Discussion: This patient interested me, because I saw a similar case in the mid 1980s and researched the topic at that time.  He was in his 60s and had a history of recurrent sciatica and urinary obstruction.  He’d been worked up by neurology, orthopedics and urology.  One day, he came in with sacral HSV and anamnesis revealed that this had been going on a few times a years and seemed to be related to his recurrent HSV. I found the article by a Layzer and Conant¹.  When they wrote it, acyclovir was not on the market, but it was in 1985².  I placed that patient on the then new acyclovir and his chronic neuropathy and urinary symptoms improved.  I have always remembered this man.

 

This recent patient is similar.  I did a Pubmed search on "Sciatica Herpes simplex" and found only 8 hits.  Most old.

I suspect this may be an under-reported entity that is worth discussing.  This woman likely underwent an unnecessary neurological work-up and now is labeled now with "small fiber neuropathy."  It was recently reported in the Online Journal of Community and Patient-Centered Dermatology and Our Dermatology Online.

 

References:

1. R B Layzer, M A Conant. Neuralgia in recurrent herpes simplex. Arch Neurol. 1974 Oct;31(4):233-7.

2. Oral form of acyclovir approved. FDA Drug Bull. 1985 Apr;15(1):3-4.

3. Herpes Okolealis.  OJCPCD August 2015

4.  Sharquie K. et. al. Herpes simplex (Buttockalis) of the buttock is a variant of herpes simplex genitalis Khalifa E. Our Dermatology Online 2020;11(e):e170.1-e170.5.

Maskacne

Then felt I like some watcher of the skies
When a new planet swims unto his ken…

 

The patient is a 35 yo OB/Gyn junior faculty with a 2 month history of “Maskacne.”  She uses a standard surgical mask for ~ 12 hrs a day. Her skin care regimen is: “wash with Aveno cleanser, apply Cerave moisturizer. If going out will apply Shiseido sunscreen as well. I try not to wear makeup under mask, but if I do it will be Tarte foundation and a blush
Night time: wash with Avene cleanser, sometimes apply toner, and followed by Cerave moisturizer."

Prior to Covid 19 she only used a mask in the OR and Labour & Delivery room but for the past 10 months she’s been masked 10 – 16 hrs a day.

O/E: Papules and pustules on the lower face.

 Diagnosis:  Acneiform eruption under a mask in a young woman with no previous history of inflammatory acne.

In the Differential Dx
1) Perioral dermatitis
2) Demodex folliculitis
3) Oil acne/Occlusive acne
4) Acne mechanica  (A report from the BMJ in 1976 is helpful.  Strangely, this entity has been understudied)

Has any reader had experience with Maskacne?  Your thoughts will be appreciated.

Addendum: I week after posting the patient writes "I just cleaned face without moisturizers this past week and it is improving everyday. Still doesn’t look great but the pustules are gone (photos below).

Reference:
1. Yu J, et. al. Occupational dermatitis to facial personal protective equipment in health care workers: A systematic review J Am Acad Dermatol. 2021 Feb;84(2):486-494. PMC Full Text.

2. Jillson OF, Perioral dermatitis. Cutis 1984 Nov;34(5):457-8.

3. Khalifa E Sharquie  et. al. Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5% zinc sulphate solution. Saudi Med J. 2008 Dec;29(12):1757-61. PMID. (See Prof. Sharquie's comment on this patient.
Conclusion: Two percent tea lotion was a good alternative remedy to be used in the treatment of acne vulgaris, and was much superior than topical 5% zinc sulphate solution.

4. Acne mechanica. BMJ 1976 Jan 17;1(6002):130.  PMC1638630 Free Full Text