In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermatology ViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis and therapeutic options.
History of present illness: A 61-year-old woman presented with chronic recurring episodes of erythematous and pruritic papulopustular eruptions on the inner thighs.
Prior treatment: none. Prior biopsy: none. Skin history: no history of skin cancer or gluten sensitivity. She routinely wears polyester-based pants.
Image Quality Asessment
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult. The image shows a bilateral erythematous papulopustular eruption with associated hyperpigmentation on the inner thigh area (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic for superficial bacterial folliculitis.
RECOMMENDATIONS
Skin Care Recommendations
Cleanse the skin with chlorhexidine twice a week (caution: avoid contact with the mucosal surfaces [e.g., eyes, ear, nose mouth, rectum, or vagina]) as it may cause irritation. Recommend refraining from razor shaving for 30 days. Apply warm compress 3-4 times a day for 15 minutes at a time with dilute vinegar soaks (1:80 ratio, three tablespoons of vinegar in half a gallon of water; Lee & Jacob, 2017). Wear absorbent cotton clothing.
Medication Recommendations
Apply topical triple antibiotic ointment twice a day for 5 days. Do not use longer than 1 week unless directed by a licensed medical practitioner.
CLINICAL PEARL
Folliculitis is a hair follicle inflammation often characterized by small perifollicular papules or pustules (Burris et al., 2018). Histologically, it is defined as the presence of inflammatory cells within the walls and ostia of the hair follicle, resulting in a follicular-based pustule (Satter, 2019). In acute cases, the inflammation can manifest as multiple discrete folliculocentric papulopustules, whereas chronic cases can exhibit hyperkeratosis and keratotic plug formations (Luelmo-Aguilar & Santandreu, 2004). Any hair-bearing site can be affected. It is most commonly seen on the face, scalp, thighs, axilla, and inguinal area. Patterned folliculitis can also occur in areas that are well shaved or occluded (Satter, 2019).
Folliculitis can be superficial or deep. The pilosebaceous unit is divided into three compartments: the superficial infundibulum, the middle isthmus, and the inferior stem and hair bulb (Luelmo-Aguilar & Santandreu, 2004). Superficial folliculitis is inflammation restricted to the infundibular segment of the follicle, whereas deep folliculitis, which can eventuate from chronic superficial folliculitis, extends inferiorly into the surrounding dermis and often results in scarring (Satter, 2019).
Bacteria, such as Staphylococcus aureus, fungi, viruses, or parasites are common causes of infectious folliculitis. Predisposing factors to cutaneous infections include chronic antibiotic use, other pruritic skin disorders, topical corticosteroids, exposure to contaminated waters such as in hot tubs, immunodeficiency conditions or immunosuppressive treatments, shaving against the direction of hair growth, or occlusive clothing (Burris et al., 2018). The presence of superficial pustules does not always imply an infectious origin. Noninfectious etiologies are most commonly from follicular trauma, inflammation, occlusion, drug- or chemical-induced folliculitis, eosinophilic pustular folliculitis, and folliculitis decalvans (Burris et al., 2018; Satter, 2019).
Diagnosis is typically made based on history and physical examination findings. However, laboratory investigations are used in cases resistant to standard therapy (Satter, 2019). Laboratory investigation include a routine swab and gram stain of the pustule content to test for bacterial or viral folliculitis. In some cases, polymerase chain reaction can be used to diagnose viral folliculitis as well. In the case of herpetic viral folliculitis, a Tzanck smear can be used. Scrapings can be used for fungal culture, and a potassium hydroxide preparation can identify yeast or candida (Luelmo-Aguilar & Santandreu, 2004).
Skin care recommendations include cleansing the area with antibacterial soap and refraining from shaving for 30 days. Standard treatment includes application of warm compresses 3-4 times a day for 15 minutes and a topical antibiotic to the affected area.
NURSING PERSPECTIVE
Folliculitis is a very common condition that can easily be identified and diagnosed by the healthcare team. Most folliculitis cases are self-limiting and will resolve on their own with proper hygiene and home care. The nursing role of patient education in this condition cannot be overstated. Although a relatively benign condition, the proper involvement of an interprofessional team approach to the diagnosis and management of folliculitis is essential for producing better patient outcomes (Winters & Mitchel, 2019).
REFERENCES