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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 270-274

Clinico-epidemiological profile of patients with traumatic anserine folliculosis: A retrospective study from a tertiary care center in North India


Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan, India

Date of Submission21-Feb-2019
Date of Decision13-Mar-2019
Date of Acceptance26-Apr-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Suresh Kumar Jain
Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_11_19

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  Abstract 


Background: Traumatic anserine folliculosis (TAF) is an uncommon follicular dermatosis. It is characterized by multiple closely set grouped follicular papules with goose skin appearance. There are few publications about this condition, and little is known about the incidence and peak age and sex groups. Aims and Objectives: The aim of this study is to describe the various pattern of TAF in children of 6 years to 18 years of age group. Methods: A retrospective study was conducted to identify cases of TAF in 26 patients at the dermatology department of our tertiary care hospital. The study population was 6–18 years age group children. History, variables, cutaneous and systemic examination, and routine laboratory investigations data were collected from previously recorded forms. Results: Twenty-six patients with TAF were identified. Of these, 19 were male and 7 were female. The mean age was 12.11 ± 2.2 years, ranging from 8 to 16 years. Only four patients were older than 14 years. The mean duration of lesions was 10.23 ± 7.2 months. We classified the clinical patterns as mental, mandibular, and malar according to anatomic location. The most common lesion locations were the chin in 20 (76.7%) followed by the body of mandible in 4 (15.38%) and cheek in 2 (7.69%) cases. Friction and pressure were the predisposing factors in most of the cases. Conclusion: The most commonly affected age group was 8–14 years in 22 (84.6%) children, and the most common predisposing factors were friction and pressure. Therefore, early diagnosis with proper counseling and lifestyle modification of TAF provides rapid relief for patients and avoid unnecessary tests and treatments.

Keywords: Dermaoscopy, follicular dermatosis, friction, pressure


How to cite this article:
Kumar R, Singh A, Badyal R, Jain SK, Yadav D. Clinico-epidemiological profile of patients with traumatic anserine folliculosis: A retrospective study from a tertiary care center in North India. Indian J Paediatr Dermatol 2020;21:270-4

How to cite this URL:
Kumar R, Singh A, Badyal R, Jain SK, Yadav D. Clinico-epidemiological profile of patients with traumatic anserine folliculosis: A retrospective study from a tertiary care center in North India. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Nov 25];21:270-4. Available from: https://www.ijpd.in/text.asp?2020/21/4/270/296842




  Introduction Top


Traumatic anserine folliculosis (TAF) is characterized by grouped closely set white-yellow or skin-colored papules with or without erythema that form a poorly demarcated patch. The chin and jaws are the commonly affected sites.

In 1975, Arai reported follicular-papular lesions on the chins of two children and diagnosed the lesions as variants of the follicular nevus.[1] In 1979, Padilha-Goncalves [2] described 11 patients with papular lesions on the chin and on the jaw, and named this entity “TAF” and suggested that the lesions were due to localized prolonged pressure and friction on the naked skin is the main etiological factor. This disease has since been called keratotic papular lesions of the chin [3],[4] or follicular keratosis of the chin.[5],[6] TAF is an underreported clinical entity. There is scarce data about this in the Indian context. The objective is to describe the various pattern of TAF and its predisposing factors.


  Methods Top


A retrospective study was performed to identify cases of TAF diagnosed over 3 years (July 2014 to August 2017) in the dermatology department of our tertiary care hospital. The study population was 6–18 years of age group children. History, variables, cutaneous and systemic examination, routine laboratory investigations data were collected from previously recorded forms. The study has been approved by ethical committee at our institution. Collected variables included age, sex, anatomic location, duration, and comorbid conditions. We divided the clinical patterns as mental, mandibular, and malar according to anatomic involvement of follicular papular lesions over chin as mental, body of mandible as mandibular and cheeks as malar type. Dermoscopy was done in all patients using DL1dermoscope system (magnification × 10). Considering the characteristic history of the patient, the site of affection and dermoscopic findings a diagnosis of TAF was made. Skin biopsy was not done in any patient due to denying for consent by patients and their parents. Statistical analysis-Qualitative or categorical variables were described as frequencies and proportions.


