dermatology. disorders of sebaceous and sweat glands.(dr.faraydwn)
DISEASES OFSEBACEOUS GLANDS and SWEAT GLANDS By: Dr. Faraedon Kaftan College of Medicine Sulaimani University L2 2011 - 2012
DISEASES OF SEBACEOUS GLANDSsebaceous gland: holocrine glands in the skin that secrete sebumusually through the hair follicles.1- Sebaceous hyperplasia2- Adenoma sebaceum (Sebaceous adenoma)3- Sebaceous cyst (Epidermoid cyst)4- Acne5- Sebaceous gland carcinoma1- Sebaceous hyperplasia• sebaceous glands enlarge & produce yellow, shiny bumps (papules), cauliflower -shaped on the face, affects newborns & middle-aged to elderly adults
2- Adenoma sebaceum (Sebaceous adenoma): Epiloia (tuberous sclerosis):• is a noncancerous slow-growing tumor (angiofibroma) of an oil- producing gland• Red. pink, flesh-coloured, or Yellow papules or nodules on the face, scalp, belly, back, or chest.• It is associated with tuberous sclerosis (Epiloia): is a genetic disorder that affects the brain/nervous system (Seizures), kidneys, and heart, and cause tumors to grow.• (Epiloia): Epi=epilepsy, loi=low intelligence, a=adenoma sebaceum
Skin signs in Tuberous sclerosis (Epiloia):• Adenoma sebaceum: (angiofibroma): Red papules on the face containing many blood vessels• Cafe-au-lait spots• Shagreen spots: Raised patches of skin with an orange-peel texture often on the back• Ash leaf spots: White areas of skin that look like an ash leaf
3- Sebaceous cyst (Epidermoid cyst)• Epidermoid cyst originates in the epidermis and a pilar cyst originates from hair follicles, but neither type of cyst is strictly a sebaceous cyst• The fatty, white, semi-solid material in both cysts is not sebum, but keratin, and under the microscope neither entity contains sebaceous glands.• "True" sebaceous cysts are known as steatocystomas or, if multiple, as steatocystoma multiplex.Steatocystoma multiplex Epidermoid cyst
4- Acne:• is a chronic inflammatory disease of the pilosebaceous follicles.• is rare in children and old age.• The sites involved are the seborrheic areas rich in sebaceous glands mainly face, upper chest , back and the shoulder areas.• The usual types of acne occur after puberty. Pilosebaceous follicle
Etiology1- Increase in the activity of sebaceous glands (↑ sebum) and occlusion of the pilosebaceous orifices are the main factors of acne pathogenesis.2- Hormones :• Androgens ↑ the activity of sebaceous gland in both sexes.• Estrogens antagonize the effect of androgens.• ACTH ↑s the activity of the sebaceous glands due to its stimulation of production androgens.3- Infections: Corynebacterium (Propionibacterium) acnes and staphylococci are considered important in the pathogenesis of acne.4- Diet: The effect of diet is variable. Some types of diet such as high carbohydrate, fatty foodstuffs, chocolate, diets rich in iodides such as seafood may have some effect on exacerbation and not the pathogenesis of acne in certain individuals.5- Drugs: acniform eruption results due to different systemic and topical medications. Tetracyclines , corticosteroids, certain vitamins with mineral supplements such as iodides may be accompanied by acniform eruptions.6- Stress and lack of sleep may have some role.
Pathogenesis: formation of acne1- Increased activity of sebaceous glands with production of excess sebum plays an important role2- Occlusion of the pilo sebaceous orifices plays an important role2- Hormones : Increased activity of sebaceous glands and occlusion of the cornfied hypertrophic pilosebaceous follicles lead to retention of sebum into the follicles, which dilate and rupture by time.3- Anaerobes such as Corynebacterium (Propionibacterium) acne, Pityrosporon ovale and Staphylococci cause split of the sebum into fatty acids and triglycerides which act as an important irritating factors & → to the formation of the different clinical types of acne which varies from papules, pustules ,cysts and comedones
(A) Normal follicle;(B) open comedo (blackhead);(C) closed comedo (whitehead);
CLINICAL TYPES OF ACNE1- NEONATAL ACNE• begins shortly after birth as small papules on the seborrheic areas mainly on the forehead and cheeks• There is usually a family history of severe acne .• The condition resolves spontaneously within few weeks .• Rx: antiseptic lotions (Clindamycin or Erythrocin topically) .
