78: Acne Vulgaris Flashcards
1
Q
What are the common clinical features of acne vulgaris?
A
- Comedones
- Papules
- Pustules
- Nodules
These lesions typically appear on the face, chest, and back.
2
Q
What is the prevalence of acne vulgaris among adolescents aged 12-25 years?
A
The prevalence of acne vulgaris is approximately 85% among individuals aged 12 to 25 years.
3
Q
What factors are considered in the history of a patient with acne vulgaris?
A
- Gradual onset of lesions around puberty
- Abrupt onset may indicate an underlying etiology
- Hyperandrogenism in females with severe acne
- Drug-induced acne from various medications
4
Q
What are the types of lesions associated with acne vulgaris?
A
- Noninflammatory comedones (open or closed)
- Inflammatory lesions (red papules, pustules, or nodules)
Closed comedones are referred to as whiteheads, while open comedones are known as blackheads.
5
Q
What is the significance of family history in patients with acne vulgaris?
A
Family history of acne has been reported in 62.9% to 78% of patients, with those having a family history tending to be male and experiencing earlier onset, truncal involvement, and scarring.
6
Q
What are the four key elements of pathogenesis in acne vulgaris?
A
- Follicular epidermal hyperproliferation
- Sebum production
- Presence and activity of Propionibacterium acnes
- Inflammation and immune response
7
Q
How does the prevalence of acne vulgaris vary by age and gender?
A
- Prevalence: 85% among ages 12-25 years.
- Adolescents: Higher prevalence in males.
- Adults: Higher prevalence in females.
8
Q
What factors should be considered in a female patient with severe acne?
A
- Hyperandrogenism: Consider if acne is severe, sudden in onset, or associated with hirsutism or irregular menstrual periods.
- Family history: May indicate a genetic predisposition to more severe forms of acne.
9
Q
What types of scars can result from acne lesions?
A
Acne lesions can lead to different types of scars, including:
- Atrophic scars: ice pick, boxcar, rolling
- Hypertrophic scars
10
Q
What is the initial clinical lesion that develops in acne?
A
All clinical lesions in acne begin with the microcomedo, which develops into comedones, inflammatory lesions, and scarring.
11
Q
What is the significance of abandoning the term ‘nodulocystic’ in the context of severe acne?
A
The term ‘nodulocystic’ should be abandoned because true cysts are rarely found in acne. Instead, the term ‘severe nodular acne’ is more appropriate to describe severe cases of inflammatory acne.
12
Q
What are the major psychosocial impacts of acne on young people?
A
Acne is a major cause of psychosocial and psychological impairment, leading to increased rates of depression, anxiety, and psychosocial stress.
13
Q
What are the key elements involved in the etiology and pathogenesis of acne?
A
- Follicular epidermal hyperproliferation
- Sebum production
- Propionibacterium acnes
- Inflammation and immune response
14
Q
What complications can arise from acne lesions after resolution?
A
Complications that can arise from acne lesions after resolution include:
- Transient macular erythema
- Postinflammatory hyperpigmentation, especially in dark skin, which may persist for months
- Acne scars, which can be atrophic or hypertrophic.
15
Q
Describe the process that leads to the formation of a microcomedo in acne pathogenesis.
A
The formation of a microcomedo in acne pathogenesis involves the following steps:
1. Follicular epidermal hyperproliferation
2. Obstruction of the follicular ostium
3. Accumulation of keratin, sebum, and bacteria
4. Dilation of the upper hair follicle
5. Formation of a microcomedo
16
Q
What are the characteristics of a microcomedo in the pathogenesis of acne?
A
- Hyperkeratotic infundibulum
- Cohesive corneocytes
- Sebum secretion
- Dilation of follicular ostium
17
Q
What occurs during the formation of an inflammatory papule or pustule in acne?
A
- Rupture of follicular wall
- Further expansion of follicular unit
- Proliferation of Propionibacterium acnes
- Perifollicular inflammation
18
Q
What is the significance of a nodule in the context of acne pathogenesis?
A
- Rupture of follicular wall
- Marked perifollicular inflammation
- Scarring
19
Q
What defines a comedone in the acne pathogenesis process?
A
- Accumulation of shed corneocytes
- Sebum
- Dilation of follicular ostium
20
Q
What are the key pathological changes that occur during the formation of a microcomedo in acne vulgaris?