  Results Top


Twenty-six cases were identified. Nineteen were male and 7 were female. Age ranged from 8 years to 16 years (mean 12.11 ± 2.2 years). Sixteen patients presented with these lesions as their primary concern, whereas four presented with the lesions as secondary concerns. In the remaining 6 cases, the lesions were noticed on physical examination, and further history and evaluation confirmed TAF. The most common lesion location was chin 22 (84.6%) [Table 1]. Less-common locations included the chin with bilateral mandible 1 (3.8%), chin with right mandible 2 (7.69%), and chin with left mandible 1 (3.8%). The mean duration of lesions before the presentation was 10.23 ± 7 months (range 2 months to 2 years). Atopic dermatitis was seen in five cases followed by acne vulgaris, oral aphthae, and molluscum contagiosum each in one patient [Table 2].
Table 1: Demographic and clinical characteristics of 26 patients

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Table 2: Comparison of different case series of traumatic anserine folliculosis

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Two sisters aged 13 and 16 years exhibited very similar-looking lesions on their chins of several months' duration [Figure 1]. One sister had only chin involvement, while others had both chin and mandible. A family history of atopic dermatitis was positive in 3 patients, one in father while two in siblings. History of friction or pressure was recalled by 16 patients while 10 patients not remembered. Out of these 8 patients accepted pressure during watching television by dorsum of hand and knee while in others during writing or study [Figure 2]. Twenty four patients were right dominant hand while two were left handed. In right-handed patients, mandibular and cheek lesions predominantly over the left side while in left-handed patients, lesions predominantly over the right side [Figure 3]. Laboratory parameters were within the normal range. The dermoscopic examination revealed many well-demarcated yellow spindle bodies in the patchy lesion [Figure 4]. The oral mucosa, hair, and nails were uninvolved. The general and systemic examination was within normal limits.
Figure 1: (a) Traumatic anserine folliculosis over chin; (b) pictorial presentation of pressure over chin

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Figure 2: (a) Traumatic anserine folliculosis over bilateral mandible; (b) pictorial presentation of pressure over bilateral mandible

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Figure 3: (a) Traumatic anserine folliculosis over left chin in right handed person; (b) pictorial presentation of pressure over left chin

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Figure 4: (a) Dermascopic finding TAF over chin showing yellow spindle bodies; (b) close up view

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  Discussion Top


The lesion of TAF is consists of white-yellow or skin-colored papules with or without slight erythema, predominantly present on the chin or jaws. The papules are closely set and grouped together with goose skin appearance, and form a poorly demarcated patch.[1],[2],[3],[4],[5]

TAF can be classified according to the presence of tiny grouped follicular papules with goose skin appearance over chin as mental, body of mandible as mandibular, and cheeks as malar type.

We observed the white-yellow colored spindle bodies in the patch under the dermoscope.

Histopathology is characterized by dilated follicles filled with keratin and the lack of perifollicular inflammatory infiltration,[1],[2],[3],[4],[5],[6] and these spindle bodies appear to correspond to the dilated, keratin filled follicles.

To date, 35 occurrences of follicular keratosis of the chin have been reported: Eleven patients were from Brazil,[2] thirteen from India,[3],[7],[9] six from Japan,[10] three from Korea [11],[12] and two from Israel.[4] The lesions occurred mostly in children and teenagers.[2] Of these 13 Indian patients, 12 were girls while one was a boy. Padilha-Goncalves reported that 63.6% of the patients had an atopic history.[2] In this study, 5 (19.23%) patients had a personal history of atopic dermatitis and 3 patients had a family history of atopy.

Most patients were in the habit of resting their chin or jaw on their hands or knee while watching television, playing games, or studying.[2],[5],[6] Similarly, in our study, 16 (61.5%) patients had history of friction and pressure.

Follicular keratosis at amputation sites [13] and “fiddler's neck”[14] of violin players have similar follicular lesions. In the fiddler's neck, the lesions usually consist of a localized area of lichenification on the left-hand side of the neck, just below the angle of the mandible and pigmentation, erythema, and inflammatory papules or pustules are frequently present.[14] It is emphasized that in the fiddler's neck, and follicular keratosis at amputation sites, the pressure and friction is provided by other material, while in TAF pressure and friction is provided by the skin of the patient.

The differential diagnosis of TAF includes keratosis pilaris, lichen spinulosus, trichostasis spinulosa, trichodysplasia spinulosa, and disseminate and recurrent infundibular folliculitis.

