Acne Flashcards
acne types
acne vulgaris: commonest, rest of LOs; comedones, greasy, inflammation
acne fulminans/condylomata: overactive; nodules, cysts, scars; isotretinoin
acne conglobata: rare, highly inflammatory, abscess
tropical acne: young caucasian, hot/humid climate, acne on trunk
neonatal/infantile: M>F,
impact
self-esteem and lack of confidence (67%) depression, anxiety (63%) anger/frustration embarrassment (63%), shame (70%) social isolation (57%) unemployment/poor academics
anatomy/physiology
follicular pore in epidermis
canal/duct through dermis
sebaceous gland and hair follicle in dermis
sebum oil
pathogenesis - general (3)
comedogenesis: hyperkeratosis + desquamation (SER); debris occludes pore; lipid-filled keratinous material (lipids, keratinocytes, androgens, CK)
seborrhoea: androgens, SER, hypersensitivity; associated with PCOS and tumours (androgens)
infection + inflammation: P. acnes growth in sebum; mediators and exudate; follicle rupture into dermis; inflammation affects barrier function
lesions - non-inflammatory
open comedone: blackhead; open pore, impacted lipid, keratin, melanin; flat or raised +/- inflammation
closed comedone: whitehead; pale elvated papule; difficult to see (stretch skin); more likely to rupture and cause inflammation
lesions - inflammatory
papules and pustules from burst comedones (FFA irritates dermis); 1-2 weeks
nodules (tender) and cysts (rarer); dermal inflammation; weeks/months
can cause scarring or tethering
resolution
after small superficial inflammatory lesions (pap/pust); temporary
erythematous macules
hyperpigmented and/or hypopigmented macules
(colour changes)
scarring
larger inflammatory lesions (nodules, cysts)
lost collagen: ‘ice pick’, macular atrophic, deep atrophic, depressed fibrotic scars
increased collagen: hypertrophic and keloid scars; upper back, chest, shoulders common
diagnosis/DDx
diagnosis: clinical; Ix: endocrine screen
differentials: no comedones
- rosacea
- peri-oral dermatitis
- folliculitis: can be a complication of acne ABx
- DLE
- drug eruption
- endocrine:sudden, severe, hirsutism/hyperandro, menstrual
severity
mild: may have inflam;
moderate: small inflam lesions; no/few large; some inflammation
severe: many small and some large inflam lesions, marked inflammation
very severe: severe inflammation, multiple extensive lesions, scarring
aggravating factors
occlusion
heat/humidity
trauma e.g. vigorous washing
exogenous meds: steroids, POP/high progesterone pills
treatment - summary
3 stages:
patient education
topical medication (at least 6/52): 1st line mild/mod
systemic medication (at least 6/52): 1st line mod/severe, failed topical, or scarring/hyperpigmentation; ?chest/back
*combo best
choice based on severity, impact/QoL, previous Rx responses, SE/CI
education - Rx
causes
myth-busting
therapy options, pros/cons, recommendations, SE
risk of scarring
topical antibacterials
reduce inflammation and bacteria
SE: sensitivity/irritation
apply OD/BD
BPO: anti-inflam (decreases cornification, destruction, less P. acnes), no resistance, better w/ABx combo (duac/benzomycin)
Azelic acid: no resistance, combo best (ABx, BPO, retinoid), less effective than EPO
topical abx
reduce inflammation and bacteria
erythromycin/clindamycin: tolerated but resistance (better w/combo e.g. BPO; 6/12 max)