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Diseases of hair follicles

5  Non-tumorous skin diseases

5.15  Diseases of hair follicles

5.15.1  Acne vulgaris

Clinical signs:

  • affects usually adolescents
  • location: face, shoulders
  • common disease
  • in man the course is usually more severe
  • afects the skin with so called sebaceous follicles: the face, upper half ot the trunk
  • I. grade - acne comedonica - black (open) and white (closed) comedones
  • II. grade - acne papulopustulosa I., II., III.
  • III. grade - acne conglobata (nodulocystica) levis et gravis

Pictures

Acne conglobata, forhead; comedones, papulopustules, scars:
Acne conglobata, CLINIC (644)

Acne papulopustulosa, face, healing with scars:
Acne vulgaris, CLINIC (645)

Acne papulopustulosa, excoriated:
Acne vulgaris, CLINIC (647)

Acne papulopustulosa III, scarring:
Acne vulgaris, CLINIC (648)

Acne conglobata, scars:
Acne vulgaris, CLINIC (952)

Acne fulminans:
Acne vulgaris, CLINIC (953)

Acne conglobata:
Acne vulgaris, CLINIC (954)

Acne papulopustulosa:
Acne vulgaris, CLINIC (955)

Acne, detail:
Acne vulgaris, detail of the pustule, CLINIC (956)

Acne, scars:
Acne, scars in the face, CLINIC (957)

Acne papulopustulosa:
Acne vulgaris, face, CLINIC (958)

Acne papulopustulosa:
Acne vulgaris, face, CLINIC (959)

Acne tetrada:
Acne tetrada, buttocks, CLINIC (960)

Acne papulopustulosa:
Acne papulopustulosa, CLINIC (2769)

Acne and hirsutism:
Acne vulgaris and hirsutism, CLINIC (2759)

Acne comedonica:
Acne comedonica, CLINIC (2760)
Acne comedonica, CLINIC (2761)
Acne comedonica, CLINIC (2762)

Acne conglobata:
Acne conglobata, CLINIC (2763)
Acne conglobata, CLINIC (2764)

Acne conglobata:
Acne conglobata, CLINIC (6347)

Acne cystica:
Acne cystica, CLINIC (2765)

Acne oleosa:
Acne oleosa, CLINIC (2766)
Acne oleosa, CLINIC (2767)
Acne oleosa, CLINIC (2768)

Further examples of acne:

Histology:

Ruptured pilosebaceous unit surrounded by infiltration with neutrophils; foreign body (granulomatous) reaction to release of follicular contents

Acne cystica: irregular, multiple cysts filled by compact keratin, connected to the follicle, inflammation.

Pictures

Acne vulgaris:
Acne vulgaris, HE 2.5x (1157)
Acne vulgaris, HE 10x (1156)

Infiltrate with features of foreign body granuloma:
Acne vulgaris, HE 10x (1155)

Deep draining sinus of acne inversa:
Acne inversa, HE 20x (4378)  [zoomify]

Another case:
Acne inversa, HE 20x (5076)  [zoomify]

Acne inversa:
Acne inversa, HE 20x (13975)

Acne folliculitis:
Acne vulgaris, HE 20x (4651)  [zoomify]

Acne cystica:
Acne cystica, HE 20x (5121)  [zoomify]

5.15.2  Rosacea

Etiology, pathogenesis:

  • idiopathic
  • aggravated by heat, alcohol, spices and other vasodilatators

Clinical signs:

  • center and sides of the face: nose, forhead, cheeks, chin
  • I. grade: transient erythemas, teleangiectasiae
  • II. grade: papules, papulopustules, pustules; severe form: rosacea fulminans
  • III. grade: nodules and plaques, rhinophyma
  • ocular involvement
  • severe form with deformation of the nose: rhinophyma

Pictures

Rosacea, erythematous:
Rosacea, CLINIC (1128)

Rosacea, 2nd grade:
Rosacea, CLINIC (1129)

Rosacea, rhinophyma:
Rosacea, CLINIC (1130)

Rosacea and demodicosis:
Rosacea, CLINIC (1131)

Rosacea papulosa:
Rosacea, CLINIC (3326)
Rosacea, CLINIC (3327)
Rosacea, CLINIC (3328)
Rosacea, CLINIC (3329)

Pyoderma faciale, rosacea fulminans:
Pyodermia, CLINIC (1126)

Rosacea and reaction to steroid treatment:
Drug reaction, CLINIC (1135)

Rhinophyma (hyperplastic rosacea):
Rhinophyma, CLINIC (3324)
Rhinophyma, CLINIC (3325)

Further examples of rosacea:

Histology:

Sebaceous hyperplasia, inflammatory periadnexal infiltrates, sometimes granulomatous. Parasitic infestation of follicles (Demodex) is sometimes present.