A
The formation of a microcomedo involves:
1. Hyperkeratinization of the infundibulum.
2. Accumulation of shed corneocytes.
3. Formation of comedones.
4. Sebum secretion leading to dilation of the follicular ostium.
21
Q
Describe the inflammatory process that leads to the formation of a nodule in acne vulgaris.
A
The formation of a nodule involves:
1. Rupture of the follicular wall.
2. Marked perifollicular inflammation.
3. Development of papules or pustules.
4. Potential scarring as a result of the inflammatory response.
22
Q
What role does Propionibacterium acnes play in the pathogenesis of inflammatory acne lesions?
A
Propionibacterium acnes contributes to the pathogenesis of inflammatory acne lesions by:
- Proliferating within the follicular unit, leading to inflammation.
- Triggering an immune response, which exacerbates the inflammatory process.
23
Q
What factors contribute to keratinocyte hyperproliferation in acne?
A
Factors include:
- Androgen stimulation
- Decreased linoleic acid
- Increased IL-1 activity
- Effects of P. acnes
- Dihydrotestosterone
24
Q
How does P. acnes contribute to inflammation in acne?
A
P. acnes induces inflammation through various mechanisms:
- Contains a carbohydrate antigen that stimulates antibody development.
- Elicits a delayed-type hypersensitivity response.
- Stimulates host innate responses via secretion of proinflammatory cytokines and chemokines.
25
What is the role of dietary factors in acne development?
Dietary factors may influence acne as follows:
- High glycemic load diets may exacerbate acne.
- Dairy ingestion appears weakly associated with acne, but studies are inconclusive.
26
What is the predominant cell type within 24 hours of comedo rupture in acne?
The predominant cell type within 24 hours of comedo rupture is the lymphocyte.
27
What laboratory tests are indicated for evaluating androgens in acne patients?
Laboratory tests for evaluating androgens in acne patients include:
1. DHEAS levels to assess for testosterone and DHT precursors.
2. Luteinizing hormone (LH) to follicle-stimulating hormone (FSH) ratio.
28
A female patient with acne has irregular menstrual periods and hirsutism. What underlying condition should be considered?
Hyperandrogenism should be considered. Tests to confirm include serum total testosterone, DHEAS levels, and LH-to-FSH ratio.
29
What role do androgenic hormones play in the pathogenesis of acne vulgaris?
Androgenic hormones activate sebocyte proliferation and differentiation, leading to increased sebum production, which contributes to the development of acne.
30
How does P. acnes contribute to the inflammatory response in acne?
P. acnes induces inflammation by producing lipases, proteases, and chemotactic factors, stimulating host innate responses.
31
What is the significance of low levels of linoleic acid in individuals with acne?
Low levels of linoleic acid induce follicular keratinocyte hyperproliferation and the production of proinflammatory cytokines.
32
What laboratory tests can help identify an adrenal source of androgens in patients with acne?
Luteinizing hormone (LH) to follicle-stimulating hormone (FSH) ratio or serum 17-hydroxyprogesterone can be used to identify an adrenal source of androgens.
33
What DHEAS levels are associated with congenital adrenal hyperplasia?
DHEAS levels in the range of 4000 to 8000 ng/mL may be associated with congenital adrenal hyperplasia.
34
What are the characteristics of microcomedones and closed comedones in acne pathology?
Microcomedones are characterized by a dilated follicle with a narrow follicular orifice filled with shed keratinocytes.
35
What factors can predict the risk for the development of moderate to severe acne?
Factors that may predict the risk for the development of moderate to severe acne include:
1. Family history
2. Body mass index
3. Diet
4. Prepubescent females with comedonal acne
5. Females with high DHEAS levels
36
What are the four main components of an effective acne management regimen?
An effective acne management regimen should include the following components:
1. Correct the altered pattern of follicular keratinization.
2. Decrease sebaceous gland activity.
3. Decrease the follicular bacterial population, particularly P. acnes.
4. Exert an anti-inflammatory effect.
37
What are the implications of elevated DHEAS levels in relation to adrenal health?
Elevated DHEAS levels can indicate:
- Congenital adrenal hyperplasia if levels are between 4000 to 8000 ng/mL.
- Adrenal tumors if levels exceed 8000 ng/mL.
38
What are the key pathological features of microcomedones, closed comedones, and open comedones in acne?
