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Pruritic Axillary Papules



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Am Fam Physician. 2008 Jun 15;77(12):1735-1736.

A 27-year-old woman presented with pruritic papules in the right axilla that had persisted for five months. The lesions arose suddenly, and she denied a personal or family history of similar lesions. She had no history of skin disease. The patient's only medication was an oral contraceptive. She had not changed brands of deodorant or soaps recently.

On physical examination, the right axillary vault contained confluent, flesh-colored, firm, perifollicular papules, 2 mm in size (Figures 1 and 2). Some of the lesions were umbilicated with atrophic hairs. The skin in the surrounding area and on the left axilla, areolae, inframammary folds, and groin was normal. Her lipid panel was unremarkable.

Figure 1.

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Figure 1.


Figure 1.

Figure 2.

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Figure 2.


Figure 2.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Folliculitis.

B. Fox-Fordyce disease.

C. Lichen nitidus.

D. Miliaria rubra.

E. Syringomas.

Discussion

The answer is B: Fox-Fordyce disease. Fox-Fordyce disease (apocrine miliaria) is an uncommon chronic condition with characteristic clinical findings. Patients present with multiple small, firm, smooth, dome-shaped perifollicular papules in areas of apocrine sweat gland concentration. The papules are flesh-colored or have a slightly yellowish hue and occur, in decreasing order of frequency, in the axillae, groin, areolae, and inframammary folds.1

The condition predominantly affects post-pubescent women in their midteens through mid-30s. Rapid onset after exposure to hot conditions or after sweating is common. The chief complaint generally is intermittent, moderate-to-severe pruritus in the affected areas. The pathogenesis of Fox-Fordyce disease is poorly defined; however, the presence of a keratin plug in the follicular infundibulum, with apocrine duct rupture and spongiotic inflammation on histologic analysis, is characteristic.2

There are no reported cases of spontaneous resolution, and there is no known cure for Fox-Fordyce disease. Many treatment strategies have had poor success and include oral contraceptives; oral tretinoin; topical retinoids, antibiotics, and steroids; intralesional triamcinolone (Kenalog-10); ultraviolet light; and dermabra-sion.3 Irritation from topical retinoids generally limits long-term therapy. Successful treatment with clindamycin (Cleocin) in alcoholic propylene glycol solution has been reported.1,3 Surgical excision has been suggested for the treatment of recalcitrant cases.4 Because severe pruritus is often present and because of the nature and limitations of potential treatment modalities, dermatology consultation should be considered.

Folliculitis is characterized by tender perifollicular pustules with surrounding erythema. Lesions are caused by infection, mechanical trauma, or chemical irritation and may occur anywhere on the body surface.

Lichen nitidus appears as multiple and discrete pinpoint, pink or flesh-colored, flat-topped, round papules with a characteristic glistening appearance. These asymptomatic lesions typically occur on the genitalia, abdomen, or extremities.5

Miliaria rubra, also known as prickly heat or heat rash, occurs in susceptible persons as a result of eccrine sweat duct occlusion. Small, diffuse papules and vesicles with surrounding confluent erythema appear suddenly in occluded areas during sweating, such as with physical exertion. There is no follicular association, and patients may describe a “prickly” sensation.6

Syringomas are benign, flesh-colored or white-yellow, flat-topped papules that typically occur on the lower eyelids or vulva. The lesions are asymptomatic, arise gradually, and slowly increase in number.7

Summary Table

Condition Characteristics

Folliculitis

Tender perifollicular pustules with surrounding erythema

Fox-Fordyce disease

Firm, dome-shaped, perifollicular, skin-colored or yellowish, pruritic papules

Lichen nitidus

Multiple and discrete pinpoint, pink or flesh-colored, flat-topped, asymptomatic papules with a glistening appearance

Miliaria rubra

Small, diffuse papules and vesicles with surrounding confluent erythema

Syringomas

Asymptomatic, yellowish, flat-topped papules; typically occur on the lower eyelids or vulva

Summary Table

View Table

Summary Table

Condition Characteristics

Folliculitis

Tender perifollicular pustules with surrounding erythema

Fox-Fordyce disease

Firm, dome-shaped, perifollicular, skin-colored or yellowish, pruritic papules

Lichen nitidus

Multiple and discrete pinpoint, pink or flesh-colored, flat-topped, asymptomatic papules with a glistening appearance

Miliaria rubra

Small, diffuse papules and vesicles with surrounding confluent erythema

Syringomas

Asymptomatic, yellowish, flat-topped papules; typically occur on the lower eyelids or vulva

Address correspondence to Donald P. Kineston, LT, MC, USN, at dkineston@yahoo.com. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Naval Service at large.

REFERENCES

1. Feldmann R, Masouyé I, Chavaz P, Saurat JH. Fox-Fordyce disease: successful treatment with topical clindamycin in alcoholic propylene glycol solution. Dermatology. 1992;184(4):310–313.

2. Böer A. Patterns histopathologic of Fox-Fordyce disease. Am J Dermatopathol. 2004;26(6):482–492.

3. Miller ML, Harford RR, Yeager JK. Fox-Fordyce disease treated with topical clindamycin solution. Arch Dermatol. 1995;131(10):1112–1113.

4. Ghislain PD, van Der Endt JD, Delescluse J. Itchy papules of the axillae. Arch Dermatol. 2002;138(2):259–264.

5. Lichen nitidus. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008.

6. Acne, rosacea, and related disorders. In: Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, Pa.: Mosby; 2004:205.

7. Benign skin tumors. In: Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, Pa.: Mosby; 2004:721.

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