5.15.3  Dermatitis perioralis

Introduction:

A variant of acne rosacea.

Pictures

Dermatitis perioralis:
Dermatitis perioralis, CLINIC (1002)

Dermatitis perioralis:
Dermatitis perioralis, CLINIC (1001)

Histology:

Histology similar to acne rosacea.

5.15.4  Lupus miliaris disseminatus faciei

Clinical signs:

  • papules in the central area of the face, eyebrows and eyelids
  • heals withous scarring after months
  • no relation to tuberculosis, it is rather form of rosacea

Histology:

Necrotizing dermal granulomas with epithelioid histiocytes and Langhan's cells. Some of the granulomas have relation to ruptured pilosebaceous units.

5.15.5  Alopecia

5.15.5.1  Alopecia areata

Introduction:

Localized loss of hair.

  • Alopecia areata (one or several areas without hair);
  • alopecia totalis (whole scalp is affected);
  • alopecia universalis (whole body)

Etiology, pathogenesis:

  • unknown

Clinical signs:

  • alopetic areas of various size and duration, sharp demarcation, roundish
  • smooth surface, no clinical signs of inflammation, scales
  • in the margins of there are broken hairs, narowing towards the follicle (exclamation marks) — sign of activity
  • alopetic areas usually regrow
  • affects usually the scalp, but sometimes any other body hairs
  • widespread forms (alopecia universalis) are permanent

Histology:

Deep perifollicular lymphocytic inflammation (often with scattered eosinophils), diminutive early anagen follicles closer to the epidermis.

5.15.5.2  Diffuse alopecia

Clinical signs:

  • loss of hair affects the whole scalp
  • loss of hair (defluvium) is sudden or gradual

Pictures

Diffuse alopecia:
Alopecia diffusa, CLINIC (657)

5.15.5.3  Defluvium

Clinical signs:

  • see diffuse alopecia

Pictures

Woman with the defluvium of androgenic type:
Defluvium, CLINIC (704)

Further examples of androgenic alopecia:

Histology:

Small, miniaturized hairs with remnants of fibrous tracts bellow. Sometimes slight lymphocytic perifollicular and/or superficial infiltrate.

5.15.5.4  Pseudopelade of Brocq

Introduction:

Inflammatory and scarring alopecia; late stage of lichen planopilaris

Clinical signs:

  • location: usually top of the head
  • irregular atrophic areas with permanent loss of hair
  • focuses of ininvolved hair separate alopetic areas
  • no scaling, no clinical signs of inflammation in terminal lesions

Pictures

Pseudopelade Brocq:
Pseudopelade, CLINIC (1110)

Histology:

Perifollicular lichenoid inflammation of the upper parts of hair follicles, then destruction and fibrosis of remnants of hair follicles.

5.15.5.5  Alopecia in lupus erythematodes

Introduction:

Lupus erythematodes in the scalp leads to alopecia, usually of scarring type. The pictures are in the chapter on lupus erythematodes.

5.15.5.6  Follicular mucinosis (alopecia mucinosa)

Introduction:

This process is characterized by accumulation of mucin within follicular epithelium. Primary form is a benign disease, leading to permanent alopecia. Secondary follicular mucinosis is associated with lymphoma, most often T lymphoma (mycosis fungoides). Differenciation of primary and secondary forms may be difficult, especially in early stages of the disease.

5.15.5.6.1  Primary follicular mucinosis

Etiology, pathogenesis:

  • unknown

Clinical signs:

  • alopetic patches of various size
  • erythematous papules and plaques

Histology:

Mucin deposits within infundibular epithelium with lymphocytes, perifollicular lymphocytic and histiocytic infiltration.

5.15.5.6.2  Secondary follicular mucinosis in mycosis fungoides

Etiology, pathogenesis:

  • mucin within follicular epithelium in mycosis fungoides

Clinical signs:

  • alopetic areas of varying size
  • erytematous papules, plaques or nodules
  • tumorous infiltration and other clinical signs of a malignant process

Histology:

Mucin deposits of follicular epithelium, pronounced lymphoid exocytosis, perifollicular lymphocytic and histiocytic infiltrate, sometimes with polymorphous, mitotically active lymphoid elements.