2- JUVENILE ACNE• mainly males, facial acne at around 3 months - 5 years of age .Etiology• Transplacental stimulation of the adrenals.• Drugs• Virilizing tumour or congenital adrenal hyperplasia.Treatment• Erythromycin 125 mg 3 times daily.• Topical preparations: erythromycin or Clinamycin lotion.
3- Acne vulgaris (common): (POST-PUBERTAL ACNE)• is a common human skin disease, the commonest type of acne & characterized by areas of skin with Seborrhea (scaly red skin), Comedones [blackheads: (open) & whiteheads: (closed)], Papules (pinheads), Pustules (pimples), Nodules (large papules) and possibly scarring• affects mostly skin with the densest (high density) population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back.• is of 2 types inflammatory (severe) & noninflammatory• occurs most commonly during adolescence, and often continues into adulthood, in adolescence usually caused by an increase in testosterone, which people of both genders accrue (gain) during puberty.• For most people, acne diminishes over time and tends to disappear or decrease after one reaches early twenties, there is no way to predict how long it will take to disappear entirely, and some individuals will carry acne well into their thirties, forties & beyond.• main effects are: scarring & psychological (reduced self-esteem & depression or suicide)
4- NODULAR (CYSTIC) ACNE• Cysts containing thick , viscid or blood tinged fluid .• The most common sites involved are the face and the back• DD: cysts of neurofibromatoses (café au lait macules & the cysts are more soft)Cystic , Black dot and Keloidal acne papulo-pustular and scarring acne
5- ACNE CONGLOBATA• is a severe type of acne that may affect the face and back.• The lesions are boggy and heal in some cases by scar formation• more common in girls.6- SOLAR ACNE (senile comedones)• in elderly people, especially in the periorbital areas.• Due to high exposure to UV radiation (solar damage)
7- DETERGENT ACNE• Uncommon, occurs in patients who wash many times daily• Certain bacteriostatic soaps contain weak acnegenic compounds8- ACNE KELOIDALIS• due to pyogenic infection of the sebaceous glands leading to more destruction and disfiguration of tissues with formation of keloids.Acne keloidalis nuchae:
9- ACNE EXCORIATA• is common in neurotic patients, who play by picking or squeezing the lesions.• may lead to crust and pitted scarring.10- TROPICAL ACNE• Hot humid environment leads to excessive sweating.• Occlusion of the pores of the sweat glands leads to miliaria
11- ACNE ROSACEA• Erythema of the face usually has the appearance of butterfly where papules are embedded in the erythematous patches of the face.
12- ACNIFORM ERUPTIONS• Red papules mainly (and to lesser extent pustules) simulating acne vulgaris• Lesions appear suddenly.• Lesions are not necessarily located on the seborrheic areas but may be distributed on the chest ,trunk and extremities.Drugs & factors may cause acniform eruption are:• Tetracycline, Minocycline, Doxycycline and Cs.• Topical corticosteroids especially when occluded.• Iodides and bromides in vitamins and mineral supplements• isonicotine hydrazine (INH), ACTH, Chloral hydrates and pro-banthin• Chemicals: Chloracne, which is due to excess chlorination of swimming pool.• Chloronaphthalines, cutting oils, crude coal tar, petrol and its derivatives
13- ACNE FRONTALIS (Acne necrotica)• Follicular papulopustules appear on the forehead which has a central depressed surface due to central necrosis.• may heal with pitted scars resembling the late lesions of Variola (Acne varioliformis)14- MECHANICAL ACNE• is due to physical trauma, which may lead to licheinification , occlusion of the pilo sebaceous orifices and pigmentation.• Tight caps especially in young babies and children, pressing bands and headgears.• Head bands and tight under wears are other causes.• Continuous friction from turtleneck sweaters may localize acne to the neck.
