Acneiform Eruption in an 11 year-old boy

Abstract: 11 y.o. boy with localized papular dermatitis of face

HPI: This 11 yo boy has a 2 month history of a facial eruption. Initially, his mother applied Bacitracin ointment. It was not effective and they then used a prescription "hydrocortisone" ointment for a few weeks which was similarly unhelpful. Good general health. He takes Adderal for ADHD.

O/E: There are erythematous acneiform papules around the right alar groove. Face is otherwise clear.

Clinical Photos




Labs: N/A

Clinical Diagnosis: My first thought is that this may be a variant of perioral dermatitis. Prior to puberty, P.O.D. is seen in both sexes. We see women with "perialar dermatitis" which is usually bilateral but can look like this. In the differential diagnosis one would consider Demodicois and atypical acne. Perhaps, I should have done a scraping for demodex mites.
Alternatively, this could be the onset of acne vulgaris, localized at this early stage. Perhaps, I jumped at a zebra when this is just common acne.

Therapy: The patient was given a prescription for doxycycline 100 mg b.i.d. and ketoconazole cream which I have found to be effective for perialar dermatiis. He will be reevaluated in a month.

Questions: Do you think this is periorificial dermatitis, demodicosis, or atypical acne? Your comments will be appreciated.

References:
1. Nguyen V, Eichenfield LF. Periorificial dermatitis in children and adolescents. Volume 55, Issue 5, Pages 781-785 (November 2006)
There has been very little evaluation of the history, morphology, or disease course of perioral/periorificial dermatitis in children.
Objective: We sought to elucidate the clinical manifestations and treatment outcomes in this condition.Methods A retrospective chart review with telephone follow-up was used to study 79 children and adolescents. Results: Patients ranged from 6 months to 18 years of age. The average duration of the rash at presentation was 8 months. Seventy-two percent had a history of topical, inhaled, or systemic steroid exposure. Seventy percent of patients had perioral involvement, 43% perinasal, and 25% periocular involvement. A perivulvar rash was reported in 1% of patients. Treatment with topical metronidazole was associated with clearing on follow-up examination.
Limitations: This is a retrospective study without case controls and is subject to interviewer and memory bias. Conclusion: Perioral dermatitis appears at all ages in childhood and adolescence and may be associated with topical corticosteroid use. It may be responsive to topical metronidazole in children and adolescents and is more appropriately termed periorificial dermatitis.

2. Hsu CK, Hsu MM, Lee JY. Demodicosis: a clinicopathological study. J Am Acad Dermatol. 2009 Mar;60(3):453-62.
Department of Dermatology, College of Medicine, University Hospital, Tainan, Taiwan.
BACKGROUND: Demodex mites are common commensal organisms of the pilosebaceous unit in human beings and have been implicated in pityriasis folliculorum, rosacea-like demodicosis, and demodicosis gravis. OBJECTIVE: We sought to describe the spectrum of clinicopathological findings and therapeutic responses of demodicosis in Taiwanese patients. METHODS: We conducted a retrospective study to review clinicopathologic findings and therapeutic responses of 34 cases of diagnosed demodicosis. RESULTS: Fifteen cases with positive results of potassium hydroxide examination, standardized skin surface biopsy specimen, and/or skin biopsy specimen, and resolution of skin lesions after anti-Demodex treatment were included for final analysis. Nineteen cases were excluded because of insufficient positive data to make a definite diagnosis. There were 4 male and 11 female patients (age 1-64 years, mean age 38.7 years). The disease was recurrent or chronic with a duration ranging from 2 months to 5 years (mean 15.7 months). The skin lesions were acne rosacea-like (n = 8), perioral dermatitis-like (n = 5), granulomatous rosacea-like (n = 1), and pityriasis folliculorum (n = 1). Skin biopsy was performed in 7 patients. Overall, the histopathology was characterized by: (1) dense perivascular and perifollicular lymphohistiocytic infiltrates, often with abundant neutrophils and occasionally with multinucleated histiocytes; (2) excessive Demodex mites in follicular infundibula; and (3) infundibular pustules containing mites or mites in perifollicular inflammatory infiltrate. The skin lesions resolved after treatment including systemic metronidazole, topical metronidazole, crotamiton, or gamma benzene hexachloride. LIMITATIONS: Small sample size and a fraction of patients without long-term follow-up are limitations. CONCLUSION: Demodicosis should be considered in the differential diagnosis of recurrent or recalcitrant rosacea-like, granulomatous rosacea-like, and perioral dermatitis-like eruptions of the face. Potassium hydroxide examination, standardized skin surface biopsy, skin biopsy, or a combination of these are essential to establish the diagnosis.