The key pathological features include:
- Microcomedones: Dilated follicle with a narrow orifice filled with shed keratinocytes.
- Closed Comedones: Increased distension of the follicle, creating a cystic space with eosinophilic debris, hair, and bacteria.
- Open Comedones: Enlarged follicular ostia with atrophic or absent sebaceous glands.
39
How does the clinical course and prognosis of acne vary among individuals?
The clinical course and prognosis of acne can vary significantly:
- It may begin as early as 8 years or as late as 20 years.
- The course typically lasts several years, often followed by spontaneous remission.
40
What are the recommended management strategies for acne to prevent permanent sequelae?
Management strategies for acne include:
1. Correct the altered pattern of follicular keratinization.
2. Decrease sebaceous gland activity.
3. Decrease the follicular bacterial population.
4. Exert an anti-inflammatory effect.
41
When can acne begin?
Acne may begin as early as 8 years or as late as 20 years.
42
What is the typical duration of acne?
The course typically lasts several years, often followed by spontaneous remission.
43
What factors influence the severity of acne?
Factors influencing severity include family history, body mass index, diet, prepubescent females with comedonal acne, and females with high DHEAS levels.
44
What are the recommended management strategies for acne?
Management strategies include correcting the altered pattern of follicular keratinization, decreasing sebaceous gland activity, reducing the follicular bacterial population, and exerting an anti-inflammatory effect.
45
What are the first-line treatment options for mild comedonal acne?
The first-line treatment options include topical retinoid and combination therapy (topical retinoid + topical antimicrobial or combination).
46
What is the recommended treatment for severe papular or pustular acne?
The recommended treatment includes oral antibiotic + topical retinoid ± BPO or combination.
47
What additional options are available for managing comedonal acne?
Additional options include comedone extraction, laser or light therapy, and photodynamic therapy.
48
What is the maintenance treatment for moderate papular or pustular acne?
The maintenance treatment is topical retinoid + BPO, or combination.
49
What are the treatment options for females with severe nodular acne?
Treatment options include oral contraceptive–antidandrogen and oral isotretinoin or oral antibiotic + topical retinoid ± BPO or combination.
50
What are the vehicles and concentrations available for Tretinoin topical treatments?
Vehicles and concentrations include:
- Cream: 0.025%, 0.05% (20 g, 45 g)
- Gel: 0.01%, 0.025% (15 g, 45 g (0.025% only))
- Liquid: 0.05% (28 ml)
- Gel with microsponge: 0.04%, 0.1% (20 g, 45 g)
51
What are the different vehicles available for Benzoyl peroxide?
Vehicles and concentrations include:
- Gel: 2.5%, 5%, 10%
- Wash: 2.5%, 5%, 10%
- Cream: 5%
- Foamy wash: 10%
- Creamy wash: 4%, 8%
52
What is the concentration of Clindamycin in its various formulations?
Formulations and concentrations include:
- Lotion: 1%
- Gel: 1%
- Solution: 1%
- Pledget: 1%
53
What are the trade names for Erythromycin and their respective concentrations?
Trade names and concentrations include:
- Generic: 2%
- Ointment: 30 g
- Solution: 2%
- Pledget: 2%
54
What are the different formulations of Dapsone and their concentrations?
Formulations and concentrations include:
- Gel: 5%, 7.5%
55
What is the concentration of Azelaic acid in its various formulations?
Formulations and concentrations include:
- Gel: 15%
- Cream: 20%
56
What is the recommended cleansing routine for acne treatment?
Twice-daily washing with a gentle cleanser followed by the application of acne treatments is recommended.
57
What are the properties and uses of retinoids in acne treatment?
Retinoids bind to and activate retinoic acid receptors (RARs), modifying corneocyte accumulation and inflammation. They have comedolytic and anti-inflammatory properties.
58
What is the role of benzoyl peroxide in acne treatment?
Benzoyl peroxide is an antimicrobial agent that reduces bacterial populations by releasing free oxygen radicals.
59
How do topical antibiotics function in acne treatment?
Topical antibiotics, such as erythromycin and clindamycin, are commonly used to treat acne.
60
What are the characteristics of salicylic acid in acne treatment?
Salicylic acid is a lipid-soluble β-hydroxy acid with comedolytic properties, although weaker than retinoids.
61
What are the benefits of azelaic acid in acne treatment?
Azelaic acid has both antimicrobial and comedolytic properties and is well tolerated.
