Henry Foong, FRCP Ipoh, Malaysia
on October 13, 2001
Ms A is a 22-year-old accountant from Singapore. She was seen in Ipoh, Malaysia with a two week history of explosive acne. She describes her complexion as "spotless" prior to that. Just 1 week after returning to Malaysia from Singapore her face erupted with scores of pustules, nodules and cysts. The lesions were tender and disturbed her sleep. She was otherwise well and had no systemic or gastrointestinal symptoms.
General condition satisfactory. She was afebrile. Extensive erythematous nodules, pustules and papules were noted on the cheeks and forehead. Few cysts and comedones were noted. Rest of exam was unremarkable.
Diagnosis: Pyoderma faciale
There was no
known trigger. The patient was unhappy working in
Singapore and had decided to return home to Malaysia for a vacation and to find a new job. It was after her return that the process began. She was extremely anxious about her appearance and refused all visitors at home. Understandably, she was very worried and apprehensive as to her future.
The initial treatment was isotretinoin 40mg daily, erythromycin ethylsuccinate 400mg bd and intralesional triamcinolone but there was minimal response after 2 weeks . After online discussions with colleagues, prednisolone was added at a dose of 15mg tid and then tapered over a period of 8 weeks. The nodular areas were also treated with intralesional triamcinolone at a dose of 10 mg/ml. She completed a total cumulative dose of 4800 mg of isotretinoin over a period of 8 months. She had 6 intermittent glycolic acid peel done reaching a 70% concentration over this period.
Pyoderma faciale affects mainly female patients (age from 20-30 years old). It is characterised by the sudden onset of painful cysts with minimal comedones on the face, especially on the central part of the face. The trunk is usually spared. In some cases, there are interconnecting sinus tracts.
Histopathologic examination revealed a dense perivascular and periadnexial infiltrate, including granulocytes, eosinophils with epithelioid granulomas, and septal and lobular panniculitis. No consistent laboratory abnormalities were found.
The patient responded well to isotretinoin in combination with topical and systemic corticosteroids. The response to these agents is superior to those patients treated with oral antibiotics. The sequele is favourable if treated early with little scarring. Some regard it as a variant of rosacea and suggest it be renamed rosacea fulminans (cf acne fulminans).
There has been report of a patient with pyoderma faciale and Crohn's disease. The patient is interesting in that on two occasions the relapse in her skin condition coincided with the introduction of non-steroidal anti-inflammatory drugs. Therapy with isotretinoin was effective and well tolerated.
Comments from VGR-D Members:
From Jean Holland, M.D. on 10/14/01:
I am still puzzled over one of my adult female patients who had huge facial cysts, mainly forehead and lower cheeks, which responded only partially to isotretinoin, IL steroids, and occasional bursts of prednisone. She developed periorbital cellulitis (not obviously related to any acneiform cysts), and was hospitalized for high-dose IV cephalosporin therapy. Her face cleared, and remained clear for five years -- until she recently became pregnant at age 38. This eruption is much less severe, so far. Still, I'm counting on her obstetrician to follow through with plans for IV antibiotics after delivery to treat a chronic UTI.
From J.W. Bard, M.D. on 10/14/01:
This is a rare condition but one which a dermatologist should recognize quickly as not acne and initiate corticosteroid therapy immediately. Isotretinoin and antibiotics are adjuctive and probably help spare the dosage and time of steroids. In the 2 cases I have treated (1 teen male, 1 female in her early 20's) both recoved without recurrence, but enough damage had beeen wrought that scarring was inevitable. Long term -- several years -- follow up showed pretty decent results. Spot dermabrasion was helpful for the female.
From email@example.com on 10/14/01:
Dapsone may be helpful but liver function studies and CBC with neurologic testing may be indicated. Low dose steroid may be employed with the Dapsone.
From James Herndon, M.D. on 10/18/01:
Though a regimen including isotretinoin plus systemic corticosteroid holds first place currently in the treatment of this condition [Seukeran DC and Cunliffe WJ, Brit J Dermatol. 1999 Aug; 141(2):307-9.], I have had excellent results with isotretinoin and dapsone [Tan BB et al Clin Exp Dermatol. 1997 Jan;22(1):26-7.]
From Leana Quintanilla,
Very interesting the treatment with triamcinole intralesional, very painful, but useful. How long does the patient take isotretinoin? I like the case, with some frequency in my clinic. Thank you.