What is the etiology of small pustules on the face?

From the Guidelines

Small pustules on the face are most commonly caused by acne vulgaris, which results from clogged hair follicles with oil and dead skin cells, leading to inflammation and bacterial growth (primarily Cutibacterium acnes) 1.

Etiology of Small Pustules on the Face

The etiology of small pustules on the face can be multifactorial, involving:

• Follicular hyperkeratinization
• Microbial colonization with Cutibacterium acnes
• Sebum production
• Complex inflammatory mechanisms involving both innate and acquired immunity
• Neuroendocrine mechanisms
• Genetic and nongenetic factors Other potential causes include rosacea, folliculitis, perioral dermatitis, contact dermatitis, or less commonly, fungal infections.

Risk Factors

Risk factors for acne development include:

• Increasing age during adolescence
• Family history of acne
• Oily skin type

Treatment

Treatment depends on the specific cause but often includes topical medications like benzoyl peroxide (2.5-10% strength), retinoids (tretinoin 0.025-0.1%), or antibiotics (clindamycin 1%) 1. For moderate to severe acne, oral medications may be necessary, including antibiotics (doxycycline 100mg twice daily for 2-3 months), hormonal treatments for women (combined oral contraceptives or spironolactone 25-100mg daily), or isotretinoin (0.5-1mg/kg/day for 4-6 months) for severe cases.

Good Skincare Practices

Good skincare practices are essential, including:

• Gentle cleansing twice daily with a mild, non-comedogenic cleanser
• Avoiding picking or squeezing pustules
• Using oil-free moisturizers The development of these pustules involves excess sebum production, often triggered by hormonal fluctuations, which creates an environment where bacteria can thrive, leading to inflammation and the characteristic pustules 1.

Rosacea

Rosacea is a chronic inflammatory disease of the skin predominantly affecting the centrofacial region, with a complex pathophysiology involving dysregulation of the innate and adaptive immune system, and potential trigger factors such as Demodex and ultraviolet radiation exposure 1. Rosacea may be difficult to diagnose in patients with darker skin tones, and its diagnosis is often overlooked, especially in children who may present with chronic recurrent keratoconjunctivitis, phlyctenules, punctate erosions, keratitis, meibomian gland dysfunction (MGD), or recurrent chalazia and have subtle signs of rosacea 1.

Ocular Rosacea

Ocular rosacea is a condition that affects the eyes, with characteristic features including blepharitis, blurred vision, foreign body sensation, interpalpebral bulbar hyperaemia, photophobia, redness, tearing, and telangiectasia 1. Referral to an ophthalmologist should be considered for greater severity of ocular rosacea that cannot be controlled with lid hygiene.

Recommendations

Treatment for inflammatory papules/pustules should vary by severity, and for phyma, treatment should depend on whether it is clinically inflamed (‘active’) or clinically noninflamed (‘fibrotic’ or ‘burnt out’) 1.

From the FDA Drug Label

Dermatologic: Dermatitis bullous, fixed drug eruption, erythematous rash and pruritus. Hypersensitivity: Toxic epidermal necrolysis (TEN), Stevens-Johnson Syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP)

The etiology of small pustules on the face may be related to hypersensitivity reactions or dermatologic adverse reactions associated with metronidazole use, such as acute generalized exanthematous pustulosis (AGEP) 2 2.

From the Research

Etiology of Small Pustules on the Face

The etiology of small pustules on the face can be attributed to several factors, including:

• Acne vulgaris, a common skin disease affecting about 70-80% of adolescents and young adults, characterized by the influence of androgens, increased sebum production, and colonization with Propionibacterium acnes 3
• Rosacea, an inflammatory condition of the skin, presenting with erythema, edema, telangiectasia, papules, pustules, and nodules of the face, with unknown exact etiology but thought to be an inflammatory process incited by vascular instability 4
• Other factors, such as hormonal changes, stress, and genetic predisposition, which can contribute to the development of acne and other skin conditions

Possible Causes

Some possible causes of small pustules on the face include:

• Blockage of the pilosebaceous duct, leading to the development of microcomedones and subsequent inflammatory reactions 3
• Increased proliferation and altered differentiation of the follicular epithelium, leading to the formation of comedones and inflammatory lesions 3
• Colonization with Propionibacterium acnes, which can induce inflammatory reactions and contribute to the development of acne lesions 3

Associated Conditions

Small pustules on the face can be associated with various conditions, including:

• Acne vulgaris, which can present with a range of lesions, including comedones, inflammatory papules, and pustules 5, 6
• Rosacea, which can present with erythema, edema, telangiectasia, papules, pustules, and nodules of the face 4
• Adult female acne, which is considered a different disease from acne vulgaris and requires a holistic approach to treatment 7