62
What is the mechanism of action of sulfur and resorcinol in acne treatment?
Sulfur has antibacterial properties and inhibits the formation of free fatty acids.
63
What are the common tetracyclines used in acne treatment?
Doxycycline and minocycline are the most commonly used tetracyclines for acne treatment.
64
What advice should you provide regarding cleansing for a patient using harsh soaps?
Advise the patient to cleanse twice daily with a gentle cleanser to avoid disrupting the skin's pH.
65
What precautions should a patient take when using topical dapsone?
Patients should avoid using dapsone with benzoyl peroxide to prevent skin discoloration.
66
What instructions should a patient follow when prescribed tretinoin?
Patients should apply tretinoin at bedtime and use sunscreen to prevent photosensitivity.
67
What are the benefits and potential drawbacks of benzoyl peroxide?
Benzoyl peroxide is an antimicrobial agent that can cause dryness and irritation.
68
What are the benefits and potential side effects of azelaic acid?
Azelaic acid has antimicrobial properties and may cause transient burning.
69
How does salicylic acid work in acne treatment?
Salicylic acid helps exfoliate the stratum corneum.
70
What precautions should be taken with tazarotene?
Tazarotene is a potent retinoid that requires avoiding pregnancy and careful application.
71
What are the common side effects of Doxycycline?
Common side effects include photosensitivity reactions, GI upset, and photo-onycholysis.
72
What is the recommended dosage for Minocycline in acne treatment?
The recommended dosage is 100 to 200 mg/day.
73
What are the common side effects of Doxycycline when used for acne treatment?
Common side effects of Doxycycline include:
- Photosensitivity reactions
- GI upset
- Photo-onycholysis
74
What is the recommended dosage for Minocycline in acne treatment and what are its potential side effects?
The recommended dosage for Minocycline is 100 to 200 mg/day. Potential side effects include:
- Blue-black pigmentation
- Vertigo
- Rarely, autoimmune hepatitis, SLE-like syndrome, and DRESS syndrome
75
What are the serious adverse reactions associated with Trimethoprim-Sulfamethoxazole?
Serious adverse reactions associated with Trimethoprim-Sulfamethoxazole include:
- Stevens-Johnson syndrome
- Toxic epidermal necrolysis spectrum
- Aplastic anemia (monitor for potential hematologic suppression monthly)
76
What is the mechanism by which oral contraceptives improve acne?
Oral contraceptives improve acne by:
1. Decreasing gonadal androgen production by suppressing LH production.
2. Decreasing free testosterone by increasing sex hormone binding globulin.
3. Inhibiting the activity of 5-α reductase, preventing conversion of testosterone to DHT.
4. Progestins with antiandrogenic effects block androgen receptors on keratinocytes and sebocytes.
77
What are the risks associated with the use of Cephalexin for acne treatment?
The risks associated with the use of Cephalexin for acne treatment include:
- Poor penetration into the pilosebaceous unit due to its hydrophilic nature.
- Risk of resistance, leading authors to discourage its use for acne.
78
What are the side effects of Dapsone when used for acne treatment?
Dapsone can cause the following side effects:
- Monitor G6PD levels and liver function tests.
- Generally low cost and should be considered in severe cases when isotretinoin is not an option.
79
What is the significance of bacterial resistance in acne treatment?
Bacterial resistance in acne treatment is significant because:
- Resistance is highest with erythromycin and lowest with lipophilic tetracyclines like doxycycline and minocycline.
- It should be suspected in patients unresponsive to appropriate antibiotic therapy after 6 weeks of treatment.
- Long-term use of antibiotics should be limited, and combination with benzoyl peroxide is recommended.
80
A patient with severe acne is unresponsive to oral antibiotics after 6 weeks. What should be suspected, and what is the next step?
Antibiotic resistance should be suspected. The next step is to combine antibiotics with benzoyl peroxide to reduce resistance and consider alternative treatments like isotretinoin.
81
A patient with acne is prescribed doxycycline. What are the common side effects, and what precautions should they take?
Common side effects include photosensitivity reactions and GI upset. Patients should use sunscreen and avoid prolonged sun exposure.
82
A patient with acne is prescribed oral contraceptives. What are the mechanisms by which they improve acne?
Oral contraceptives improve acne by suppressing LH production, increasing sex hormone-binding globulin, inhibiting 5-α reductase activity, and blocking androgen receptors.
