78 - Acne Vulgaris Flashcards
The prevalence of acne is adolescents is higher in _____, but in adults is higher in _____
Males
Females
Two indigenous populations that have been described that do not develop acne
Papua New Guinea
Paraguay
Drug-induced acne may be caused by
Anabolic steroids Corticosteroids Corticotropin Phenytoin Lithium Isoniazid Vitamin B complexes Halogenated compounds Certain chemotherapy medications, particularly with EGFR inhibitors
Hormonal therapy which can exacerbate or induce acne vulgaris
Progestin-only contraceptives
Injectables
Intrauterine devices
Y/N: True cysts are rarely found in acne
Yes
Although the majority of inflammatory lesions appears to originate from _____ (54%), a significant number of inflammatory (26%) lesions arise from _____
Comedones
Normal uninvolved skin
Categories of atrophic scars in acne
Ice pick scars
Boxcar scars
Rolling scars
Narrow, deep scars that are widest at the surface of the skin and taper to a point in the dermis
Ice pick scars
Wide sharply demarcated scars that do not taper to a point at the base
Boxcar scars
Shallow, wide scars that have an undulating appearance
Rolling scars
Another type of scar, which typically presents as atrophic soft papules on the upper part of the trunk
Perifollicular elastolysis
Key elements in the pathogenesis of acne vulgaris
- Follicular epidermal hyperproliferation
- Sebum production
- Propionibacterium acnes
- Inflammation and immune response
Dihydrotestosterone (DHT) is converted from dehydroepiandrosterone sulfate (DHEA-S) by
17-beta hydroxysteroid dehydrogenase (HSD)
5-alpha reductase
Compared with epidermal keratinocytes, follicular keratinocytes have increased _____, thus enhancing DHT production
17-beta hydroxysteroid dehydrogenase (HSD)
5-alpha reductase
(High/Low) levels of linoleic acid induce follicular keratinocyte hyperproliferation and the production of proinflammatory cytokines
Low
IL-_____ induces follicular keratinocyte hyperproliferation and microcomedone formation
1alpha
On average, people with acne excrete more sebum than those without acne, and secretion rates (have been shown/have not been shown) to correlate with the severity of clinical manifestations
Have been shown
Main component of sebum
Triglycerides
Broken down into free fatty acids by P. acnes
Triglycerides
The dose of estrogen required to decrease sebum production is (greater/less) than the dose required to inhibit ovulation
Greater
Released by the hypothalamus and increased in response to stress
Corticotropin-releasing hormone
Predominant cell type within 24 hours of comedo rupture
Lymphocyte
_____ lymphocytes are found around the pilosebaceous unit, and _____ cells are found perivasularly
CD4+
CD8+
One to two days after comedo rupture, the _____ becomes the predominant cell type
Neutrophil
Gram-positive, anaerobic, microaerophilic bacterium found in the sebaceous follicle
Dominant bacterial inhabitant of the human sebaceous gland
P. acnes
There is a significant increase in P. acnes colonization at
Puberty
Y/N: There are no consistent data correlating the raw number of P. acnes organisms present in a sebaceous follicle and the severity of the acne
Yes
Recent studies provide evidence that _____ diets may exacerbate acne and _____ ingestion appears to be weakly associated with acne
High glycemic loads
Dairy
Excess androgens may be produced by
Adrenal gland
Ovary
Laboratory workup to measure excess androgen
Serum DHEAS Total testosterone Free testosterone LH:FSH ratio Serum 17-hydroxyprogesterone
Considered the most sensitive for PCOS
Free testosterone
Additional test to consider to identify an adrenal source of androgens
Serum 17-hydroxyprogesterone
Androgen testing should be obtained
Just before or during the menstrual period
Patients taking contraceptives that prevent ovulation will need to discontinue their medication for at least _____ before testing
1 month
Values of DHEAS in the range of 4000 to 8000 ng/mL may be associated with
Congenital adrenal hyperplasia
Patients with a serum DHEAS greater than 800 ng/mL could have a/an
Adrenal tumor
Serum total testosterone in the range of 150 to 200 ng/dL or an increased LH-to-FSH ratio (>2.0) can be found in cases of
