ACNE

Question 1

What is acne vulgaris?

Answer 1

A chronic inflammatory skin condition characterised by the blockage and inflammation of the pilosebaceous unit

Question 2

What is the pilosebaceous unit?

Answer 2

The hair follicle, hair shaft and sebaceous gland

Question 3

Where on the body does acne vulgaris typically affect?

Answer 3

Face 99%
Back 60%
Chest 15%

All areas with a high density of pilosebaceous glands

Question 4

What are non-inflamed lesions known as in acne vulgaris and what are the types?

Answer 4

Comedones
Open - blackheads
Closed - white heads
Microcomedones - clinically invisible

Question 5

What are inflamed lesions in acne vulgaris?
In severe disease what can these develop into?

Answer 5

Papules
Pustules

In severe disease they can develop into larger, deeper pustules, nodules or cysts

Question 6

Age of onset typical for acne vulgaris ?

Answer 6

Over 85% are 12-24, 8% are 25-34, and 3% are 35-44
Usually resolves by the time adolescence ends
Persistent acne can last into adulthood for a small number of people
A smaller proportion may experience acne for the first time in adulthood

Question 7

Rough staging for acne vulgaris?

Answer 7

Mild acne - predominantly non-inflamed lesions
Moderate acne - widespread with an increased number of inflammatory papules and pustules
Severe acne - widespread inflamamtory papules, pustules or nodules or cysts. Scarring may be present

Question 8

What is conglobate acne?

Answer 8

A rare and severe form of acne
Most often found in men
Presents with extensive inflammatory papules, suppuration nodules which may coalesce to form sinuses, and cysts on the trunk and upper limbs

Question 9

What is acne fulminans?

Answer 9

Sudden severe form of inflammatory acne that precipitates deep ulcerations and erosions
Sometimes has systemic effects - fever, arthralgia and myalgia)
Occurs after unsucceful treatment of acne conglobata

Question 10

Pathogenesis of acne vulgaris?

Answer 10

Altered follicular keratinocyte proliferation -> formation of follicular plugs (comedones)
Androgen-induced seborrhoea within sebaceous follicles around the time of puberty
Proliferation of bacteria, such as cutibacterium acnes, within sebum in hair follicles
Inflammation of the pilosebaceous unit

Other factors that may contribute to- genetics, racial and ethnicity factors, diet, hormones

Question 11

Diet and acne

Answer 11

May be a correlation between acne and high glycaemic index diets

Other foods inconclusively linked:
- milk and whey proteins
- dairy and meat products high in leucine

Diets with sufficient levels of the following may reduce acne lesions:
- omega 3 fatty acids
- y-linoleic acid (often found in veg oil)

Question 12

Hormonal factors and acne

Answer 12

Females may notice increased eruptions slightly prior to the first few days of their menstrual period
Hyperandrogenism or PCOS increases risk of acne

Question 13

Epidemiology of acne?

Answer 13

9% of people worldwide
Affects 80-90% of teenagers
More common in males during adolescence
More common in women during adulthood
Men are more likely to experience severe acne

Question 14

Presentation of acne vulgaris?

Answer 14

Comedones - open ans closed
Papules
Pustules
Nodules
Cysts
Scarring
Depigmentation or hypderpurgmnetation
Seborrhoea

Question 15

Types of scarring secondary to acne?

Answer 15

Ice pick - small, sharp indentations that are wider at the skin’s surface and narrow into point as they reach down into the skin
Hypertrophic - raised, thickened, wider

Question 16

How does drug-induced acne present?

Answer 16

It will be monomorphic
For example, with steroid use, pustules are normally seen

Question 17

Which drugs can cause or exacerbate acneiform eruptions?

Answer 17

Dioxins - chloracne
Corticosteroids
Anti-epileptic meds
Lithium
Isoniazid
Ciclosporin
Vitamins B1, B6 and B12
Anabolic steroids

Question 18

Advice for acne vulgaris?

Answer 18

Avoid over-cleaning the skin
Use a non-alkaline synthetic detergent cleaning product twice daily
Avoid oil-based comedogenic skin care products, makeup and sunscreen
Dont pick or scratch lesions
Not enough evidence to support specific diets

Question 19

Managing mild-moderate acne?

Answer 19

12 week course of one of he following - apply OD in evening:
- topical adapalene with topic benzoyl peroxide
- topical tretinoin with topical clindamycin
- topical benzoyl peroxide with topical clindamycin

Question 20

Management of moderate-severe acne vulgaris?

Answer 20

12 week course of one of the following:
- topic adapalene with topic benzoyl peroxide OD in evening
- topical tretinoin with topical clindamycin OD in evening
- topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
- topical azaleic acid + either oral lymecycline or oral doxycycline

In women, COCP can be considered as an alternative to systemic antibiotics. Dianette (co-cyprindiol) is often used as it has anti-androgen effects but note it has increased risk of VTE!

Question 21

Why should a topical retinoid or benzoyl peroxide always be considered-prescribed with oral antibiotics when treating acne vulgaris?

Answer 21

To reduce the irks of antibiotic resistance developing
Topical + oral antibiotics shold not be used in combination!
Likewise mono therapy with a topical antibiotic or oral antibiotic should not be used

Question 22

Which pt with acne vulgaris should be referred to dermatology?

Answer 22

Acne fulminans - refer to be assessed within 24 hours!!

