1. DISEASES OFSEBACEOUS GLANDS and SWEAT GLANDS By: Dr.
Faraedon Kaftan College of Medicine Sulaimani University L2 2011 -
2012
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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.
8. 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
9. (A) Normal follicle;(B) open comedo (blackhead);(C) closed
comedo (whitehead);
10. 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) .
11. 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.
12. 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)
13. 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 (caf au lait macules
& the cysts are more soft)Cystic , Black dot and Keloidal acne
papulo-pustular and scarring acne
14. 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)
15. 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:
16. 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
17. 11- ACNE ROSACEA Erythema of the face usually has the
appearance of butterfly where papules are embedded in the
erythematous patches of the face.
18. 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
19. 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.
20. 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.
21. 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 Cushings disease, adrenogenital
syndrome and the polycystic ovarian syndrome are associated with
acne besides the other systemic manifestations.
22. 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.
23. 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.
24. 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.
25. 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
26. 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.
27. 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.
28. 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.
29. 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.
30. 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
31. 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
32. 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
33. 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
34. 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
35. 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
36. 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:
37. 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.
38. 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.
39. 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
40. 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.
42. 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)
43. 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.
44. 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.