Pressure-induced facial follicular papules: 15 cases of an under-recognised dermatosis

Sir,

Repetitive prolonged pressure and friction results in cutaneous changes such as knuckle pads from boxing and prayer sign on the forehead. Relieving pressure/friction is an important element of treatment. The association with pressure appears under-recognised in a follicular facial eruption leading to inadequate management. We describe 15 patients with this distinctive eruption that, once identified, can be easily treated by a simple change in posture.

We evaluated ten men and five women, aged 10–59 years who presented to the department of dermatology at the All India Institute of Medical Sciences, New Delhi, with asymptomatic, hyperpigmented papules on the face that appeared insidiously over a period of two months to 20 years.

There were tiny, closely aggregated keratotic papules on a background of ill-defined dark brown pigmentation [Figure 1]. In three patients, there were a few slightly larger, yellowish-white to dark brown comedones. Papules were noted on the cheek in eight (53.3%) patients, chin in four (26.6%), left mandibular jawline in two (13.2%) and both the jawline and neck in one (6.6%). The eruption was bilateral in two and unilateral in nine patients with the left side affected in eight and the right in one; it was located centrally on the chin in the remaining four patients [Table 1]. All patients were right handed.

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Figure 1a:

Demonstrating the resting position of face against palm (Case 6)

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Figure 1b:

Demonstrating the resting position of face against palm (Case 8)

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Figure 1c:

Follicular papules and pigmentation at the corresponding site (Case 6)

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Figure 1d:

Follicular papules, pigmentation and slight thickening of skin at the corresponding site (Case 8)

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Seven (46.6%) patients had a history of atopy; there were no other cutaneous or systemic illnesses. Thirteen (86.7%) patients were in the habit of resting their face on their hand for long periods while studying or watching television. In all these patients, the papules corresponded exactly to the area of the face that rested on the palm.

Dermoscopy was done in four patients, out of which two revealed coiled hair shafts in the affected area. There were no follicular plugs. Two patients consented for skin biopsy. The histopathological findings included focally compact hyperkeratosis, papillomatosis and mild acanthosis with one biopsy showing a keratotic follicular plug [Figure 2].

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Figure 2a:

Case 9: Polarized dermoscopy(×10) showing ill-defined area of yellowish to dark brown discolouration in the centre surrounded by a zone of light brown pigmentation and mild erythema and multiple coiled hair shafts in the affected area

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Figure 2b:

Biopsy from a keratotic papule showing focally compact hyperkeratosis, papillomatosis, mild acanthosis and follicular plugging (haematoxylin and eosin, ×100)

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All patients were advised to stop resting their face on their hand and prescribed topical tretinoin 0.05% for application at night. There was near complete resolution in patients who were compliant with instructions [Figure 3 and Table 1].

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Figure 3a:

Multiple tiny, closely aggregated follicular papules involving the left jawline, at the baseline

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Figure 3b:

Marked improvement after 6 months of application of tretinoin (0.05%) cream and avoidance of friction (Case 5)

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The development of grouped follicular papules exclusively on portions of the face rested on the palm for several hours a day with resolution when posture was changed provides strong evidence for prolonged pressure as the cause of this eruption. Patients rested their face on the hand in slightly different ways and this resulted in papules at different places but the distribution always corresponded to the site of contact with the palm. These papules lacked erythema and were monomorphic, unlike acne where pustules, comedones and/or inflammatory papules can be seen. In the initial few cases, the differentials of keratosis pilaris, lichen spinulosus and trichostasis spinulosa were considered.

Padilha-Goncalves described traumatic anserine folliculosis, a similar eruption in 11 patients who had a history of prolonged friction on the chin, jawline and neck. Patients were aged four–21 years and the author suggested that the delicate skin of adolescents was predisposed to the effects of chronic friction,¹ though we saw the eruption in older people, too. The condition is probably not uncommon as we saw 15 patients over a period of nine months in our department.^1-11

Interestingly, patients readily accepted the explanation of pressure/friction when it was pointed out to them but they were not themselves aware of the causal relation. Removal of pressure, along with a topical retinoid or keratolytic agent, led to gradual resolution over several weeks.