PCOS
Greater elevations in serum testosterone (>200 ng/dL) may indicate a/an
Ovarian tumor
In women, there is often variation in relation to the menstrual cycle, with a flare just before the onset of menstruation, especially in those older than _____ of age
30 years
Binding of these agents to nuclear RAR affects the expression of genes involved in cell proliferation, differentiations, melanogenesis, and inflammation
Retinoids
Retinoids have _____ properties
Comedolytic
Antiinflammatory
Some newer formulations use a microsphere delayed-delivery technology or are incorporated within a polyolprepolymer to decreased the _____ potential of tretinoin while allowing greater concentration of medication
Irritancy
Inactivated by concomitant use of benzoyl peroxide and is photolabile
Generic tretinoin
Specifically targets the RARgamma receptor
Both photostable and can be used in conjunction with benzoyl peroxide
Adapalene
The only retinoid recently made available by the US FDA for over-the-counter treatment for acne in those 12 years and older
Adapalene 0.1% gel
Tazarotene exerts its action through its metabolite, _____, which in turn inhibits the RARgamma receptor
Tazarotenic acid
Powerful antimicrobial agent, markedly reducing the bacterial population via release of free oxygen radicals
Also has mild comedolytic properties
Benzoyl peroxide
Can produce significant dryness and irritation
Can bleach clothing and hair
Benzoyl peroxide
Bacteria are unable to develop resistance to _____, making it the ideal agent for combination with topical or oral antibiotics
Benzoyl peroxide
Most recently approved topical antibiotic for acne
Topical dapsone 5% and 7.5% gel
Y/N: Topical dapsone is not safe for use in patients with G6PD deficiency
No -safe for use
Topical dapsone should not be applied concomitantly with _____, or it may impart an orange color on the skin
Benzoyl peroxide
Lipid-soluble beta-hydroxy acid which has comedolytic properties by somewhat weaker than those of a retinoid
Causes exfoliation of the stratum corneum through decreased cohesion of the keratinocytes
Less effective then benzoyl peroxide
Salicylic acid
Dicarboxylic acid which has both antimicrobial and comedolytic properties
Also a competitive inhibitor of tyrosinase
Azelaic acid
Thought to have antibacterial properties though their inihibition of para-aminobenzoic acid (PABA), an essential substance for P. acnes growth
Sulfonamides
Inhibits the formation of free fatty acids and has presumptive keratolytic properties
Often combined with sodium sulfacetamide to enhance its cosmetic tolerabilty due to sulfur’s disctinctive odor
Sulfur
Resorcinol is also indicated for use in acne for its _____ properties
Antimicrobial
Does not alter sebum production
Decreases the concentration of free fatty acids while the esterified fatty acid content increases
Oral tetracyclines
Doxycyline and minocycline are the most commonly used tetracycline derivatives for acne. They have the distincy advantage that
They can be taken with food with minimal impaired absorption
Major disadvantages of doxycycine and minocycline
Potential risk of photosensitivity reaction
Can cause blue-black pigmentation, especially in acne scars
Minocycline
Should be taken on an empty stomach, 1 hour before or 1 hours after meals
Tetracycline
Tetracycline should not be administered to pregnant women, especially after the fourth month of gestation, and are not recommended for use in children younger than
9 years of age
Because of the prevalence of _____-resistant strains of P. acnes, the use of oral _____ is generally limited to pregnant women or children
Erythromycin
First-generation cephalosporin
Hydrophilic; penetrates poorly into the pilosebaceous unit
Success is most likely caused by antiinflammatory rather than antimicrobial properties
Cephalexin
Antibiotic resistance should be suspected in patients unresponsive to appropriate antibiotic therapy after _____ of treatment
6 weeks
Resistance is highest with _____ and lowest with _____
Erythromycin
Lipophilic tetracylines, doxycyline and minocycline
The least resistant is noted with
Minocycline
Recent guidelines recommend limiting the duration of oral antibiotic therapy in acne to _____ to reduce risk of resistance
