papules on face

1. DIFFERENTIAL DIAGNOSIS OF
PAPULAR LESIONS ON FACE
DR.MIKHIN GEORGE THOMAS

2. CLASSIFICATION
INFECTIONS
INFLAMMATORY DISORDERS
TUMOURS
OTHERS

3. INFECTIONS
• Molluscum contagiosum
• Tinea faciei
• Lupus vulgaris
• Demodicidosis

4. INFLAMMATORY DISORDERS
• Acne
• Rosacea
• Perioral dermatitis
• Lupus miliaris disseminatus faciei
• FACE
• Sarcoidosis
• Follicular mucinosis
• Pseudofolliculitis barbae

5. TUMOURS
BENIGN EPIDERMAL TUMORS
AND CYSTS:
DPN
Seborrhoeic keratosis
Keratoacanthoma
Milia

6. Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS
 Actinic keratosis
 Cutaneous horn
MALIGNANT
 Basal cell carcinoma

7. Tumors of skin appendages
• Eccrine gland tumors : syringoma, eccrine hidrocystoma
• Apocrine gland tumors : syringocystadenoma papilliferum
• Sebaceous gland tumors : sebaceoma, sebaceous adenoma,
sebaceous hyperplasia
• Tumor of hair follicle mesenchyme : trichodiscoma
• Hair follicle tumors : dilated pore, trichoadenoma
• External root sheath tumors : trichilemmoma
• Hamartomas : trichoepithelioma, trichofolliculoma

8. Soft tissue tumors
• Fibrous tumor : fibrous papule of face
• Fibrohistiocytic tumors : atypical fibroxanthoma

9. OTHERS
• Colloid milia
• Angiofibroma

10. INFECTIONS

11. MOLLUSCUM
CONTAGIOSUM
• Pox virus family
• MCV 1-4; majority : type 1
• Contact with infected persons or contaminated
objects, sexual abuse
• Peak incidence : 2-5 yrs
• IP: 14 days to 6 mths
• C/F : shiny, pearly white, hemispherical, umbilicated
papule, 5-10 mm
• Agminate form or giant molluscum
• Distribution depends on the mode of infection

12. • Widespread and refractory
mollusca on the face- HIV
infection and iatrogenic
immunosuppression.
• Viral entry into the basal layer
where an early increase in cell
division extends into the
supra basal layer.
• Molluscum bodies

13. Course & treatment :
Spontaneous clearance
• Curettage
• Cryotherapy
• Electrosurgery
• Phenol
• cantharidin
• tricholoroacetic acid
• pot.hydroxide solution
• topical salicylic acid preparations
tretinoin
• imiquimod cream
• cidofovir

14. LUPUS VULGARIS
• Chronic progressive post primary,
paucibacillary form of cutaneous tuberculosis
• Moderate or high degree of immunity
• Underlying focus- bone, joint or lymph node
• Haematogenous or lymphatic spread
• C/F: 80%- head and neck
India- buttocks and trunk
Initial lesion : small reddish brown plaque,
soft, with peripheral extension.
5 types: plaque, ulcerative, vegetating,
tumour like, papular and nodular forms.
• Diascopy : apple jelly nodules

15. • Diagnosis
• Treatment : standard ATT
• Differential diagnosis :
 Rosacea
 leprosy nodules: firmer
 Nodules of sarcoidosis :
resemble grains of sand

16. DEMODICIDOSIS
• Demodex folliculorum - follicle mite
• Areas of high sebum production
• Head down position in the follicle, 2-6 mites, motile
• Can produce papular and papulopustular lesions in
immunosuppressed individuals
• Pathogenic role: pityriasis folliculorum, rosacea, perioral
dermatitis, blepharitis
• Treatment : topical acaricides

17. TINEA FACIEI
• Ringworm of glabrous skin of face
• Trichophyton mentagrophytes, T.rubrum
• Direct inoculation or secondary spread from
other sites
• Itching, burning & exacerbation with sun
exposure
• Erythema +, Scaling less prominent
• Simple papular lesions or flat patches of
erythema
• D/D : PMLE and DLE
• Treatment : antifungals