83
A patient with acne is prescribed minocycline. What are the potential side effects, and how should they be monitored?
Potential side effects include blue-black pigmentation, vertigo, and rare autoimmune hepatitis. Monitor for symptoms and consider alternative treatments if side effects occur.
84
A patient with acne is prescribed erythromycin. What is a major concern with this antibiotic, and how can it be mitigated?
A major concern is bacterial resistance. Combining erythromycin with benzoyl peroxide can reduce the likelihood of resistance.
85
A patient with acne is prescribed oral contraceptives but experiences nausea and weight gain. What should be done?
These are common side effects of oral contraceptives. Consider switching to a different formulation or using alternative acne treatments.
86
What are the potential risks associated with the use of Doxycycline for acne treatment?
- Photosensitivity reactions including photo-onycholysis
- Gastrointestinal upset
87
What are the side effects of Minocycline, particularly in the context of acne treatment?
- Blue-black pigmentation in acne scars
- Vertigo
- Rarely causes autoimmune hepatitis, SLE-like syndrome, and DRESS syndrome
88
What are the recommended dosages and precautions for Tetracycline in acne treatment?
- Dosages of 500 to 1000 mg/day, severe cases up to 3500 mg/day (monitor liver function)
- Taken on an empty stomach, 1 hour before or 2 hours after meals
- Not recommended for pregnant women after the fourth month and children under 9 years
89
What is the significance of antibiotic resistance in acne treatment, particularly regarding erythromycin and tetracyclines?
- Resistance is highest with erythromycin and lowest with lipophilic tetracyclines, doxycycline, and minocycline.
- Avoid antibiotic monotherapy and limit long-term use of antibiotics.
- Combine usage with benzoyl peroxide whenever possible.
90
How do oral contraceptives improve acne, and what are the mechanisms involved?
- Decrease gonadal androgen production by suppressing LH production
- Decrease free testosterone by increasing sex hormone binding globulin
- Inhibit 5-α reductase activity, preventing conversion of testosterone to DHT
- Progestins with antiandrogenic effects block androgen receptors on keratinocytes and sebocytes
91
What are the side effects associated with the use of oral contraceptives for acne management?
- Common side effects: nausea, vomiting, abnormal menses, weight gain, breast tenderness
- Rare serious side effects: thrombophlebitis, pulmonary embolism, hypertension
92
What are the considerations for using glucocorticoids in acne treatment?
- Use is usually restricted to severely involved patients
- Often overlaps with isotretinoin to limit potential flaring from the start of treatment
93
What is the role of low-dose prednisone or dexamethasone in the treatment of acne?
Low-dose prednisone (2.5 mg or 5 mg) or dexamethasone can be given orally at bedtime to suppress adrenal androgen production, which is beneficial in treating acne associated with elevated serum DHEAS levels.
94
What are the side effects associated with the use of spironolactone in acne treatment?
Side effects of spironolactone include diuresis, potential hyperkalemia, irregular menstrual periods, breast tenderness, headache, and fatigue. There is also a risk of feminization of a male fetus if a pregnant woman takes this medication.
95
What is the mechanism of action of isotretinoin in treating severe recalcitrant nodular acne?
Isotretinoin produces profound inhibition of sebaceous gland activity, leading to decreased sebum production. It also has anti-inflammatory activity and affects the pattern of follicular keratinization.
96
What are the potential psychiatric side effects of isotretinoin therapy?
Psychiatric side effects of isotretinoin include risks of depression (1% to 11%; adolescents 10% - 20%), suicide, psychosis, and aggressive or violent behavior.
97
What monitoring is required for patients on isotretinoin therapy regarding triglyceride levels?
Patients on isotretinoin therapy should have their serum triglyceride levels monitored at baseline, and then repeated at 4 and 8 weeks of therapy. If levels are above 500 mg/dL, they should be monitored closely, and if they reach 700 to 800 mg/dL, therapy may need to be interrupted or treated with a lipid-lowering drug.
98
A patient with acne is prescribed isotretinoin but experiences mood changes. What should be done?
Monitor for psychiatric side effects such as depression or suicidal thoughts. Discontinue isotretinoin if symptoms worsen and consider alternative treatments.
99
A 16-year-old patient presents with severe nodular acne. What is the recommended first-line treatment, and what precautions should be taken?
