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Wiadomości dermatologiczne

4 grudnia 2018

NR 1 (Grudzień 2018)

Trądzik i dermatozy trądzikopodobne w okresie dzieciństwa
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Trądzik oraz dermatozy trądzikopodobne, szczególnie w wieku dziecięcym stanowić mogą duży problem diagnostyczno-terapeutyczny i niejednokrotnie wymagają poszerzonego zakresu badań diagnostycznych. Dla lekarza praktyka konieczna jest wiedza w zakresie diagnostyki różnicowej oraz stała aktualizacja możliwości diagnostycznych w celu minimalizacji możliwości popełnienia błędu diagnostycznego, co oczywiście skutkować może wdrożeniem niewłaściwego postepowania terapeutycznego. Poniższa praca opisuje kilka przykładów klinicznych, z którymi warto się zapoznać, gdyż podobnych pacjentów spotkać możemy we własnej praktyce klinicznej.

IIn the first life decade acne and acne-like clinical patterns may occur quite frequently on the face of children, rarely on the integument.

The anatomy and function of the skin in newborns and infants and also up to about the 8th year of life in children the sebaceous apparatus is not fully developed. The Anlage for the sebaceous gland is microscopically to be seen, however, the missing stimulus of insulin growth factor and of DHEA (dihydrotestosterone) acting in the preadolescent period has not started to enlarge the sebaceous gland and to produce significant amounts of sebum. The follicular openings host the microbiota with only very low numbers of Cutibacterium acnes playing no inflammatory role at this time. The newborn and infant skin is more susceptible of getting superimposed by Malassezia furfur (Pustulosis cephalica benigna) in the first months of life, Candida species and Staphylococci and Streptococci (impetigo). Also the acrosyringeal openings can host microbes.

Differential Diagnoses

In general, the skin of neonates, infants and preadolescents can show almost all types of lesions which can be seen also in adolescents and adults, i.e. macules, papules, pustules, small nodules < 1cm, and nodules > 1cm.  Sinuses are rarely observed. Deposition diseases except those such as gangliosidoses or amyloidoses with and without inflammation are rare and, therefore, inflammatory infiltrates with neutrophiles, lymphocytes and macrophage patterns are usually those which contribute to the clinical picture. Non-sterile (pyoderma, mycotic infections, acne, viral infections, scabies) and sterile pustules (psoriasis, leukemia, drug-induced skin lesions) or macrophage or Langerhans cell or lymphocyte and mast cells, dominated cell infiltrates of systemic or primary cutaneous lymphomas or histiocytoses or mastocytosis or plasma cells (syphilis, borreliosis) dominate the papular or nodular pattern on the face.

Acne-like pattern diseases are composed of a variety of non-microbial origins to which, for example, belongs childhood perioral dermatitis. This is mostly provoked by inappropriate use of moisturizers with the appearance of a few small tiny pustules around the perioral area spreading to cheeks and periorbital areas. If, unfortunately, topical corticosteroids are used, the pattern becomes even worse and an additional candida superinfection may occur.

Rosacea is exceptionally rare but may come up in the preadolescent time. In this age the first formation of closed comedones in acne can be seen at the glabellar region spreading to the forehead and cheeks. The tiny small keratotic follicular pins of Ulerythema ophryogenes are a challenging differential diagnosis. Full body skin inspection is essential. Aggregated closed comedones, so called sandpaper type, should lead to a look for the upper arm surface for keratotic follicular casts and a case history of night blindness or color disturbances. 
It needs to be strongly underlined that such  dermatoses originating from  the Langerhans cell and Non-Langerhans cell histiocytosis types which may sometimes mimic severe acne infantum are of a very special importance. In such cases an exceptionally detailed case history, appropriate panel of blood tests, as well as skin biopsy, are absolutely necessary (see case 1 and 2, table 1 and 2). It is necessary to explain to the parents of our patient  that a small punch biopsy of 4mm will help us a lot  to clarify a  proper diagnosis because blood sampling alone or LN-ultrasound will not solve the problem of defining it. 

 

CASE I

Fot. 1. Benign cephalic self-healing Non-Langerhans cell histiocytosis of childhood,
clinical picture on the first day of hospitalization
Fot. 2. Clinical picture of the child 2 months a...

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