C h a p t e r 4 6
Disorders of Skin Integrity and Function
1161
be used in women who are pregnant or may become
pregnant.
A frequently seen adverse effect of acne in darker
skinned persons is postinflammatory hyperpigmenta-
tion. Hence, treatment measures for persons of color
may vary.
23
Acne Conglobata
Acne conglobata occurs later in life as a severe, chronic
form of acne. Comedones, papules, pustules, nodules,
abscesses, cysts, and scars occur on the back, buttocks,
and chest. Lesions occur to a lesser extent on the abdo-
men, shoulders, neck, face, upper arms, and thighs.
The comedones or cysts have multiple openings, large
abscesses, and interconnecting sinuses. Inflammatory
nodules are not uncommon. Their discharge is odorif-
erous, serous or mucoid, and purulent. Healing often
leaves deep keloidal lesions. Affected persons have ane-
mia with elevated white blood cell counts, erythrocyte
sedimentation rates, and neutrophil counts. The treat-
ment is difficult and stringent. It often includes debride-
ment, systemic corticosteroid therapy, oral retinoids,
and systemic antibiotics.
Rosacea
Rosacea is a chronic skin disorder of middle-aged and
older persons. The disease has a variety of clinical mani-
festations (blushing, presence of telangiectatic vessels,
eruption of inflammatory papules and pustules) that pri-
marily affect the central areas of the face. In the early
stage of rosacea development, there are repeated episodes
of blushing.
24,25
The blush eventually becomes a perma-
nent, dark-red erythema on the nose and cheeks that
sometimes extends to the forehead and chin (Fig. 46-12).
This stage often occurs before 20 years of age. Ocular
problems occur in at least 50% of persons with rosacea.
Prominent symptoms include eyes that are itchy, burning,
or dry; a gritty or foreign body sensation; and erythema
and swelling of the eyelid. As the person ages, the ery-
thema persists, and telangiectasia with or without acne
components (e.g., comedones, papules, pustules, nodules,
erythema, and edema) develops. After years of affliction,
rosacea may develop into an irregular bullous hyperpla-
sia (thickening of the skin) of the nose, known as
rhino-
phyma
. Although rosacea is more common in women,
rhinophyma is more common in men.
The cause of rosacea is unknown; however, it is
believed to be a chronic inflammatory process involving
the area surrounding the pilosebaceous units, accom-
panied by vascular instability with leakage of fluid and
inflammatory mediators into the dermis. The lesions are
accompanied by nonspecific perifollicular infiltrate of
lymphocytes surrounded by dermal edema and dilated
capillaries and terminal arterioles (telangiectases).
24,25
In the pustular phase, neutrophils may colonize the
follicles, and follicular rupture may produce a granu-
lomatous response. Rhinophyma is associated with
hypertrophy of the sebaceous glands.
Rosacea is distinguished from acne vulgaris by the
presence of the neurovascular component and absence
of comedones. Treatment measures are similar to those
used for acne vulgaris. Persons with rosacea are heat
sensitive. They are instructed to avoid vascular stimulat-
ing agents such as heat, sunlight, hot liquids, foods, and
alcohol. Topical metronidazole and azelaic acid creams
have proved effective as treatment. Topical antibiotics
(e.g., clindamycin, erythromycin), as well as systemic
antibiotics (e.g., tetracycline and its derivatives) are also
used in treatment of the disorder.
26
Pulsed dye laser ther-
apy may be used for ablation of vessels in persons with
prominent telangiectases. Rhinophyma can be treated by
a number of surgical methods, including electrosurgery,
laser ablation, dermabrasion, cryosurgery, and excision.
Allergic and Hypersensitivity
Dermatoses
Allergic and hypersensitivity dermatoses involve the
inflammatory response to multiple exogenous and
endogenous agents. The disorders, which are usually
characterized by epidermal edema with separation of
epidermal cells, include atopic dermatitis, urticaria,
drug-induced skin eruptions, and allergic contact der-
matitis (discussed in Chapter 16).
Atopic Dermatitis
Atopic dermatitis (atopic eczema) is a highly pruritic
chronic inflammatory skin disease. It usually begins
early in life and often occurs in children with a personal
or family history of other atopic disorders, such as aller-
gic rhinitis and asthma.
27,28
The condition often remits
during childhood, although it may reappear in adoles-
cence and persist throughout adulthood.
28
The hall-
marks of atopic dermatitis are a chronic, relapsing form
of skin inflammation; a disturbance in the epidermal
barrier function that leads to increased transepidermal
FIGURE 46-12.
Papulopustular and ocular rosacea of
moderate severity.The pustules are seen over the central
portion of the face with sparing of the periocular area.
Erythema and edema of the upper eyelids are also present.
(From Powell FC. Rosacea. N Engl J Med. 2005;352:793–803.
Copyright © 2005. Massachusetts Medical Society.)