Pt with acne conglobate
Pt with nodulo-cystic acne

Consider:
Mild-mod acne not responded to 2 completed courses of Tx
Mod-severe acne that has not responded to Tx that included an oral antibiotic
Acne with scarring
Acne with persistent pigmentary changes
Acne causing/contributing to persisting psychological distress or mental health disorder

Question 23

Complications of acne vulgaris?

Answer 23

Scarring
Post-inflammatory pigmentation changes
Psychological distress
Systemic comorbidities e.g. obesity, DM, hyperlipidaemia, hypertension, metabolic syndrome

Question 24

How does topical benzoyl peroxide help manage acne?

Answer 24

Antiseptic - toxic to cutibacterium acne

Question 25

How do retinoids help manage acne?

Answer 25

These are chemicals related to vitamin A
They promote desqamation = increases turnover of skin cells, removing dead cells from skin surface and reducing inflammation
Also reduce production of sebum, reduce inflammation and reduce bacterial growth

Question 26

Topical retinoid examples?

Answer 26

Tretinoin - aka all-trans-retinoic-acid
Adapalene

Question 27

Examples of oral retinoids used for acne?

Answer 27

Isotretinoin (roaccutane)
Alitretinoin
Acitretin

Question 28

Most effective COCP for acne?

Answer 28

Co-cyprindiol (dianette)
Due to its anti-androgen effects

Question 29

Side effects of isotretinoin?

Answer 29

Dry skin, eyes, nose, lips - most common!
Low mood
Raised triglycerides
Hair thinning
Nose bleeds caused by dryness of nasal mucosa
Intracranial hypertension
Photosensitivity

Rarely: Steven’s-Johnson syndrome and toxic epidermal necrolysis

Question 30

Why should retinoids not be combined with tetracyclines for treatment of acne?

Answer 30

Due to risk of intracranial hypertension

Question 31

Teratogenicity and retinoids?

Answer 31

Females should be using 2 forms of contraception e.g. COCP and condoms

Avoid getting pregnant for 1 month after stopping

Question 32

What is rosacea?

Answer 32

A chronic inflamamtory skin condition predominantly affecting the convexities of the centrofacial region

Question 33

What is ocular rosacea?

Answer 33

Eye symptoms associated with rosacea
Lid margin telangiectasia
Blepharitis
Conjunctivitis
Keratitis
Anterior uveitis

Question 34

Who does rosacea typically affect?

Answer 34

Women
Mean age 40 (45-60)
Fair skin!!

(But can affect men and all skin types!)

Question 35

Cause of rosacea?

Answer 35

Not known

Some risk factors:
- genetics
- increasing age
- photosensitive skin types
- UV radiation exposure
- smoking
- hot or cold ambient temperatures
- spicy food
- Hot drinks
- alcohol
- emotional stress and exercise
- drugs e.g. CCB and topical corticosteroids

Question 36

Prognosis of rosacea?

Answer 36

May progress and severity and transform to include additional clinical phenotypes
Often characterised by repeated remissions and exacerbations
Risk of relapse is high following Tx

Question 37

Clinical features of rosacea?

Answer 37

Diagnostic clinical features:
- phymatous changes - facial skin thickening or sebaceous glandular hyperplasia - mostly on nose giving a bulbous appearance (rhinophyma) - may be clinically inflamed or non-inflamed
- persistent erythema partcuarly centrofacial that may periodically intensify in response to triggers

Major clinical features:
- flushing and transient erythema lasting <5 mins - centrofacial but may spread to neck and chest (flushing is usually the first feature)
- inflamamtory papules and pustules )later it may develop into this!)
- telangiectasia
- ocular manifestations

Minor clinical features:
- burning sensation
- stinging sensation
- skin dryness
- oedema

Question 38

Simple measures for managing rosacea?

Answer 38

Daily application of high-factor sunscreen
Camouflage creams to conceal redness
Uv protection sunglasses for people with features of ocular rosacea
Use of regular non-oily emollients if skin is dry
Gently soap-free OTC cleansers

Question 39

Managing erythema and flushing in rosacea?
How does it work?
How long does it take to work?

Answer 39

Topical brimonidine gel used as required (for pt with flushing but limited telangiectasia)
It’s a topical alpha-adrenergic agonist
Typically reduces redness within 30 mins, reaching peak action at 3-6 hours, after which redness returns to baseline

Question 40

Managing mild-moderate papules or pustules in rosacea?

Answer 40

Topical ivermectin

(Alternatives: topical metronidazole or azelaic acid)

Question 41

Managing moderate-severe papules or pustules in rosacea?

Answer 41

Combination of topical ivermectin and oral doxycycline

Question 42

When should you refer someone for rosacea?

Answer 42

If symptms have not improved with optimal management in primary care-> may require laser therapy if predominant telangiectasia
Pt with a rhinophyma

Question 43

brimonidine gel for rosacea moa

Answer 43

Alpha-2 adrenergic agonist
Constricts dilated facial blood vessels to reduce the redness

Question 44

What is ivermectin?

Answer 44

An antihelminitic and insecticidal preparation

Question 45

What can exacerbate rosacea symptoms?

Answer 45

Heat
Alcohol
Sun exposure
Warm baths
Stress
Spicy foods
Irritating cosmetic products

Question 46

Which acne Tx are contraindicated during pregnancy?

Answer 46

Topical retinoids
Oral tetracyclines
Isotretinoin (oral retinoid)