264. Acne/Rosacea Flashcards
Pathogenesis of Acne (4 pillars)
- Follicular Epidermal Hyperproliferation (can clog hair follicle)
- Excess Sebum Production: triggered by androgens, empties to hair follicles
- Inflammation (IL-1 mediated)
- Cutibacterium acnes: feeds on excess sebum and multiplicates = additional inflammation + sebum breaks down to pro-inflammatory markers (TGs - FFAs)
How does C. acnes promote inflammation?
Binds TLR-2 - increases pro-inflammatory cytokines (IL-1,8,12 TNFa) - Innate immune system response
Acne Vulgaris skin manifestations
- Comedone: non-inflammatory, non-painful small papules (open = sebum oxidizes = black heads)
- Papule = more robust inflammation
- Pustule = neutrophil recruitment
- Nodule = follicle wall bursts - large tender nodule with no epithelial lining
- Sinus tracts = significant scarring risk with greater inflammation
Polycystic Ovary Syndrome (what is it)
Acne causes increased sensitivity to higher levels of androgens
Increased androgen state: facial hair and hair loss in females
Acne fulminans
Dermatologic emergence coalition of comedones and heme crusting explosive onset of very severe acne fever, malaise, bone/back pain, truncal involvement, high ESR/WBC Occurs most in adolescent males
Tx of comedones/mild inflammatory acne
Topicals!
- Retinoids: 1st line tx - normalize keratinocyte maturation (less sticky and good prevention)
- Benzoyl Peroxide: ABx alternative - antimicrobial, antiinflammatory, no drug resistance (ProActive)
Tx of moderate-severe inflammatory acne
Systemic!
- Doxycyclines: dont use in pregnant women/kids
- Isotretinoin (Accutane): CURE for acne - decreases sebum production, decreases androgen synthesis, induces sebocyte apoptosis, use if resistant to everything else (80% clear up in 5 years) - good for acne fulminans
Hormonal Therapy for acne
Combination birth control pills: decrease androgen production
Spironolactone: androgen receptor blocker in sebaceous glands/hair follicles
Use if hyperandrogenemic and female
Acne Rosacea (Epidemiology, Pathogenesis)
Age 30+ yrs, F»M but males have severe disease
higher risk for fair-skinned patients
-Neurovascular instability = more reactivity = more blushing/flussing
-Innate immunity abnormality (TLR2)
-Inflammation of follicle + surrounding dermis
Cathelicidins: anti-microbial peptide, increased in rosacea pts, induces inflammation/flushing
Demadex mite = high TLR2 activity = high cathelicidins = high altered peptide = high inflammation
Acne Rosacea (Features, Tx)
ERYTHEMATOTELANGIECTATIC ROSACEA (redness and blood vessel dilation)
Papulopustular rosacea - NO COMEDONES
Phymatous Rosacea: hypertrophy of sebaceous glands/c.t. in nose/eyebrows/cheek
Ocular Rosacea: could threaten sight, white flakes around eyelid and conjunctival hyperemia, peripheral neovascularization
Tx: avoid sun/triggers
Vasoconstrictor topicals: Brimonide Tartrate gel, Oxymetazoline HCL cream
Pustules: Metronidazole
Oral meds if severe: ABx, Isotretinoin (CAN FLARE OCULAR ROSACEA, but good for phymatous rosacea)
Topical Ivermectin: antiparasitic - eliminates demadex mites
Periorifacial dermatitis
Epidemiology, Skin, Tx
Young women 15-45y/o
Red patches with tiny pus bumps/flaking, burning/stinging, spares lip borders, around eye, lip, nose
tx: STOP CORTICOSTEROIDS (will rebound when you stop), topical abx/calcineurin inhibitors - antiinflammatory
Hidradenitis Supperativa
what it is, sex, location, features
Acne Inversa - acts on body folds
F»M Women: axillae, breasts
Men: perianal, butt involvement, groin creases
bilateral tender red draining nodules/abscesses
Open comedones = double comedones
scarring
Treatment of Hidradenitis Supperativa
- Behavioral Change (weight loss, smoking cessation)
- Topical Agents (prevent secondary infeciton)
- Adalimumab: TNFa-i: 50% get 50% reduction
- Intralesional injection of GC (temporary benefit)
- I+D of acute abscess
- Surgical excision of diseased areas - remove all tissue to subQ fat - long/difficult post-op recovery