15- ACNE SCAR:• acne is accompanied by severe scarring due to: - secondary bacterial infection, - repeated playing in the lesions - excoriations in neurotic patients.16- IMMOBILITY ACNE• Adolescent patients lying in bed for a long time, as in the orthopedic ward, due to a change in the environment of the skin, which may enhance bacterial colonization of the duct.
17- COSMETIC ACNE• Due to continuous use of cosmetic creams and powders and kept for a long time without cleaning and removal.• Preparations containing lanolin, petrolatum, certain vegetable oils, butylstearate, lauryl alcohol and oleic acid, are comedogenic.• Grease that is applied to the scalp may cause acne Cosmetic acne & contact dermatitis (Clindamycin)18- ENDOCRINE ACNE• Endocrine abnormality such as Cushing‘s disease, adrenogenital syndrome and the polycystic ovarian syndrome are associated with acne besides the other systemic manifestations.
19- OCCUPATIONAL ACNE• workers in petrol products as those who wash cars, drivers, and mechanics may have acniform eruption.• Cutting oils, industry of chlorine , bromine and swimming pools maintenars as well.
TREATMENT OF ACNE• Dealing with acne lesion is simple & very difficult at the same time• Too many preparations (pharmaceutical, cosmetic, herbal, traditional, over the counter, & body shop preparations are available and the patients are some times confused and shift from one medication to another by himself , according to the advice of others and prescriptions from different centers. In most cases such patients will loose a lot of time , money and have their lesions usually exacerbated or accompanied by unwanted complications.• Playing in lesion and spending a long time looking in mirror and trying to squeeze the pimples or pustules may lead to hazardous effect complicated by scars.• Cosmetics (powders, creams and others used as camouflage ), & sun blocks especially if left for a long time) lead to occlusion of the pilosebaceous orifices leading to more complications. Hot humid environment should be avoided if possible.• Excessive washing of the affected areas may do harmful effects, especially if certain detergents are used.• Facial cleaning and peeling should be done by professionals• Irritating diet should be avoided.• sunlight may have a good beneficial effect on acne lesion.
Active Treatment: Topical & systemic medicationsA- Topical medications• Washing the area once or twice daily with mild anti seborhea soap• Erythrocin lotion, Clindamycin lotions (Dalacin lotion) are usually effective in pustular acne.• Benzyl peroxide is effective medication but there is possibility of irritation.• Retinoic acid preparations such as (Retin A gel or cream).B- Systemic MedicationsJuvenile acne: Erythrocin suspension can be used .• systemic medications (used in the adults) are not indicated for children.Adult acne: Different systemic medications are used in adults.• The type of medication depends on the severity of the lesion , age and sex.• The cause of acne should be discussed and the potential success of therapy be highlighted.• Mild acne requires only topical therapy.• moderate or severe acne needs both oral and topical therapy besides other lines of medical and cosmetic procedures.
1- Oral antibiotics: given for 6 months with topical therapy & they are:Tetracycline: are bacteriostatic- 250mg X 4 daily for 10 days and the dose is reduced to twice daily for 20days then a single daily dose may be given for 1-6 months.- decreases the split of fats to fatty acids and triglycerides- inhibits enzyme activities, affects chemotaxis & lymphocyte functions.- Care should be taken for the side effects of tetracycline.- tablet should be taken with water (not milk) half an hour before foodErythromycin: is effective in young age and the childbearing age in females.Azitromycin is effective medication but more expensive than erythromycinDoxycycline tablets or capsules (100mg/day) and minocycline (100mg/day) areeffective medications but they are more expensive.Trimethoprim (400-600 mg/day) is a third-line antibiotic.Clindamycin: Its risk is pseudomembranous colitis
2- Oral Contraceptives (OCs): Hormonal Therapy:• are effective in the management of mild & moderate acne vulgaris, as elevated levels of androgens in acne patients are underlying pathophysiological factor.• All low dose OCs reduce serum free testosterone (T) to a similar extent.• Anti androgens such as Diane may be effective in controlling severe acne lesions in young girls.• Cyproterone acetate (CPA) (2 mg) combined with 50- microgram ethinyl oestradiol• Dianette (35 micro g. ethinyl estradiol and 2 mg CPA) appears to be of value in women with acne resistant to other therapies.• Oral spironolactone 100-200 mg for 6 months, is of considerable benefit in old females.
