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Many generalized dermatologic conditions can affect the face and scalp. This chapter discusses the acneiform eruptions, seborrheic dermatitis, erysipelas and facial cellulites, impetigo, herpes zoster, herpes simplex, tinea capitis and barbae, head lice, allergic contact dermatitis, and photosensitivity/sunburn.

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The acneiform eruptions include acne vulgaris, pyoderma faciale, dissecting cellulitis of the scalp, and acne keloidalis nuchae. Pathophysiology of these disorders is similar. Sebum secretion is increased within the sebaceous follicle by androgen stimulation. Keratin accumulates in the hair follicle as well as sebum. Host inflammation occurs, and the bacteria Propionibacterium acnes (gram-positive rods) proliferate and accumulate, intensifying inflammation. At this stage, an inflammatory papule or pustule occurs. An influx of neutrophils and T-helper cells occurs during inflammation. In addition, marked inflammation can cause a nodule and cyst, and scarring can result. Pathophysiology of cutaneous scarring includes follicle blockage, rupture with keratin dispersion, and neutrophilic and granulomatous response.

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Acne vulgaris, although commonly afflicting young patients, can occur in adult patients as well. White males tend to have the more severe form of nodulocystic acne. Other predisposing conditions include polycystic ovarian syndrome and hypercortisolism such as congenital adrenal hyperplasia. Acne fulminans is the most severe form of nodulocystic acne and may prompt patients to seek emergency medical attention. It usually affects males between the ages of 13 and 16 years. Most patients have a history of acne before onset. Some individuals with severe acne who have started isotretinoin without systemic corticosteroids are predisposed to developing acne fulminans. Clinical features of acne fulminans include acute onset of suppurative cysts and nodules with ulcerations and hemorrhagic crusting (Figure 246-1). Ulcerating lesions can lead to severe scarring. Acne fulminans commonly affects the chest and back as well. Systemic symptoms also occur and include osteolytic bone lesions of the clavicle and sternum, fever, arthralgias, myalgias, and hepatosplenomegaly. Diagnosis is clinical. Acute treatment includes administration of 40 to 60 milligrams of prednisone once a day. If the patient is on isotretinoin, it should be continued in conjunction with the corticosteroids. Isotretinoin should not be given in the acute care setting. Referral to a dermatologist is appropriate. In that setting, topical, intralesional, oral corticosteroids, and/or oral isotretinoin with or without oral antibiotics can be initiated. Isotretinoin has potential severe teratogenic effects in pregnant women and requires patient registration, and online documentation of pregnancy test results.

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Figure 246-1.
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Nodulocystic acne. (Reproduced with permission from Wolff K, Johnson R, Suurmond R: Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005, p. 5.)

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Pyoderma faciale, or rosacea fulminans, is an inflammatory cystic acneiform eruption on the central face of young women. The eruption may occur without a history of rosacea. Inflamed papules and pustules are present on the centrofacial region and can coalesce into large plaques. Diagnosis is clinical. Severe scarring can occur without ...

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