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Study Letter
88 (
3
); 419-422
doi:
10.25259/IJDVL_1_2020
pmid:
35434990

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

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
Corresponding author: Prof. M. Ramam, Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. mramam@hotmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Dev T, Balaji G, Mehta N, Ramam M. Pressure-induced facial follicular papules: 15 cases of an under-recognised dermatosis. Indian J Dermatol Venereol Leprol 2022;88:419-22.

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.

Figure 1a:: Demonstrating the resting position of face against palm (Case 6)
Figure 1b:: Demonstrating the resting position of face against palm (Case 8)
Figure 1c:: Follicular papules and pigmentation at the corresponding site (Case 6)
Figure 1d:: Follicular papules, pigmentation and slight thickening of skin at the corresponding site (Case 8)
Table 1:: Clinical features and treatment response of patients
Age (year) Gender Site involved Duration Occupation Activity associated with prolonged pressure History of atopy Duration of treatment Improvement (%) Duration of follow-up
17 F Chin One year Student Studying Yes NA NA Baseline
18 M Left cheek Six years Student Studying, watching television No Six months Nearly complete Six months
19 F Chin Five years Student Studying, general posture while conversing Yes Six months Complete Six months
21 F Chin Four months Student Listening to lectures No NA NA Baseline
27 F Left mandibular area Two years Student Studying, watching television Yes Six months Nearly complete Six months
29 M Left cheek Two years Student Studying, watching television No Three months Marked Three months
30 M Left cheek Six years Student Studying, reading, watching television No One month Slight One month
59 M Left mandibular area 20 years Professor Studying, reading No Two weeks Marked Six months
12 F Left mandibular area, left side of neck Two months Student Studying, watching television Yes One month Marked One month
21 M Left cheek Two years Medical student Studying Yes NA Marked One month
22 M Left cheek One year Student Studying NA One month Marked One month
22 M Cheeks, more on left Ten years Student Studying, watching television Yes One month Marked One month
10 M Chin One year Student None reported No One month Marked One month
27 M Cheeks, more on right Three years Student Studying Yes NA NA Baseline
17 M Right cheek One year Student None reported No NA NA Baseline
NA: Not available

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].

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
Figure 2b:: Biopsy from a keratotic papule showing focally compact hyperkeratosis, papillomatosis, mild acanthosis and follicular plugging (haematoxylin and eosin, ×100)

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].

Figure 3a:: Multiple tiny, closely aggregated follicular papules involving the left jawline, at the baseline
Figure 3b:: Marked improvement after 6 months of application of tretinoin (0.05%) cream and avoidance of friction (Case 5)

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.

Acknowledgement

None.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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