3- Isotretinoin: (Isotroin: Roacutane: Retane: 13-Cis retenoic acid)* is more effective than Diane for acne patients, in mild, moderate or severe acne* precautions, SEs and C/I should be always taken into consideration before its use* produces a striking benefit & is superior to other treatment* is teratogenic & (females using the drug should use contraception.* The precautions and contra-indications especially in adult females should be strictly considered as fetal abnormalities and other complications may occur.* pregnancy should be at least after 1 or 2 ms after stopping the drug.* Pregnancy test should be negative before using isotretinoin.* dose of is 0.5 -1.0 mg/kg for younger patients & for a period of 4 months.* influences all the major factors involved in acne in doses of 0.5-2.0mg/kg .* Each Isotretinoin capsule is 20 mg.Action of Isotretinoin:1- Reduces sebum secretion.2- The populations of of P. acnes fall gradually & ductal cornification.3- Stimulates the T-helper cells, increase in Igs (IgE) and reduces chemotaxis.4- Has effect on bacteria, ductal corneocytes & inflammation & comedon formation5- interfers with endogenous vitamin A metabolism.
Treatment of Post Acne Scars1- Peeling: by fruit acids such as 10% Glycolic acid for superficial scars and superficial wrinkles .2- Ultraviolet light is useful in some cases especially in mixed acne lesions of papules and pustules. PUVA can induce superficial peeling leading to improvement of skin lesions.3- Surgical repair or local collagen injection or fat tissue for deep scars.
4- Laser skin resurfacing by CO2 Laser (recently) to smoothen and correction of superficial scars.5- Dermabrasion: a technique, done with a rotating brush applied on the scars.
DISEASES OF THE SWEAT GLANDSDiseases of Eccrine sweat glands: 1- Hyperhidrosis 2- Anhidrosis 3- MiliariaEccrine sweat glands can be seen under usual microscope whileApocrine sweat glands are seen under electron microscope
1. HYPERHIDROSIS• is an abnormal increase in the amount of sweat in the eccrine sweat glands.• Types:1- Generalised hyperhidrosis: factors affect the eccrine sweat glands and increase their sweat production: A- Physiological hyperhidrosis: emotional, hot humid environment, work or exercise. B- Pathological hyperhidrosis:• Febrile illnesses.• Endocrine problems: hyperthyroidism and diabetes.• Trauma to the brain or inflammatory conditions of the hypothalamus• Drugs: sympathomimetic drugs and others that can affect the hypothalamus2- Localized hyperhidrosis: is very common, mainly affects palms, soles and axilla
Treatment of Hyperhidrosis• Reassurance and psychotherapy in the emotional Hyperhidrosis.• Anticholinergic drugs• Sedatives: Benadryl or other types of mild sedatives• Synthetic analogues of atropine such as Banthin and Probanthin have temporary inhibitory effect of sweat .The side effects as some patients may not easily accept, are dryness of mouth, blurring of vision with higher doses.• Antihistamine: Cyproheptadine or Citrizine.• Topical preparations: Most antiperspirants contain aluminum salts• Astringents: Palm and foot soaks with: Potassium permanganate 1: 2000
• Powders: used for dusting of the feet and the interdigital spaces to minimize sweating in localized hyperhidrosis as :R/x• Aluminum chloride 3• Potassium alum 10• Salicylic acid 3• Starch 5• Talc powder 100• Botulinum toxins: Botox: for severe palmer hyperhidrosis.• Aluminum-chloride hexahydrate 25% (driclor) in absolute ethanol can give effect in axillary hyperhidrosis.• Iontophoresis: treatments of the hands and feet. No drugs, no surgery, no needles, Mild electrical current is passed down high quality cables to the treatment electrodes which are placed into trays filled with tap water, it slows down secretion at the gland
POMPHOLYX (Dyshidrosis) (dyshidrotic eczema):is a deep seated vesicular eruption (sago grains) of the palms & soles (bilateral around the fingers & toes) .Treatment• Treatment of the cause: hyperhidrosis or infections.• Potassium permanganate 1: 8000 soaks are effective for the hands and feet.• Topical Cs cream alone or in combination with antibacterials
2. ANHIDROSISmeans absence of sweating in the eccrine sweat glands due todefect in production or conduction of sweat to the skin surfaceTypes of anhidrosis:1- Generalised anhidrosis: occurs in: Miliaria, Congenital ectodermal defects, Orthostatic hypotension, Diabetic neuropathy, Multiple myeloma, Thyrotoxicosis, Myxedema & Pemphigus2- Segmented type of anhidrosis:Treatm: General measures: Avoid vigorous exercise, Avoidexposure to hot environment & Air-condition and humidifiers
3. MILIARIA (SWEAT RETENTION):• in children and older age groups is due to interference in free delivery of sweat to the skin surface.• Occlusion of the sweat ducts pores by keratin in response to epidermal injury may lead to rupture of the sweat glands• 4 types A. Miliaria crystallina: B. Miliaria rubra or prickly heat: C. Miliaria pustulosa: D. Miliaria profunda:
Types of miliaria:A. Miliaria crystallina: is due to occlusion of the sweat orifices and escape of sweat in the stratum corneum,• superficial & mildest type• numerous discrete vesicles with clear fluid, which ruptures easily.• little burning or stinging sensation in hot humid environment.
