Continually Updated Clinical Reference
 
 
  All Sources     eMedicine     Medscape     Drug Reference     MEDLINE
 
eMedicine - Trichostasis Spinulosa : Article by

Quick Find
Authors & Editors
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Multimedia
References

Related Articles
Acne Vulgaris

Keratosis Pilaris

Lichen Spinulosus




Patient Education
Click here for patient education.


AUTHOR AND EDITOR INFORMATION

Section 1 of 10 Click here to go to the next section in this topic  

Author: Stephen J Krivda, MD, Assistant Professor of Dermatology, Uniformed Services University of the Health Sciences; Chief of the Integrated Department of Dermatology, Chief of Dermatology Service, Director of Dermatopathology, Staff Dermatopathologist, Walter Reed Army Medical Center; Head, Department of Dermatology, Staff Dermatologist and Dermatopathologist, National Naval Medical

Stephen J Krivda is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Association of Military Dermatologists, and Phi Beta Kappa

Coauthor(s): George E vonHilsheimer, MD, Staff Physician, Instructor of Dermatology, Uniformed Services University, National Capitol Consortium Dermatology Program, Walter Reed Army Medical Center

Editors: Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: TS, vellus hairs, keratosis pilaris, acne comedones, open comedones

INTRODUCTION

Section 2 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Background

In trichostasis spinulosa (TS), clusters of vellus hairs become embedded within hair follicles, with resultant elevated, dark, spiny papules on the face or trunk. TS frequently is discovered as an incidental finding, and often it is confused with keratosis pilaris or acne comedones.

Pathophysiology

TS results from successive production and retention of vellus telogen club hairs from a single hair matrix in a follicle. Hyperkeratosis plugs the follicle and results in the retention of the vellus hairs in the obstructed follicular infundibulum. The precise cause of this phenomenon remains undetermined.

Frequency

United States

To the authors' knowledge, studies of prevalence have not been undertaken, but published reports indicate that the condition is common, especially in elderly persons.

Mortality/Morbidity

  • TS is primarily a cosmetic concern.
  • TS does not cause morbidity.
  • The condition may become more severe with age.

Sex

Most reports state that TS more frequently affects male patients, but it may occur equally in men and women.

Age

Rarely, cases are reported in children, but the condition nearly always occurs in adults, especially older adults.


CLINICAL

Section 3 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

History

  • In most cases the condition, does not lead to any subjective complaint, and TS may be noticed only as an incidental finding.
  • Pruritus is occasionally present, as is roughness of the skin. Pruritus may be more common when lesions are present on the trunk and arms of young adults.
  • No report predisposing conditions are reported, although TS is more common among older patients.
  • In younger patients, the chief complaint may be cosmetic concern about lesions on the face.
  • TS lesions are frequently confused with open comedones, and patients may report a history of unsuccessful treatment for acne (eg, acne vulgaris).

Physical

Pertinent physical findings of TS are limited to the skin. Because spinous plugs may be inapparent to the naked eye, examination of suspected lesions under a hand lens is recommended.

  • Skin - Primary lesion
    • Lesions typically appear as elevated, dark, follicular plugs or papules.
    • The lesions may have protruding tufts or spines of fine hair that can easily be removed with a comedo extractor or small-toothed forceps without discomfort to the patient.
    • The horny plugs are soft and contain 5-25 hairs per plug.
    • Scales may sometimes be present.
  • Skin - Distribution
    • Lesions may occur anywhere on the body, but they characteristically appear on the face, especially the nose, and the upper part of the trunk and arms, especially the interscapular area.
    • Lesions less typically appear on other areas of the head, neck, and cheeks.
  • Skin - Color
    • Lesions are characteristically smaller than 1 mm.
    • Lesions are characteristically black, follicular papules.

Causes

The cause is unknown.

  • Various explanations for the hyperkeratosis and plugging of the follicular apparatus are proposed.
    • Internal mechanisms, such as endocrine or metabolic disturbances, are suggested. Widespread trichostasis spinulosus has been reported with renal failure.1
    • External mechanisms include the use of irritating soaps or paraffin-containing creams and prolonged exposure to dust, hydrocarbons, or industrial oils. TS has also been associated with prolonged use of clobetasol.2
  • Some consider TS to be a variant of the comedonal lesions of acne; they note the similar distribution of lesions and the rarity of TS among preadolescent patients.
  • Microorganisms are also suggested to have a causative role. Propionibacterium acnes and Pityrosporum species are implicated as possible organisms.


DIFFERENTIALS

Section 4 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Acne Vulgaris
Keratosis Pilaris
Lichen Spinulosus

Other Problems to be Considered

Acne comedones3


WORKUP

Section 5 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Lab Studies

  • The diagnosis of TS can be made clinically without obtaining a biopsy specimen.
  • If the diagnosis is in doubt, a specimen may easily be obtained by removing a hair plug with a forceps or comedone extractor.
  • The specimen should be placed on a glass slide and covered for examination.