3 to 6 months
Two progestins have demonstrated antiandrogenic properties
- Cyproterone acetate
2. Drospirenone
Usually restricted to severely involved patients, often overlapping with isotretinoin to limit any potential flaring at the start of treatment
Glucocorticoids
Glucocorticoids in low dosages are also indicated in
Female patients who have an elevation in serum DHEAS associated with an 11- or 21-hydroxylase deficiency
Other individuals with demonstrated androgen excess
Act on the pituitary gland to disrupt its cyclic release of gonadotropins
GnRH agonists, such as leuprolide
GnRH agonists are used in the treatment of
Ovarian hyperandrogenism
Aldosterone agonist and functions in acne as both an androgen-receptor blocker and inhibitor of 5-alpha reductase
Spironolactone
Side effects of spironolactone
Diuresis Potential hyperkalemia Irregular menstrual periods Breast tenderness Headache Fatigue
Combining spironolactone treatment with _____ can alleviate the symptoms of irregular menstrual bleeding
Oral contraceptive
Long-term studies in rats receiving high doses of spironolactone demonstrated an increased incidence of _____, resulting in a black box warning by the FDA
Adenomas on endocrine organs and the liver
Progestational antiandrogen that blocks the androgen receptor
Cyproterone acetate
Androgen receptor blocker
Flutamide
Liver function tests should be monitored while using flutamide because cases of _____ have been reported
Fata hepatitis
Isotretinoin is also effective in the treatment of
Gram-negative folliculitis
Pyoderma faciale
Acne fulminans
The risk of _____ may be increased with concomitant used of tetracyclines and isotretinoin
Pseudotumor cerebri
Most common musculosketal complain with the use of isotretinoin
Myalgia
Baseline laboratory monitoring for patients taking isotretinoin
CBC
Liver function tests
Lipid panel
The greatest attention should be paid to following serum _____ levels
Triglyceride
Baseline values for serum triglycerides should be obtained and repeated at _____ of therapy
4 and 8 weeks
If serum triglycerides increase above _____, the levels should be monitored frequently. Levels above _____ are a reason for interrupting therapy or treating the patient with a lipid-lowering drug
500 mg/dL
700 to 800 mg/dL
Y/N: Isotretinoin is not mutagenic; its effect is on organogenesis
Yes
Y/N: Because isotretinoin is not mutagenic, there is no risk to a fetus conceived by a man who is taking isotretinoin
Yes
Patients with severe acne often need pretreatment for 1 to 2 weeks with _____, which may be continued for the first 2 weeks of therapy
Prednisone (40-60 mg/day)
It is standard practice to allow at least _____ between courses of isotretinoin
2 to 3 months
Preferable type of comedo extractor
Has a broad flat plate and no narrow sharp edges
Unna
The removal of _____ comedones is desirable for cosmetic purposes. In contrast, _____ comedones should be removed to prevent their rupture
Open
Closed
Subcision is most effective for _____ acne scars
Rolling
Major endogenous porphyrin of P. acnes
Can absorb light at the near-UV and blue spectrum of 415 nm
Coproporphyrin III
_____ light is currently approved for the treatment of moderate inflammatory acne
Blue
Penetrates deeper into the dermis and has greater antiinflammatory properties but causes less photoactivation of the porphyrins
Red light
The most consistent improvement in acne after light treatment has been demonstrated with
Photodynamic therapy
Photodynamic therapy involves the topical application of aminolevulinic acid (ALA) 1 hour before exposure to a low-power light source. The topical ALA is taken up by the pilosebaceous unit and metabolized to
Protoporphyrin IX
Applies negative pressure (ie, suction) to the skin and then delivers a broadband-pulsed light (400-1200 nm)
Photopneumatic device
Retinoid: “may use during pregnancy”
Adapalene
Retinoid: “consider avoiding use during pregnancy”
Tretinoin
Retinoid: “use alternative during pregnancy”
Tazarotene
Pregnancy Category B mediations
Azelaic acid Clindamycin Erythromyin Metronidazole Oral amoxicillin Oral azithromycin Oral cephalexin Oral erythromycin