Keratosis pilaris is characterized by keratinous follicular plugs with or without perifollicular erythema over the extensors of the arms while Lichen spinulosus has pruritic, symmetric plaques comprising tiny, thorny, grouped follicular papules predominantly occur on neck, trunk, buttocks, and extremities.[15]

Trichostasis spinulosa is characterized by multiple follicular papules resembling comedones on the face, especially nose with multiple tufts of hair projecting through the follicle.[16]

Polyoma virus-associated trichodysplasia spinulosa is a rare entity which is characterized by multiple small skin-colored or erythematous follicular spiky papules over the face and ears in immunocompromised patients.[17]

Disseminate and recurrent infundibulo folliculitis characterized by monomorphic tiny skin-colored follicular papules with a variable degree of plugging without erythema over the trunk in adult males usually with atopic dermatitis.[18]


  Conclusion Top


Thus, we conclude that children of 8–14 years age group are more prone to develop TAF. Friction and pressure during watching television and studying are the predominant predisposing factors. The prognosis was excellent with the total disappearance of the lesion after the patients advised to stop their habit of resting their chin or jaw on their hands or knee. Folliculocentric lesions frequently pose a diagnostic challenge to the dermatologist. TAF must be differentiated from other follicular lesions. Identifying and avoiding the pressure or friction over the area often leads to complete resolution of the lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arai H. A kind of follicular nevus. Hifuka No Rinsho 1975;17.  Back to cited text no. 1
    
2.
Padilha-Gonçalves A. Traumatic anserine folliculosis. J Dermatol 1979;6:365-9.  Back to cited text no. 2
    
3.
Mehta VR. Keratotic papular lesions on the chin in young females. J Cutan Pathol 1983;10:376.  Back to cited text no. 3
    
4.
Brenner S, Ilie B. Familial keratotic papular lesions on the chin. Int J Dermatol 1985;24:320-1.  Back to cited text no. 4
    
5.
Kanzaki T, Morita A, Takashima A. Follicular keratosis of the chin. J Am Acad Dermatol 1992;26:134-5.  Back to cited text no. 5
    
6.
Gushi A, Hozumi H, Kanzaki T. A case of follicular keratosis of the chin. Nishinihon J Dermatol 2003;65:95-6.  Back to cited text no. 6
    
7.
Rambhia KD, Wankhade V, Mukhi J, Singh RP. Traumatic anserine folliculosis. Indian Dermatol Online J 2017;8:59-61.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Yelwanti GK, Jawed MW. Keratotic papules of chin: A case series. J Evid Based Med Healthc 2016;3:3281-2.  Back to cited text no. 8
    
9.
Sharma R, Kanwar AJ, Abraham A, Radotra BD. Keratotic papules on chin. Indian J Dermatol Venereol Leprol 1990;56:391-2.  Back to cited text no. 9
  [Full text]  
10.
Yanagihara M, Takeda K, Tanabe H, Abe S, Ishizaki H. Follicular keratosis of the chin treated with 1.24R-dihydroxyvitamin D3 ointment. Pediatr Dermatol 2007;24:412-4.  Back to cited text no. 10
    
11.
Kim MJ, Cho KH, Park KC, Yown SW. Two cases of traumatic anserine folliculosis: A case report. Korean J Dermatol 2008;46:1626-8.  Back to cited text no. 11
    
12.
Ahn KJ, Kim KJ, Kim WS. A case of traumatic anserine folliculosis. Korean J Dermatol 1982;20:117-9.  Back to cited text no. 12
    
13.
Ibbotson SH, Simpson NB, Fyfe NC, Lawrence CM. Follicular keratoses at amputation sites. Br J Dermatol 1994;130:770-2.  Back to cited text no. 13
    
14.
Peachey RD, Matthews CA. Fiddler's neck. Br J Dermatol 1978;98:669-74.  Back to cited text no. 14
    
15.
Friedman SJ. Lichen spinulosus. Clinicopathologic review of thirty-five cases. J Am Acad Dermatol 1990;22:261-4.  Back to cited text no. 15
    
16.
Goldschmidt H, Hajyo-Tomoka MJ, Kligman AM. Trichostasis spinulosa: A common inapparent follicular disorder of the aged. In: Brown AC, editor. First Human Hair Symposium. New York: Medcom Press; 1974. p. 50-6.  Back to cited text no. 16
    
17.
Pedergnana V, Martel-Jantin C, Nicol JT, Leblond V, Tortevoye P, Coursaget P, et al. Trichodysplasia spinulosa polyomavirus infection occurs during early childhood with intrafamilial transmission, especially from mother to child. J Invest Dermatol 2017;137:1181-3.  Back to cited text no. 17
    
18.
Aroni K, Grapsa A, Agapitos E. Disseminate and recurrent infundibulo-folliculitis: Response to isotretinoin. J Drugs Dermatol 2004;3:434-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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