18. TINEA BARBAE
• A disease of adult male
• Ringworm of beard and moustache areas of
face
• Invasion of coarse hairs
• Commonly farm workers
• Trichophyton verrucosum,
T.mentagrophytes
• C/F: highly inflammatory pustular
folliculitis
Hairs surrounded by red inflammatory
papules or pustules
Loose hairs in affected areas
• Treatment : antifungals

19. ACNE
• A chronic inflammatory disease of pilosebaceous units
• Usually starts in adolescence
• Seborrhoea , open & closed comedones, erythematous
papules & pustules, nodules, pseudocysts, scarring
• Pathogenesis : 4 factors
• 99% - lesions on face
• Early lesions – comedones
• Grading of acne
• Acne variants – infantile, occupational, mechanical,
tropical, acne excoriee, acne conglobata, acne fulminans
fulminans.

21. Treatment :
 Topicals – retinoids, benzoyl
peroxide, topical antibiotics,
nicotinamide, azelaic acid
 Physical modalities
 Systemic therapy : antibiotics,
oral retinoids, hormonal
therapy, zinc
 Acne surgery
Differential diagnosis :
rosacea, perioral dermatitis,
gram negative folliculitis

22. ROSACEA
• A vascular disorder affecting central face
• Presence of one or more of the following:
flushing, non transient erythema, papules and
pustules, telangiectasia
• Not a disorder of sebaceous glands, absence of
comedones
• Pathogenesis :
o Damage to dermal connective tissue
o Abnormal vascular reactivity
o Sensitivity to noxious stimuli
o High levels of cathelicidin
o H.pylori, Demodex folliculorum

23. Cont…
• Early : episodic flushing, mild telangiectasia, transient
edema
• Progressive : papules, pustules, sustained edema, extensive
telangiectasia
• Late : induration, rhinophyma
• Lymphoedema, eye involvement, salivary gland involvement
• Histopathology :
– Dilated capillaries & lymphatic channels in mid dermis
– Perivascular lymphohistiocytic infiltrates
– Solar elastosis
– Sometimes granulomas
– Pustules – neutrophilic infiltration

24. • Treatment
• Topical : metronidazole, tretinoin,
clindamycin, tacrolimus, azelaic acid
• Systemic : tetracyclines, metronodazole, isotretinoin
• Rhinophyma : surgical excision, intense pulsed light lasers,
dermabrasion

25. PERIORAL DERMATITIS
• Persistent erythematous eruption
of tiny papules and papulopustules
– perioral
• Periocular dermatitis
• Pathogenesis :
 Demodex, candida , fusiform
bacteria
 Irritant and allergic contact factors
 Atopy
 Topical steroids, cosmetic products
 Hormonal factors, sensititvity to
sunlight

26. Cont..• Begins in nasolabial areas  perioral areas; sparing lip
margins
• Monomorphic papules & pustules
• Histopathology – eczematous changes, mononuclear
infiltrate; rarely granulomatous inflammation
• Treatment
– Discontinue topical steroids
– Avoid potential contact allergens
– Oral tetracyclines for 4 weeks
– Topical tetracycline, metronidazole, erythromycin
– Pimecrolimus 1% cream

27. ACNE AGMINATA
• Lupus miliaris disseminatus faciei – historical
• Acnitis or FIGURE
• A self limiting variant of granulomatous form of rosacea
• C/F : Multiple, monomorphic, symmetrical, reddish-brown
papules on the chin, forehead, cheeks and eyelids
• Clustering around mouth or eyelids or eyebrows - ‘agminata’
• Diascopy – apple jelly nodules
• Granulomatous histology with large area of caseation
• D/D : micropapular sarcoidosis
• Treatment : tetracyclines, dapsone, low dose prednisolone

29. Facial Afro-Caribbean childhood
eruption
• FACE or granulomatous periorificial dermatitis
• A juvenile form of perioral dermatitis or acne agminata
• Papular eruption confined to the face – clustering around
mouth, eyes and ears
• Pustules absent, vermilion border involved
• Histology – nonspecific inflammation with hyperkeratosis
or granulomatous mainly perifollicular
• Complete resolution
• Treatment – systemic erythromycin or minocycline or
topical metronidazole or tacrolimus

