An 83-year-old woman presents with a chief complaint of a 25-year history of enlarged pores on her nose. The lesions are asymptomatic, stable, and never drain sebaceous material.
On examination you observe a grid-like pattern of punctate black papules on the nose (figure). No similar lesions are noted on other facial areas, but there is evidence of severe sun damage. Attempts to express material from the lesions were unsuccessful.
Differential diagnosis
Consider skin conditions that cause pigmented papules on the nose.
Solar comedos (blackheads) may appear as multiple dark papules in a grid-like (follicular) distribution. These can occur as a component of sun damage, known as Favre-Racouchot syndrome. It would be extremely unusual to develop this problem only on the nose.
Retained dirt in hair follicles may occur in adults with poor hygiene. It would be unusual for this problem to be confined to the tip of the nose.
Rosacea can cause multiple papules of the nose, to the exclusion of other facial areas. However, these are always inflammatory (red).
Keratosis pilaris can involve the face, including the nose, and can produce follicular papules. They are characteristically flesh-colored, rather than dark brown in color, such as those in the figure.
[FIGURE OMITTED]
Trichostasis spinulosa is the correct diagnosis. The black dots in the hair follicles represent small tufts of hair, rather than sebaceous material. It is for this reason that no substance can be expressed from these lesions. The diagnosis can be confirmed by viewing the lesions through a hand lens.
This patient had no interest in therapy. Laser hair removal would have been a potentially effective treatment modality.
Diagnostic pearl
Consider small tufts of hair stuffing follicles on the nose as a cause of punctate dark-colored papules in this location.
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Kallmann syndrome