Pictures

Secondary follicular mucinosis in mycosis fungoides:
Follicular mucinosis in mycosis fungoides, HE 10x (244)
Follicular mucinosis in mycosis fungoides, HE 20x (246)

Alcian blue staining:
Follicular mucinosis in mycosis fungoides, alcian blue 20x (245)

The same case, later biopsy, more progressed, detail:
Follicular mucinosis in mycosis fungoides, HE 100x (247)

Another case of mycosis fungoides, with prominent mucinosis:
Mycosis fungoides, follicular mucinosis, HE 5x (322)
Mycosis fungoides, follicular mucinosis, HE 20x (318)
Mycosis fungoides, follicular mucinosis, HE 40x (320)
Mycosis fungoides, follicular mucinosis, HE 40x (321)
Mycosis fungoides, follicular mucinosis, anti-T, peroxidase 40x (319)

Another case:
Follicular mucinosis in mycosis fungoides, HE 40x (2177)
Follicular mucinosis in mycosis fungoides, HE 40x (2533)

Follicular mucinosis in mycosis fungoides:
Mycosis fungoides with follicular mucinosis, HE 20x (2420)
Mycosis fungoides, HE 40x (2421)
Mycosis fungoides, follicular mucinosis, HE 100x (2518)

Another case:
Follicular mucinosis in mycosis fungoides, HE 20x (4258)

Another case:
Follicular mucinosis in mycosis fungoides, HE 20x (4539)  [zoomify]

Another case:
Follicular mucinosis in mycosis fungoides, HE 40x (4817)
Follicular mucinosis in mycosis fungoides, alcian blue 40x (4816)  [zoomify]

Follicular mycosis fungoides with mucinosis:
Follicular mucinosis in mycosis fungoides, HE 60x (12706)

Folliculotropic mycosis fungoides, minimal mucinosis, destruction of follicles:
Follicular mucinosis in mycosis fungoides, HE 20x (4862)  [zoomify]

5.15.5.7  Alopecia androgenica

Clinical signs:

  • affects men and women
  • variable patterns of a hair loss
  • caused by diminution in the size of terminal follicles, which change into vellus follicles

Histology:

Hair follicles become smaller, change into vellus follicles. Catagen and telogen hair are increased in number. Slight perivascular inflammation is sometimes present.

5.15.5.8  Trichotillomania

Clinical signs:

  • habitual plucking of hairs
  • often in psychically altered people
  • alopetic areas

Histology:

Increased number of catagen hairs, dilated, keratin filled infundibula which may contain melanin, release of melanin pigment within the papilla, clefts around the follicular epithelium, focal perifollicular hemorrhage.

Pictures

Trichotillomania:
Trichotilomania, HE 20x (5045)

5.15.5.9  Tration alopecia

Clinical signs:

  • induced by various hairstyling practices
  • marginal and nonmarginal types

Pictures

Traction alopecia, 30 years old woman (marginal):
Traction alopecia, CLINIC (5918)
Traction alopecia, CLINIC (5919)

Another case of traction alopecia, (nonmarginal):
Traction alopecia, CLINIC (5920)

Histology:

Slight lymphocytic perifollicular infiltrate and perifollicular fibrosis. Finaly the follicules are lost.

5.15.6  Other diseases of hair follicles

Introduction:

A group of diseases affecting the scalp with possible alopecia (e.g. alopecia mucinosa, pseudopelade of Brocq) or the skin (e.g. ostiofolliculitis). Sometimes caused by fungi. Other group is characterized by follicular hyperkeratosis (e.g. keratosis pilaris).

Pictures

Keratosis pilaris:
Keratosis pilaris, HE 40x (5992)

Further examples of folliculitis:

5.15.6.1  Purulent folliculitis

Clinical signs:

  • often in friction areas
  • follicular bound papules, developing into pustules
  • inflammation
  • furunculus and carbunculus are accompanied by generalized symptoms
  • sterile foliculitis is often seen in EGFR inhibitors therapy

Histology:

Deep folliculitis is usually accompanied by follicular destruction, heals with scarring.

5.15.6.2  Folliculitis keloidalis nuchae

Introduction:

Deep chronic folliculitis of the nape of the neck; heals by scarring.

Histology:

Chronic inflammation, widespread destruction of follicles, fibrosis, scarring.

5.15.6.3  Folliculitis decalvans, folliculitis abscedens et suffodiens, tufted hair folliculitis

Introduction:

Chronic scarring folliculitis.