31. SARCOIDOSIS
• A disease characterised by formation in all or
several affected organs or tissues of epithelioid cell
tubercles, without caseation, proceeding either to
resolution or to conversion into hyaline fibrous
tissue.
• Etiology : genetic factors, infectious agents,
immunological response

32. • Acute and subacute : erythematopapular lesions, scar
sarcoidosis , papular and lichenoid variety
• Sub acute and chronic : erythrodermic, nodular, annular,
angiolupoid, subcutaneous
• Chronic : plaque ( lupus pernio)
• Others : ulcerative, psoriasiform, palmoplantar, ungual,
mucosal
• Systemic features : cardiac, respiratory, muscle, CNS,
ocular, renal, liver, spleen, lymphnodes
• Raised ACE levels , hypercalcemia

34. Cont…Histopathology
– Well defined aggregates of epithelioid cells
– Few Langhan’s type giant cells
– Naked tubercle – paucity of lymphocytes
– MNG cells with asteroid bodies and Schaumann bodies

35. Treatment :
– Corticosteroids
– Immunosuppressants
– Biologics
– Other drugs – allopurinol,
doxycycline, chloroquine,
minocycline, levamisole,
isotretinoin, fumaric acid
esters, thalidomide
– Topical therapy – high potent
topical steroids, ILS,
tacrolimus
– PUVA, cryotherapy,
radiotherapy

36. FOLLICULAR MUCINOSIS
• Alopecia mucinosa
• 2 distinct forms: associated with MF and benign inflammatory form
• C/F are identical : follicular papules and boggy cutaneous plaques
• Severe pruritus and prediliction for face and scalp
• Prominent giant comedones and alopecia
• Pathology : degeneration of involved hair follicles with a prominent
pilotropic atypical T cell infiltrate, inter follicular epidermotropism
• CD3+ve, CD4+ve and CD8 –ve
• Treatment : dapsone for inflammatory forms
Associated with MF: bexarotene, radiotherapy, total skin electron
beam therapy

38. PSEUDOFOLLICULITIS BARBAE
•Inflammation due to penetration into the skin of sharp tips
of shaved hairs
•If shaven too long – the hair may curve backwards after
emerging from the follicle to penetrate the adjacent skin
•If cut very short – it retracts into the follicle; may directly
penetrate the follicle wall
•Curly hair – more prone
•Male beard – commonest area
•Complications – keloid, hyperpigmentation

39. Treatment
• Stop shaving for 4-6 weeks
• Lifting out of reentrant hairs
• Hair maintained at 1 mm length
• Steroid-antibiotic combination
creams and emollients
• Hair removal with chemical
depilatories or topical
eflornithine hydrochloride cream
• Laser

40. TUMOURS

41. Benign epidermal tumors and
cysts
• DPN
• Seborrhoeic keratosis
• Milia

42. • Dermatosis papulosa nigra
• Pigmented papular eruption of face and neck
• Nevoid developmental defects of pilosebaceous
follicles
• Histology resembling seborrhoeic keratoses
• C/F: black or dark brown, flattened or
cupuliform papules 1-5 mm
• Malar regions and forehead
• Also on neck, chest and back
• Treatment : electrosurgery

43. SEBORRHOEIC
KERATOSIS
• Benign tumor of epidermal keratinocytes
• Increasing age ; 5th decade ; M=F
• Most frequent on face and upper trunk
• Classical, DPN, stucco keratosis
• Hyperpigmented papules or plaques
• Sign of Leser-Trelat
• Histopathological types : clonal, hyperkeratotic,
acanthotic, irritated, reticulate, melanoacanthoma
• Treatment : curettage, electrosurgery, cryotherapy

45. KERATOACANTHOMA
• Molluscum sebaceum
• Rapidly evolving tumor of the skin composed of
keratinizing squamous cells originating in pilosebaceous
follicles
• M>F; middle aged ; white races
• Etiology : sunexposure, tar and mineral oil, sorafenib
• C/F: firm, rounded, flesh colored or reddish papule
rapid growth phase- 10- 20mm
Telangiectasias, central horny plug or crust concealing a
keratin filled crater

46. • Central part of face – nose,
cheeks, eyelids and lips
• Usually solitary
• Histopathology : epidermis
normal or acanthotic, composed
of mass of rapidly multiplying
squamous cells,
hyperchromaticity, atypical
mitotic figures, dyskeratosis and
loss of polarity
• D/D : SCC
• Treatment : curettage and
coagulation of base, excision
and suture, radiotherapy, 5-FU.