The recommended first-line treatment for severe nodular acne is isotretinoin. Precautions include ensuring the patient is not pregnant, using two forms of contraception, and monitoring for side effects such as elevated triglycerides, liver function abnormalities, and psychiatric symptoms. Monthly pregnancy tests are required.
100
A patient with acne is prescribed spironolactone. What are the potential side effects, and what precautions should be taken?
Potential side effects include hyperkalemia, irregular menstrual periods, breast tenderness, and fatigue. Pregnancy should be avoided due to the risk of feminization of a male fetus.
101
A patient with acne is prescribed isotretinoin but develops severe headaches and visual changes. What condition should be suspected?
Pseudotumor cerebri (benign intracranial hypertension) should be suspected. Symptoms include severe headache, nausea, and visual changes.
102
A patient with acne is prescribed oral isotretinoin but is concerned about bone health. What should they know?
Chronic or repeated courses of isotretinoin may lead to osteopenia or delayed bone healing. Single courses typically do not significantly affect bone density.
103
A patient with acne is prescribed isotretinoin but has a history of inflammatory bowel disease. What should be considered?
Isotretinoin may exacerbate inflammatory bowel disease. Monitor symptoms closely and consider alternative treatments if necessary.
104
A patient with acne is prescribed isotretinoin but is also taking tetracyclines. What is the risk of this combination?
The combination of isotretinoin and tetracyclines increases the risk of pseudotumor cerebri (benign intracranial hypertension).
105
A patient with acne is prescribed isotretinoin but develops cheilitis. What is the cause, and how can it be managed?
Cheilitis is a common side effect of isotretinoin due to its drying effects. It can be managed with regular use of emollients or lip balms.
106
A patient with acne is prescribed isotretinoin but has a history of depression. What precautions should be taken?
Monitor for worsening psychiatric symptoms, including depression or suicidal thoughts. Discontinue isotretinoin if symptoms worsen.
107
A patient with acne is prescribed isotretinoin but has elevated liver enzymes. What should be done?
Monitor liver function tests closely. If levels remain elevated, consider reducing the dose or discontinuing isotretinoin.
108
A patient with acne is prescribed isotretinoin but experiences myalgias. What should be done?
Myalgias are a common side effect of isotretinoin. Monitor symptoms and consider reducing the dose if they become severe.
109
A patient with acne is prescribed isotretinoin but is concerned about photosensitivity. What precautions should they take?
Patients should use sunscreen regularly and avoid excessive sun exposure to prevent photosensitivity reactions.
110
What are the indications for using low-dose prednisone or dexamethasone in the treatment of acne in female patients?
Low-dose prednisone (2.5 mg or 5 mg) or dexamethasone can be given orally at bedtime to suppress adrenal androgen production, particularly in female patients with an elevation in serum DHEAS associated with an 11- or 21-hydroxylase deficiency or in individuals with demonstrated androgen excess.
111
What are the potential side effects of using spironolactone as an antiandrogen in the treatment of acne?
Potential side effects of spironolactone include:
- Diuresis
- Potential hyperkalemia
- Irregular menstrual periods
- Breast tenderness
- Headache
- Fatigue
Additionally, there is a risk of feminization of a male fetus if a pregnant woman takes this medication.
112
What is the mechanism of action of isotretinoin in the treatment of severe recalcitrant nodular acne?
Isotretinoin produces profound inhibition of sebaceous gland activity, leading to decreased sebum production. This inhibition continues for at least 1 year, although sebum production typically returns to normal after 2 to 4 months in most patients. It also has anti-inflammatory activity and affects the pattern of follicular keratinization.
113
What are the risks associated with the use of isotretinoin, particularly regarding psychiatric effects?
The use of isotretinoin carries risks of psychiatric side effects, including:
- Depression (1% to 11%; adolescents 10% - 20%)
- Suicidal thoughts
- Psychosis
- Aggressive or violent behavior
These risks necessitate careful monitoring of mental health during treatment.
114
What monitoring is required for patients on isotretinoin therapy regarding triglyceride levels?
Patients on isotretinoin therapy should have their serum triglyceride levels monitored at baseline, and then repeated at 4 and 8 weeks of therapy. If levels are normal at 8 weeks, no need to repeat. If levels exceed 500 mg/dL, monitoring is required, and if they reach 700 to 800 mg/dL, therapy should be interrupted or the patient treated with a lipid-lowering drug due to the risk of eruptive xanthomas or pancreatitis.