Pictures

Folliculitis decalvans:
Folliculitis decalvans, HE 20x (4257)  [zoomify]

Folliculitis et perifolliculitis abscedens et suffodiens:
Folliculitis purulent, HE 40x (12056)

Folicullitis et perifolliculitis abscedens et suffodiens:
Folliculitis et perifolliculitis abscedens et suffodiens, HE 60x (13323)
Folliculitis et perifolliculitis abscedens et suffodiens, HE 60x (13326)

Tufted hair folliculitis:
Tufted hair folliculitis, HE 20x (5465)

5.15.6.4  Ostiofolliculitis (superficial folliculitis)

Clinical signs:

  • small pustules with the hair in the center

Histology:

Pustule located at follicular infundibulum with neutrophilic superficial perifollicular reaction.

5.15.6.5  Perforating folliculitis

Introduction:

Abnormal follicular keratinisation caused by chronic irritation. Hair fragments are sometimes present within the dermis.

Histology:

Deformed follicles, chronic inflammation, ruptures and defects of the follicular epithelium, hair outside the follicle within the tissue.

5.15.6.6  Eosinophilic pustular folliculitis, eosinophilic pustulosis

Clinical signs:

  • papules and pustules
  • location: face, trunk, arms
  • age: adults, but sometimes in children
  • may occur in HIV infected patients

Histology:

Spongiosis of follicular epithelium; exocytosis (lymphocytes and eosinophils) of the follicular epithelium; follicular pustules.

5.15.6.6.1  Eosinophilic pustulosis Ofuji

Clinical signs:

  • age: children, typically newborns
  • localization: head (face, scalp)
  • crops of small pustules, sometimes recurrent
  • eosinophilia

Histology:

Spongiosis, spongiotic or subcorneal vesicles with eosinophils, usually no follicular involvement.

5.15.6.7  Keratosis pilaris

Introduction:

Large follicular plugs, sometimes perifollicular inflammation and follicular atrophy.

5.15.6.8  Lichen spinulosus

Clinical signs:

  • rare disease
  • tiny follicular hyperkeratotic plugs, 2 – 5 mm in size, grouped into plaques of about 5 cm in size
  • location: extensor areas of the extremities, back, chest, face, neck
  • age: adolescence

Histology:

Keratotic plugs in the follicular infundibula, perifollicular lymphocytic infiltrate, perifollicular fibrosis.

5.15.6.9  Trichostasis spinulosa

Clinical signs:

  • tiny papules on the trunk or face

Histology:

Groups of vellus hairs within hair follicles. No inflammation.

5.15.6.10  Ulerythema ophryogenes

Clinical signs:

  • erythema and follicular papules involving lateral parts of eyebrows
  • focal alopecia of the eyebrows

Pictures

Ulerythema ophryogenes:
Ulerythema ophryogenes, CLINIC (3402)

Histology:

Follicular hyperkeratosis, skin atrophy, mild chronic inflammation.

5.15.6.11  Pili recurvati

Clinical signs:

Pili recurvati may irritate surrounding epidermis, grow back into the epidermis and mimic folliculitis.

Pictures

Pili recurvati:
Pili recurvati, CLINIC (5824)

5.15.6.12  Tufted hair
5.15.6.13  Plica polonica

Clinical signs:

  • hair matting
  • caused by improper hair care (of hair with natural kinks)
5.15.6.14  Cutis verticis gyrata

Clinical signs:

  • rarely found in people with mental retardation
  • in secondary form is combined with variable lesions (skin and soft tissue tumors and nevi, metabolic disorders and many other)
  • slowly progressive
  • skin of the scalp is thickened and folded
  • may be focal (occipital) or may involve the whole scalp

Pictures

Cutis verticis gyrata:
Cutis verticis gyrata, CLINIC (5947)

5.15.7  Fox-Fordyce syndrome

Clinical signs:

  • tiny papules
  • location: axilla (and rarely around nipples, mons veneris)
  • affects women after puberty
  • severe episodic pruritus

Histology:

Not characteristic; follicular plugging, sometimes chronic inflammation, dilatation of apocrine sweat glands, erosions (pruritus). Inflammation of sweat glands in acute cases.

Chromhidrosis: pigment within epithelial cells of sweat glands.

Pictures

Fox-Fordyce disease, apocrine glands:
Apocrine miliaria Fox Fordyce, HE 40x (12882)

Apocrine miliaria with chromhidrosis:
Apocrine miliaria Fox Fordyce with chromhidrosis, HE 20x (4260)


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