03/24 Acne and Rosacea Flashcards
What population does does acne affect?
- affects 85% of adolescents
- all races affected equally
- usually presents at 8-12 (often at the 1st sign of puberty), peaks at 15-18 and resolves by 25
- some women may experience first outbreak at 20-35yo
What are the 4 pathogenic mechanisms of how acne develops?
(just list them - it’ll be described later in a different FC)
- Hyperproliferation and abnormal differentiation of follicular keratinocytes
- increased sebum production
- Propionibacterium acnes infection
- Inflammation
How does hyperproliferation and abnormal differentiation of follicular keratinocytes contribute to the development of acne?
normally keratinocytes are shed into the follicular lumen and extruded
In acne, keratinocytes are retained in the infundibulum, where it proliferates, accumulates, and combines with sebum, resulting in a micro-comedo.
Comedo expands with time and ultimately ruptures, releasing keratin and sebum into the dermis, and causing an inflammatory response
How does increased sebum production contribute to acne?
What generally causes the excess sebum production?
Can you give examples of cases where this would happen? (2)
androgen excess
- testosterone and DHT can bind to receptors in sebaceous gland and hair follicles to increase sebum production
- increased androgens during adrenarche –> increased sebum production (also high during the first 6 months of life
- examples
- Hirsutism (androgen excess due to 21a-hydroxylase deficiency)
- XYY patients tend to have acne that is unresponsive to standard treatment
Hirsutism contributes to acne development. Knowing the pathophysiology behind hirsutism, what would you treat it with? (2)
- Oral contraceptives: block adrenal and ovarian androgens
- Spironolactone: androgen receptor blocker and inhibitor of 5α reductase
What is Propionibacterium acnes?
How does it work?
- gram (+), non motile rod
- resides deep in the sebaceous follicle
- induces pro-inflammatory cytokines (via TLR2 on monocytes – IL-1, IL-8, TNFa)
- activates complement and neutrophil chemotaxis
- makes lipase, which contributes to comedo rupture
Where does acne tend to strike?
areas where sebaceous glands in high concentration:
**face, neck, upper trunk and upper arms **
How does acne develop?
- acne begins with “clogged pores” (aka comedones) that cause inflammation –> papules + pustules with erythema and edema
- pressurized follicles rupture in the dermis and result in a tender deep nodulocystic acne
What are the 2 types of non-inflammatory acne?
- Open – black heads
- Closed – white heads
What are the two types of inflammatory acne?
- Papules
- Pustules
What are the 2 types of nodulocytic acne?
- Nodules
- Cystic
- Both
How is acne classified? (3)
Non-inflammatory (open/closed comedones)
inflammatory (papules/pustules)
nodulocystic (cystic/nodules)
What does this person used to suffer from?
Acne.
Acne complications can result in:
- Scarring (often with cystic type; results in pitted scars, depressions, keloids), as this patient has.
- Hyperpigmentation
What does this person used to suffer from?
- Scarring (often with cystic type; results in pitted scars, depressions, keloids)
- Hyperpigmentation, as what this patient suffers from
What are complications of acne? (2)
- Scarring (often with cystic type; results in pitted scars, depressions, keloids)
- Hyperpigmentation
What type of acne is this?
- Non-inflammatory/Comedonal
- Open – black heads (L)
- Closed – white heads (R)
What type of acne is this?
- Inflammatory – can be scarring
- Papules
- Pustules
What type of acne is this?
- Nodulocystic
- cystic
- Nodules
- or both (nodulocystic
How would you describe this patient’s skin exam?
a. Mild comedonal acne without presence of scarring
b. Mild inflammatory acne without comedones
c. Moderate mixed comedonal and inflammatory acne with presence of scarring
d. Moderate mixed comedonal and inflammatory acne without presence of scarring
C
How would you describe her acne? (2)
- moderate comedonal acne without evidence of scarring.
- mild post-inflammatory hyperpigmentation.
How would you describe his acne?
Severe nodulocystic acne with presence of scarring
What does this child have?
When does it start?
What is the prognosis of it?
What are the 2 other forms of childhood acne?
Neonatal acne
- neonatal – occurs days after birth; resolves within 3 mo
- infantile – persists beyond neonatal or starts after 1 mo; more comedonal, resolves 1-2 yrs
- childhood – persists beyond infantile or starts after age 2, resolves after weeks or years; (+) family hx
What type of acne this patient have?
How would you treat it?
Fulminans
- rare, abrupt onset of nodular and suppurative acne on chest and back (more so than face) PLUS systemic complaints
- trmt: prednisone, followed by isotretinoin
- intralesional steroids for large open cysts
What type of acne this patient have?
How would you treat it?
Conglobata
- rare, abrupt onset of nodular and suppurative acne on chest and back (>face)
- same as fulminans, but without systemic complaints
- treatment: prednisone, followed by isotretinoin; intralesional steroids for large open cysts
Your patient is an avid biker and comes in with complaints of acne that’s developed on her chin.