115
What are the recommended contraception techniques for patients undergoing isotretinoin treatment?
Patients must use two highly effective contraception techniques, such as:
1. An oral contraceptive
2. Condoms with a spermicidal jelly
These methods should be started at least 1 month before treatment and used throughout the course of isotretinoin and for 1 month after stopping treatment.
116
What is the typical course duration for isotretinoin treatment?
The typical course of isotretinoin is 20 weeks, but it is not absolute. Patients should allow at least 2 to 3 months between courses of isotretinoin.
117
What is the purpose of subcision in acne treatment?
Subcision is used for the treatment of depressed scars, particularly effective for rolling acne scars. It involves inserting a small hypodermic needle into the periphery of a scar to loosen fibrotic adhesions, which helps release the tethered scar and promotes collagen formation during wound healing. The success rate is approximately 50%.
118
What are the risks associated with intralesional injection of corticosteroids for acne treatment?
The risks associated with intralesional injection of corticosteroids include:
- Hypopigmentation, particularly in darker-skinned patients
- Atrophy of the skin
119
What are the side effects of chemical peels used in acne treatment?
The side effects of chemical peels can include:
- Erythema (redness of the skin)
- Xerosis (dry skin)
- Exfoliation
- Burning sensation
- Increased photosensitivity
120
What is the role of phototherapy in acne treatment?
Phototherapy can improve acne in about 70% of patients. It is noted that:
- UVB can kill P. acnes in vitro, but penetrates poorly to the dermal follicle.
- High doses causing sunburn have been shown to improve acne.
- Twice-weekly phototherapy sessions are needed for any clinical improvement.
121
A patient with acne scars is considering subcision. What type of scars is this procedure most effective for, and how does it work?
Subcision is most effective for rolling acne scars. It involves inserting a small hypodermic needle under the scar to release fibrotic adhesions, promoting collagen formation during wound healing.
122
A patient with acne reports worsening symptoms after consuming high-glycemic foods. What dietary advice should you provide?
While evidence linking high-glycemic foods to acne is not definitive, patients can restrict foods they believe are triggers as long as their nutritional well-being is not compromised.
123
A patient with severe acne is prescribed isotretinoin. What is the typical course duration, and what cumulative dose is recommended?
The typical course of isotretinoin is 20 weeks, with a cumulative weight-based total dose of 120 to 150 mg/kg.
124
What dietary advice should be provided to a patient with acne who reports worsening symptoms after consuming high-glycemic foods?
While evidence linking high-glycemic foods to acne is not definitive, patients can restrict foods they believe are triggers as long as their nutritional well-being is not compromised.
125
What is the typical course duration and cumulative dose recommended for isotretinoin?
The typical course of isotretinoin is 20 weeks, with a cumulative weight-based total dose of 120 to 150 mg/kg.
126
What steps should be taken if a patient prescribed isotretinoin has elevated triglycerides?
If triglycerides exceed 500 mg/dL, monitor levels closely. If they reach 700-800 mg/dL, consider interrupting therapy or using lipid-lowering drugs.
127
What types of acids are used in chemical peels for acne treatment, and what are their effects?
Chemical peels use α-hydroxy acids (e.g., glycolic acid) to reduce hyperkeratinization and β-hydroxy acids (e.g., salicylic acid) to promote desquamation. Side effects include erythema and photosensitivity.
128
What should a patient prescribed isotretinoin know about fertility?
Isotretinoin does not affect male fertility or pose a risk to a fetus conceived by a man taking the medication.
129
What factors increase the likelihood of relapse after isotretinoin treatment?
Low-dose regimens (0.1 to 0.4 mg/kg/day) are associated with a greater incidence of relapse. Patients younger than 16-17 years old are also more likely to require repeat therapy.
130
What are the recommended contraception techniques for patients undergoing isotretinoin treatment?
Patients must use two highly effective contraception techniques, such as an oral contraceptive and condoms with a spermicidal jelly, starting at least 1 month before treatment and continuing throughout the course of isotretinoin and for 1 month after stopping treatment. This is necessary to prevent retinoic embryopathy, which can occur very early in pregnancy, particularly around the third week of gestation.
131
What are the risks associated with intralesional injection of corticosteroids for treating deep nodular lesions?