Histologic Findings

Treatment with potassium hydroxide dissolves the keratinous plug, leaving numerous vellus hairs in a characteristic tuft. If a biopsy specimen is obtained, microscopic examination reveals a dilated hair follicle with hyperkeratosis and acanthosis of the follicular epithelium (see Media File 2). Inflammatory changes are not a characteristic of TS.


TREATMENT

Section 6 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Medical Care

Treatment is usually administered for cosmetic purposes.

  • The individual plugs of impacted hairs may be removed by means of the following:
    • Tweezing with forceps
    • Pressure expression with a comedone extractor
    • Use of depilatory wax, adhesive strips,4 or laser depilation5
  • Emollients and keratolytics may also be helpful.
  • After the apparent lesions are removed, topical retinoic acids can be used to help prevent future lesions.


MEDICATION

Section 7 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Varying degrees of success are reported with the use of topical tretinoin, which is used primarily as a preventive measure.

Drug Category: Retinoids

Decrease the cohesiveness of abnormal hyperproliferative keratinocytes and may reduce the potential for malignant degeneration. These drugs modulate keratinocyte differentiation and reduce the risk of skin cancer formation in patients with renal transplants. Applied topically, retinoids may prevent the development of lesions.

Drug NameTretinoin (Avita, Retin-A)
DescriptionInhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Use 0.05% cream.
Adult DoseApply to affected areas qhs
Pediatric Dose<12 years: Not established
>12 years: Administer as in adults
ContraindicationsDocumented hypersensitivity
InteractionsCoadministration of benzoyl peroxide, salicylic acid, and resorcinol increases toxicity; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsPhotosensitivity may occur with excessive sunlight exposure; caution in eczema; do not apply to mucous membranes, mouth, and angles of nose


FOLLOW-UP

Section 8 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Deterrence/Prevention

After the apparent lesions are removed, topical retinoic acids can be used to help prevent future lesions; however, recurrence of lesions is commonplace.

Complications

TS does not cause morbidity.

Prognosis

TS persists and remains medically inconsequential; however, the condition may become more severe with age.


MULTIMEDIA

Section 9 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Media file 1:  Small, dark, follicular papules on the nose.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 2:  Biopsy specimen demonstrates a dilated follicle that contains numerous vellus hairs and keratin debris.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 3:  Potassium hydroxide mount of an extracted plug reveals multiple vellus hairs embedded in keratinous material.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo


REFERENCES

Section 10 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page

  1. Sidwell RU, Francis N, Bunker CB. Diffuse trichostasis spinulosa in chronic renal failure. Clin Exp Dermatol. Jan 2006;31(1):86-8. [Medline].
  2. Janjua SA, McKoy KC, Iftikhar N. Trichostasis spinulosa: possible association with prolonged topical application of clobetasol propionate 0.05% cream. Int J Dermatol. Sep 2007;46(9):982-5. [Medline].
  3. Harford RR, Cobb MW, Miller ML. Trichostasis spinulosa: a clinical simulant of acne open comedones. Pediatr Dermatol. Nov-Dec 1996;13(6):490-2. [Medline].
  4. Elston DM, White LC. Treatment of trichostasis spinulosa with a hydroactive adhesive pad. Cutis. Jul 2000;66(1):77-8. [Medline].
  5. Manuskiatti W, Tantikun N. Treatment of trichostasis spinulosa in skin phototypes III, IV, and V with an 800-nm pulsed diode laser. Dermatol Surg. Jan 2003;29(1):85-8. [Medline].
  6. Chung TA, Lee JB, Jang HS, Kwon KS, Oh CK. A clinical, microbiological, and histopathologic study of trichostasis spinulosa. J Dermatol. Nov 1998;25(11):697-702. [Medline].
  7. Ladany E. Trichostasis spinulosa. J Invest Dermatol. Jul 1954;23(1):33-41. [Medline].
  8. Requena L, Sánchez Yus E. Trichostasis spinulosa within an intradermal melanocytic nevus. Cutis. Sep 1991;48(3):211-2. [Medline].
  9. Strobos MA, Jonkman MF. Trichostasis spinulosa: itchy follicular papules in young adults. Int J Dermatol. Oct 2002;41(10):643-6. [Medline].
  10. White SW, Rodman OG. Trichostasis spinulosa. J Natl Med Assoc. Jan 1982;74(1):31-3. [Medline].
  11. Young MC, Jorizzo JL, Sanchez RL, Hebert AA, Thomas DR, King CA. Trichostasis spinulosa. Int J Dermatol. Nov 1985;24(9):575-80. [Medline].

Trichostasis Spinulosa excerpt

Article Last Updated: Nov 13, 2007