47. MILIA
• Small subepidermal keratin cyst
• All ages ; from infancy onwards
• Due to pilosebaceous or eccrine sweat duct plugging
• Primary or secondary
• Subepidermal blistering diseases(BP , EB, PCT), burns,
dermabrasion, radiotherapy
• Firm white or yellowish 1-2mm dome
shaped papules, on cheeks and eyelids
of adults
• Eruptive milia- rare
• Milia en plaque

48. • Histopathology : small
cysts lined by stratified
epithelium few cell layers
thick and contain
concentric lamellae of
keratin
• D/D : milia are whiter and
more translucent than
syringomas
• Spontaneous clearance
• Treatment : incision and
squeezing of contents,
chemical cautery,
electrosurgery.

49. Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS
 Actinic keratosis
 Cutaneous horn
MALIGNANT
 Basal cell carcinoma

50. ACTINIC KERATOSIS
• Or solar keratosis
• Premalignant epithelial lesion
• Hyperkeratotic lesions on chronically light exposed
skin
• Low risk of progression to invasive SCC
• Middle aged or elderly; fair skinned
• Relapsing or remitting lesions
• Face, scalp and dorsa of hands
• C/F : multiple macules or papules with a rough scaly
surface, 1mm to 2 cms, aymptomatic
• Hyperemic base with punctate bleeding points

51. • Histopathology :
• Treatment : curettage and cautery, cryotherapy, topical
5-FU, imiquimod, photodynamic therapy, dermabrasion
and chemical peels

52. CUTANEOUS HORN
• Horny plugs or outgrowths due to various epidermal
changes
• Infection : molluscum, viral wart
• Benign: keratoacanthoma, seborrhoeic keratosis,
trichilemmal and epidermoid cyst
• Malignant : BCC, SCC
• C/F : hard yellowish brown horn, curved,
circumferential ridges, surrounded by normal
epidermis or acanthotic collarette
• Upper face and ears
• Inflammation and induration beneath : malignant
transformation
• Histology : absent granular layer, no atypicality
• Treatment : excision

53. BASAL CELL
CARCINOMA
• Basalioma or rodent ulcer
• Most common malignant tumour of skin ; rarely metastasizes
• Composed of cells similar to basal cells an appendages
• M>F
• Etiology: UV exposure, arsenic, ionizing radiations and burns,
mutations in PTCH1 gene, immunosuppression
• C/F : small, translucent or pearly papule, raised and rounded
areas covered by thin epidermis, dilated superficial vessels,
nodule or plaque
• Erosions & crusting common, sometimes ulcerate
• Types

54. Pathology
-Tumor cells resemble
basal cells of epidermis
-Peripheral palisading of
nuclei
-Stroma
-Clefting artefact
-Atypia

55. Treatment
– Surgical excision
– Non-surgical approaches:
curettage and cautery,
cryotherapy,
laser, topical imiquimod,
topical 5FU, PDT,
systemic retinoids

56. Tumors of skin appendages
 Eccrine gland tumors : syringoma, eccrine hidrocystoma
 Apocrine gland tumors : syringocystadenoma papilliferum
 Sebaceous gland tumors : sebaceoma, sebaceous adenoma,
sebaceous hyperplasia
 Tumor of hair follicle mesenchyme: trichodiscoma
 Hair follicle tumors : dilated pore, trichoadenoma
 External root sheath tumors : trichilemmoma
 Hamartomas : trichoepithelioma, trichofolliculoma

57. SYRINGOMA
• Benign tumor with differentiation
towards eccrine acrosyringium
• F>M
• C/F : numerous small, firm, smooth
skin colored or yellowish papules,
<3 mm
• Outline – angular or crenated
• Face esp lower eyelids
• Other sites: neck, chest, trunk,
axillae, vulva,ventral trunk.
• Eruptive syringomas : familial in
adolescent girls

58. • Histopathology :
 collections of convoluted and cystic
duct spaces in upper dermis
 Lined by double layer of cells
 Tail like strand of cells into the stroma-
‘tadpole or comma appearance’
• Treatment :
electrosurgery, cryotherapy, dermabrasion,
laser resurfacing