What type of acne does she have?
Mechanica
- acne occurs secondary to repeated mechanical and frictional obstruction of Pilosebaceous outlet (helmet straps, suspenders, collars, backpacks)
- usually, the acne is linearly distributed
Jullet comes in with these lesions on her head and you suspect that these are self-inflicted.
What type of acne is it?
How do you treat her?
Excoriee “picker’s acne”
- acne due to repeated picking at typical comedones and inflammatory papules, resulting in erosions +/- scarring;
- may be due to OCD, depression, anxiety
- trmt: SSRI, behavior modification, psychotherapy
Your patient is a HS teenager with severe acne and was recommended to go on tetracyclines. He comes in 6 months later and shows you this.
What does he have?
What would you treat him with?
Gram (-) folliculitis
- occurs in pts with longstanding inflammatory acne treated with long-term tetracyclines
- results in nodule formation containing Klebsiella, E. coli, Enterobacter, Proteus (deep lesions)
- KEEP
- treatment:
- Isotretinoin to clear the acne compnent and prevent colonization of anterior nares of gram (-) organisms
- Amoxicillin or Bactram if isotretinoin is not tolerated
Your patient, self-proclaimed “cash manipulator”, comes in and says
“Yo Doc, I gots this weird thang on my neck. I think it’s acne yo.”
You correct him by telling him this.
Acne Kelodalis
- this is not actually associated with acne vulgaris, but a variant of scarring alopecia on his posterior scalp/neck
- fibrosis with firm papules developing into keloids
*
- fibrosis with firm papules developing into keloids
Your patient comes in with these weird findings in his armpit and butt.
What is it?
Where else might it form?
Is it infected?
How does it form?
How do you treat it?
Hiradentitis suppurative – “acne inversa”
- recurrent, sterile abscess formation that produces tender nodules that can rupture, resulting in suppuration, sinus tract, and extensive scarring
- typical locations affected: axillae, inguinal, perineal > buttock and submammary
- treatment: Surgical excision = best recurrence rates
Your patient comes in with these weird findings in his armpit and butt.
What is it?
Where else might it form?
Is it infected?
How does it form?
How do you treat it?
Hiradentitis suppurative – “acne inversa”
- recurrent, sterile abscess formation that produces tender nodules that can rupture, resulting in suppuration, sinus tract, and extensive scarring
- typical locations affected: axillae, inguinal, perineal > buttock and submammary
- treatment: Surgical excision = best recurrence rates
What type of rosacea is this?
How do you know?
If flushing common?
What causes it?
How is it treated?
Erythematotelangiectatic
- “flat and red” rosacea
- prolonged flushing (>10 min), often burning or stinging sensation
- Reaction to stimuli (stress, alcohol, spices, exercise, cold or hot weather)
- Treatment:
- Metronidazole
- sodium sulfacetamide
- azelaic acid
- sulfur cleansers and creams
What type of rosacea is this?
How do you know?
If flushing common?
What causes it?
How is it treated?
Papulopustular
- erythema with papules & pinpoint pustules on nose and chin
- erythematous patches on cheeks bilateraly
- flushing with less irritation
- treatment: (same as erythematotelangiectatic - MASS)
- metronidazole
- azelaic acid
- sodium sulfacetamide
- sulfur cleansers and creams
Your patient who suffers from long-standing rosacea (L) comes in 5 years later with this thing on his nose. What is it called?
What type of rosacea did he have?
If flushing common in this?
What predisposed him to developing that weird thing?
Phymatous (rhinophyma)
- facial erythema with scattered papules, pustules on the forehead, cheeks, and chin.
- flushing is less common, but there is persistent edema
- Rhinophyma is most common in men h/o adolescent acne
Your patient comes in for his annual checkup and you notice that his eyes now look like this.
What does he have?
What do you think his complaints will be?
Ocular Rosacea
- ocular involvement in 50% of rosacea cases
- “eyes have a gritty, stinging, itchy, burning, or foreign body sensation”
- Blepharitis, conjunctivitis, keratitis
skin findings can develop soon after or may never occur
Your patient was treating newly-diagnosed eczema that had developed on her face with Clobetasol propionate, a potent topical steroid, for several weeks. She comes into you with complaints of this “weird rash” that had developed on her lower face.
What is it?
What causes it?
How would you treat it? (5)
- Steroid Rosacea “Peri-oral dermatitis”
- etiology: use of potent topical steroids on the face
- peri-oral erythema and papule eruption around the mouth, with sparing around the vermillion border
- NOT rosacea despite the name, but it looks similar
- trmt:
- doxycycline
- minocycline
- erythromycin
- pimecrolimus or tacrolimus
- Non-comedogenic moisturizers