The risks associated with intralesional injection of corticosteroids include hypopigmentation, particularly in darker-skinned patients, and atrophy of the skin.
132
How do chemical peels enhance physiologic cell turnover?
Chemical peels enhance physiologic cell turnover by removing the stratum corneum. Common types of acids used include:
| Acid Type | Function |
|-----------|----------|
| α-hydroxy acids (e.g., glycolic acid) | Reduces hyperkeratinization and promotes desquamation |
| β-hydroxy acid (e.g., salicylic acid) | Lipophilic agent that decreases corneocyte cohesion and promotes desquamation |
| Combination peels | Jessner solution, typically used for superficial peels (20% to 30%) |
133
What is the role of phototherapy in acne treatment?
Phototherapy plays a role in improving acne by utilizing UV light, which can kill P. acnes. The recommended frequency for phototherapy sessions is twice weekly to achieve any clinical improvement.
134
What is the mechanism of action (MOA) of ClearLight in treating acne?
The MOA of ClearLight includes:
1. Reduction of sebaceous gland activity
2. Remodeling of the dermis through thermal stimulation
3. Stimulation of the release of growth factors and induction of collagen production.
135
What are the benefits of using red light therapy in acne treatment?
Red light therapy penetrates deeper into the dermis and has greater anti-inflammatory properties compared to blue light, making it effective in treating acne lesions. It is often combined with blue light for enhanced results.
136
How does photodynamic therapy work in the treatment of acne?
Photodynamic therapy involves the topical application of aminolevulinic acid (ALA), which is taken up by the pilosebaceous unit and metabolized to protoporphyrin IX. This compound is then targeted by light, producing singlet oxygen species that damage the sebaceous glands, leading to a reduction in acne lesions.
137
What are the advantages of microneedling for acne scars?
Microneedling is a minimally invasive procedure that uses fine needles to puncture the epidermis, leading to:
- Reduction of sebaceous gland activity
- Remodeling of the dermis
- Stimulation of collagen production
It has a better safety profile in treating acne scars, especially in darker skin types, and can be combined with treatments like platelet-rich plasma and glycolic acid.
138
What considerations should be taken into account for acne therapy during pregnancy?
During pregnancy, acne may worsen due to a rise in serum maternal androgen levels. Topical agents are generally considered safer than oral medications due to lower systemic absorption. Inflammatory lesions are more common, often affecting the trunk, and safety in lactation may differ from that in pregnancy.
139
What are the benefits of combining blue and red light therapy for acne treatment?
Blue light targets P. acnes by photoactivating porphyrins, while red light penetrates deeper and has anti-inflammatory properties.
140
What safe treatment options would you recommend for a pregnant patient with acne?
Topical agents such as azelaic acid or salicylic acid are safer options during pregnancy due to lower systemic absorption. Oral medications should generally be avoided.
141
What are the limitations of laser treatments compared to traditional medical treatments for acne?
Laser treatments are generally inferior to traditional medical treatments for acne. They may be used as adjunctive therapy but are not first-line options.
142
What are the benefits and potential risks of microneedling for acne scars?
Microneedling reduces sebaceous gland activity, remodels the dermis, and stimulates collagen production. It has a better safety profile for darker skin types but may cause transient erythema.
143
How does photodynamic therapy work in the treatment of acne?
Photodynamic therapy involves applying topical aminolevulinic acid (ALA), which is metabolized to protoporphyrin IX. Light exposure produces singlet oxygen species that damage sebaceous glands.
144
What are the advantages of using microneedling for treating acne scars?
Microneedling offers several advantages for treating acne scars:
- Minimally invasive procedure that uses fine needles to puncture the epidermis
- Reduces sebaceous gland activity and remodels the dermis through thermal stimulation
- Stimulates the release of growth factors and induces collagen production
- Better safety profile in treating acne scars, particularly in darker skin types
- Can be combined with various adjuvant treatments, including platelet-rich plasma, vitamin C, and glycolic acid.
145
What considerations should be taken into account when treating acne in pregnant patients?
When treating acne in pregnant patients, consider the following:
- Acne may worsen due to a rise in serum maternal androgen levels.
- Inflammatory lesions are more common, often affecting the trunk.
- Topical agents are generally safer than oral medications due to lower systemic absorption.
- Safety during lactation may differ from that in pregnancy, necessitating careful evaluation of treatment options.