59. ECCRINE HIDROCYSTOMA
• Tumour by mature deformed eccrine sweat units; secretions dilate
the ducts
• Rare; middle aged women; exposure to heat
• Confined to cheeks and eyelids
• Cystic, blue, increase in size on exposure to heat and flattens with
exposure to cold
• Multiple, pigmented lesions on face
• Pathology : uni or multilocular dermal cystic lesion lined by 2 layers
of cells
• Inner layer- columnar , outer layer- myoepithelial cells
• Treatment : electrodessication, CO2 laser, pulse dye laser, excision

61. SYRINGOCYSTADENOMA
PAPILLIFERUM
• Exuberant proliferating lesion with apocrine differentiation
• Birth or childhood
• C/F : Multiple warty papules, translucent and pigmented
• Majority on face and scalp
• Pathology
– Papillomatosis with invaginations
– Cystic structures –
apocrine pattern
– Dermis – plasma cells
– Sometimes sebaceous, eccrine,
follicular differentiation
• Treatment – surgical excision

62. SEBACEOUS TUMOURS
• Sebaceous adenomas and
sebaceomas
• Benign tumors composed of
incompletely differentiated
sebaceous cells
• Rare; elderly
• C/F : rounded, raised, sessile or
pedunculated, <10 mm,waxy or
yellowish, plaques or ulceration
• Face and scalp
• Multiple - Muir Torre syndrome

63. • Pathology
– Sebaceoma – irregular cell masses of mostly undifferentiated
basaloid cells
– Sebaceous adenoma – sharply demarcated lesion with peripheral
basaloid cells and central mature sebaceous cells
• Treatment – surgical excision

64. SEBACEOUS HYPERPLASIA
• Benign proliferation in middle aged
and elderly
• Yellowish-pink papules 1-3 mm
• Forehead and temples
• Renal transplant patients on CsA
• Treatment – cautery, cryotherapy,
TCA, laser

65. TRICHODISCOMA
• Hamartomatous proliferation of
mesodermal component of the
Haarscheibe
• Haarscheibe – a slowly reacting
mechanoceptor associated with
hair follicle
• C/F : multiple, discrete, flat
topped papules 2-3 mm
• Central face
• Birt – Hogg- Dube syndrome
• Pathology : non encapsulated area
of myxoid, poorly cellular stroma
wirh focal collagen deposition in
dermis, proliferation of vessels

66. DILATED PORE
• Wiener’s pore or infundibuloma
• Area of expanded follicular infundibulum
• Dilated poral opening into subcutaneous
tissue
• C/F : comedo like lesion on head and neck
in elderly
• Pathology : wide crater like cavity, from
which acanthotic areas of follicular
epithelium radiate; follicle lined by outer
root sheath epithelium

67. TRICHOADENOMA
• Rare benign tumor, with multiple cystic
structures closely resembling
infundibular portion of hair follicle
• Differentiates towards follicular
infundibulum
• C/F : Papule or nodule on the face
• Pathology : lesions in upper dermis,
cluster of cysts

68. TRICHILEMMOMA
• Proliferation of external root sheath of hair
follicle
• Infundibular keratinisation
• C/F : small non specific papules on facial
skin in young adults
• Multiple : Cowden’s syndrome
• Pathology
– Lobular tumors extending from epidermis
– Clear cytoplasm – glycogen
– Peripheral palisading
– Sometimes prominent epidermal changes
– Variant – desmoplastic trichilemmoma

69. TRICHOEPITHELIOMA
• Hamartoma of the hair germ
composed of immature islands
of basaloid cells
• Focal primitive follicular
differentiation and induction of
a cellular stroma
• 3 forms : solitary, multiple and
desmoplastic
• Solitary- skin colored papules,
5-8 mm, on face esp around
nose, upper lips, cheeks
• Brooke spiegler syndrome –
trichoepitheliomas,
cylindromas and spiradenomas

70. • Pathology
– Well circumscribed lesion in
superficial dermis
– Horn cysts and basaloid cells
– Tumor islands show
peripheral palisading
• Treatment – surgical excision,
curettage, electrosurgery,
cryotherapy ,dermabrasion

