Acne Flashcards

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1
Q

acne types

A

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,

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2
Q

impact

A
self-esteem and lack of confidence (67%)
depression, anxiety (63%)
anger/frustration
embarrassment (63%), shame (70%)
social isolation (57%)
unemployment/poor academics
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3
Q

anatomy/physiology

A

follicular pore in epidermis
canal/duct through dermis
sebaceous gland and hair follicle in dermis
sebum oil

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4
Q

pathogenesis - general (3)

A

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

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5
Q

lesions - non-inflammatory

A

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

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6
Q

lesions - inflammatory

A

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

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7
Q

resolution

A

after small superficial inflammatory lesions (pap/pust); temporary

erythematous macules
hyperpigmented and/or hypopigmented macules

(colour changes)

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8
Q

scarring

A

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

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9
Q

diagnosis/DDx

A

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

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10
Q

severity

A

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

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11
Q

aggravating factors

A

occlusion
heat/humidity
trauma e.g. vigorous washing
exogenous meds: steroids, POP/high progesterone pills

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12
Q

treatment - summary

A

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

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13
Q

education - Rx

A

causes
myth-busting
therapy options, pros/cons, recommendations, SE
risk of scarring

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14
Q

topical antibacterials

A

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

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15
Q

topical abx

A

reduce inflammation and bacteria

erythromycin/clindamycin: tolerated but resistance (better w/combo e.g. BPO; 6/12 max)

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16
Q

topical retinoids

isotretinoin, tretinoin (Retin-A), adapalene (Differin)

A

reduce comedones: unblock (surface keratin off), prevents new lesions and inflammation

first line for comedone
SE: teratogenic, irritant, photosensivity
*adapalene = anti-inflam

17
Q

systemic ABx

A

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)

18
Q

systemic retinoids

roaccutane/isotretinoin (0.5-1mg/kg for 4-6months - cumulative dose)

SINGLE AGENT (no combo)

A

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
19
Q

systemic hormones

Dianette (COCP + anti-androgen crpyroterone acetate)

A

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

20
Q

scar treatment

A

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)
21
Q

acne vulgaris

A

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

22
Q

acne rosacea

papulopustular (commonest)
erythematotelangiectasia
phymatous (thickening/rhino)
ocular

A

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)