B. Miliaria rubra or prickly heat:• is the most common, especially in hot humid climates appearing on the back, chest, side of the abdomen, antecubital, popliteal fossa and in areas exposed to friction.• Erythematous papulovesicular rash causing itching and burning sensation due to leakage of sweat into the epidermis, where the severity depends on the heat load.
C. Miliaria pustulosa:• pruritic, discrete, superficial erythematous pustules with a dark punctum at the center corresponding to the hyperkeratotic plug occluding the sweat orifice.• The common sites: intertriginous areas and the flexural surfaces of the extremities.• The contents of the pustules are sterile and it is formed due to intraepidermal sweat retention
D. Miliaria profunda: is due to deep poral occlusion and rupture of sweat ducts and escape of sweat into the epidermis at the dermo-epidermal junction.• Deep & severest type• non-inflammatory, non-pruritic and flesh colored papules where the severity of the lesion depends on the degree of sweating.• may be accompanied by systemic manifestations such as irritability, easily fatigue ; headache, anorexia, drowsiness and inability to concentrate due to heat intolerance.• Miliaria improves by cooling of the skin and the symptoms may disappear after a short time.
A- BROMOHIDROSIS: Malodorous sweat may occur in the axilla & feetCauses: Hyperhidrosis, Apocrine glands Dysfunction, Bacterial and fungalinfections, Fatty acids decomposition producing distinctive odor, Certainfoodstuffs such as garlic, onion and excessive protein ingestion & Heavymetals: arsenic.Treatment:• General cleaning of the body & frequent bathing.• Changing of socks and under wears repeatedly and using light clothes.• Avoid excess sweating.• Avoid certain types of food such as excess proteins, garlic, and spices.• Aeration of the area .• Dusting powders especially for the feet before dressing the socks.• Soaks for the feet such as potassium permanganate 1: 2000• Deodorants:• Antibacterial antiseptic soap (Cidal soap)
B- CHROMOHIDROSIS:• is colored sweat due to dysfunction of the apocrine glands.• The commonest site is the face, where the color of sweat may be black, green, blue or yellow.• The crural areas: a rusty stain may appear on the underwear.C- HIDRADENITIS SUPPURATIVA:• is chronic & recurrent infection of the apocrine sweat glands of the axilla & the inguinal areas.• Tender reddish nodule appears, firm that may cause an abscess with multiple openings on the skin surface and discharging pus.• Scarring may accompany severe cases.Treatment• Local compresses with potassium permanganate for oozing• topical antibiotics.• High doses of systemic antibiotics.• Incision and drainage of the abscess.• Cs: Chronic persisting localized cases may improve with steroid injections.
D- FOX-FORDYCE DISEASE• is a rare disease occurs mainly in young girls• Intense pruritic, small, flesh colored papules occur mainly on the axilla, mamma, umbilicus, perineum, labia• The papules may increase in size forming nodules with an empty follicular center.Treatment• is not always successful.• Estrogens and contraceptive pills may give improvement to itching and involution to the lesions.