71. TRICHOFOLLICULOMA
• Hamartoma of pilosebaceous follicle
• Several hairs form within the follicular
opening , protruding onto the epidermal
surface
• Young adults
• Prediliction for face
• C/F : small raised nodules, 2-3 hairs
protruding in a small tuft
• Pathology
– Cystic cavity lined by squamous
epithelium
– Keratinised material & fragments of hair
shafts
– Several pilosebaceous structures opening
into the canal
Treatment : excision

72. Soft tissue tumors
• Fibrous tumor : fibrous papule of face
• Fibrohistiocytic tumors : atypical fibroxanthoma

73. FIBROUS PAPULE OF FACE
• Benign tumor
• Small facial papule with distinctive
fibrovascular component
• C/F: slowly developing dome shaped skin
colored or red or pigmented papule, sessile,
• Nose, forehead, cheeks, chin or neck
• Pathology: normal epidermis, clear cells
overlying the lesion, increased collagen in
the dermis, dilated vascular channels,
increased cellularity
• Treatment : excision or surgical paring

74. ATYPICAL FIBROXANTHOMA
• Fibrohistiocytic tumor
• Sun damaged skin of elderly ; M>F
• UV induced p53 mutations
• C/F : papules or nodules with ulceration
, red fleshy appearance
• On ears, cheeks, bald scalp of elderly
males
• Local recurrence, metastasis to
lymphnodes and internal organs
• Pathology: large spindle shaped and
histiocytic cells, multinucleated in
dermis, mitotic figures, atypical forms
• Resembles a highly malignant soft
tissue sarcoma histologically
• Treatment : mohs micrographic surgery

75. COLLOID MILIA
• Degenerative change on light exposed skin
• Nonfamilial occurring in later life
• UV, trauma, hydroquinone
• C/F : small dermal papules, 1-2 mm, yellowish
brown , irregular groups
• Face esp around orbits, sides of neck, ears, dorsa of
hands and back.
• Rare juvenile and nodular form
• Histopathology : colloid globules at tips of dermal
papillae
• Treatment : electrosurgery, dermabrasion, Er:YAG
laser, topical retinoids

77. • Small flesh colored to brownish
red papules – usually on central
face
• Multiple lesions – Tuberous
Sclerosis Complex
• Composed of hyperplastic blood
vessels, sebaceous glands,
immature hair follicles
• Treatment – electrosurgery, laser
ANGIOFIBROMA

78. HOW TO
APPROACH??

79. Onset
Duration
Evolution
Mucosal lesions
Systemic Complaints
Treatment history
? Symptomatic
Triggering factors
Photosensitivity
Past history
HISTORY

80. Morphology of predominant lesion
Number of lesions, symmetry
Size, colour and surface
? Flat topped ? Translucent
Umbilication? Erythema ? Telangiectasia
Annular lesions
Diascopy
Other types of lesions
? Scarring ? Ulceration
Distribution over face
Nasolabial fold, perioral & periocular regions
Involvement of other areas
Other systems
Investigations
EXAMINATION…

82. GOECKERMAN REGIMEN
2-5% CRUDE
COAL TAR
• Applied over the lesions for period of 24hrs
• Excess wiped off with mineral oil
UV- B
• Sub erythmogenic dose for 2-5 mins
COAL TAR
BATH
• 90mL of coal tar in 120L water

83. INGRAM REGIMEN
COAL TAR BATH
• 15-30 mins
UV-B
• Exposed to suberythmogenic
dose(1/3 to ½ of MED)
ANTHRALIN(0.1%)
• Apply with spatula over lesions
• Paste is powdered with talc

84. BATH PUVA
SPECIFICATIONS
• A special room with non skid bath tiles with bath
tub containing markings for 50,65,80,100L.
• Geyser for warm water
Principle
• Final concentration- 3.75mg/L
• 3.75mL of 1% psoralen in 100L of water
Procedure
• 10mins in supine and prone, maximum coverage
• Avoid splashing of face and eyes

85. BATH PUVA
Procedure
• Gently pat dry, and exposed to UV-
A with special precautions
• 3 times a week
Follow up
• 12-15 sessions for improvement
• Maintenance for 3-4 months