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)
topical retinoids
isotretinoin, tretinoin (Retin-A), adapalene (Differin)
reduce comedones: unblock (surface keratin off), prevents new lesions and inflammation
first line for comedone
SE: teratogenic, irritant, photosensivity
*adapalene = anti-inflam
systemic ABx
reduce inflammation and bacteria: 40% improve in 2/12, 60% 4/12, 80-90% 6/12
tetracyclines 1st line
erythromycin, trimethoprim
SE: GI, resistance, ototox/nephrotox, teratogenic (TCs)
systemic retinoids
roaccutane/isotretinoin (0.5-1mg/kg for 4-6months - cumulative dose)
SINGLE AGENT (no combo)
targets glands: reduce comedones, gland size, sebum, bacteria and inflammation
severe acne, scarring, Rx-resistant, rapid relapse after PO, psych impact
longer remission, relapse 22-30%
SE: test before + 1/12
- teratogenic (incl. BF): 2x contraception + monthly tests (1 pre + 3 post-Rx)
- mucocutaneous: dry, itchy, epistaxis, fragile, hair loss
- metabolic: lipids, LFTs
- MSK: arthralgia, myalgia
- other: night vision, depression
systemic hormones
Dianette (COCP + anti-androgen crpyroterone acetate)
reduce sebum (androgens/SER)
useful for female patients resistant to PO ABx, or ?hyperandro, ?menstrual flares
also for seborrhoea/persistent inflammation
CI: preggo, DVT/VTE, migraines, FHx
scar treatment
once settled >1y (sensitivity)
microdermabrasion/dermabrasion (supf scars) laser resurfacing (atrophic scars) risk of pigment change punch biopsy (large ice pick scars) intralesional steroids (keloid)
acne vulgaris
papules, pustules, greasy, comedones
up to 85% of 12-24yo; M>F (but female longer: 30% vs. 10% until 25, 12 vs. 3 until 44)
onset in puberty, earlier in F, can be late 20s/30s
most resolve by late teens/early 20s
acne rosacea
papulopustular (commonest)
erythematotelangiectasia
phymatous (thickening/rhino)
ocular
flushing cheeks/forehead, gritty eye, facial swelling
rhinothyma, irregular nodules, telangiectasia, papulopustular
triggers: heat, alcohol, emotion
Rx: avoidance, clonidine/brumonadine, topical ivermectin/metroniidazole, tetracycline/erythro (Severe), pulse/laser (telangiectasia)
