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Case Note

Case note: Rash

History

18-year-old healthy female with a family history notable for atopic dermatitis and allergic rhinitis presents for evaluation and management of long-standing “rash” on bilateral posterior arms, which is an asymptomatic rash. Her primary concern is the cosmetic appearance.

Initial evaluation

  • Generalized xerosis
  • Bilateral posterior arms: monomorphous, closely set 1 mm hyperkeratotic non-inflammatory papules with a central spicule overlying a faintly erythematous patch
  • No pustules present
     
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of non-inflammatory keratosis pilaris is rendered

Initial Treatment

  • Recommendation: mechanical exfoliation with washcloth daily in the shower, followed by daily application of 20% urea cream
  • Gentle skin care reviewed and educational handout provided to patient

Follow-up evaluation strategy

Further to the case in question, general evaluation and treatment for keratosis pilaris is provided below.

After the keratinous plugs have been removed, use of an emollient cream containing 20% urea (Carmol) may prevent reappearance of lesions. Use of the abrasive scrub pad should be resumed at the first sign of reappearance of crops of new lesions. Patient education on gentle skin care, including discussion of bathing, mild soaps, and lubrication also should be taught; keratosis pilaris is almost invariably associated with xerosis, and xerosis may, in fact, predispose to exacerbations of keratosis pilaris.

General discussion

Keratosis pilaris is an extremely common, often autosomal dominantly inherited disorder that usually does not require treatment and is most frequently seen in association with atopic dermatitis. The classic skin lesions are small, monomorphous, hyperkeratotic papules with a central spicule, often with an erythematous base or overlying an erythematous patch. On biopsy, these lesions are characterized by keratinous follicular plugging with orthohyperkeratosis to create a follicular spicule.

Typical sites of involvement include facial cheeks, upper posterior arms, lateral thighs, and buttocks, and involvement is almost always bilateral and symmetric. Involvement of the face and upper arms may be a significant cosmetic problem for patients, and frictional folliculitis can complicate keratosis pilaris on the buttocks and thighs.

Folliculitis may present as development of increased erythema or pustules in the affected area. Since keratosis pilaris is a benign and non-curable skin condition, long-term management is the mainstay of the therapeutic strategy; cosmetic improvement and reduction of inflammation are the primary therapeutic goals.

Keratosis pilaris may be seen in association with other cutaneous features suggestive of a genetic syndrome with either cutaneous-only or systemic involvement (such as cardiofaciocutaneous syndrome). Keratosis pilaris rubra is a relatively common variant of keratosis pilaris with highly inflammatory keratosis pilaris lesions that primarily involves the cheeks, sometimes with extension of lesions onto the forehead and chin. A rarer variant is keratosis pilaris atrophicans faciei, a form that presents in infancy and is marked by atrophic lesions of the lateral eyebrows, sometimes with scarring alopecia. The latter variant is notable because it may present as an idiopathic form or in association with genetic syndromes, such as Noonan syndrome, Cornelia de Lange, syndrome Rubenstein-Taybi syndrome, as well as others

Further reading

Alcantara Gonzalez J, et al. Keratosis pilaris rubra and keratosis pilaris atrophicans faciei treated with pulsed dye laser: report of 10 cases. JEADV 2010;25:710-4.

Breithaupt AD, et al. A comparative trial comparing the efficacy of tacrolimus 0.1% ointment with Aquaphor ointment for the treatment of keratosis pilaris. Ped Derm 2011;28(4):459-77.

Clark SM, et al. Treatment of keratosis pilaris atrophicans with the pulsed tunable dye laser. J Cutan Laser Ther 2000;2:151-6.

Kaune KM, et al. Successful treatment of severe keratosis pilaris rubra with a 595-nm pulsed dye laser. Derm Surg 2009;35:1592-5.

Marqueling A, et al. Keratosis pilaris rubra: a common but underrecognized condition. Arch Derm 2006;142:1611-6.

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