Acne Flashcards by Samantha Polly

Acne gender predisposition

Most severe form more common in men but more persistent acne in females

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Post adolescent acne

Can be correlated with smoking
Low grade, mostly comedonal
Possibly hyperandrogen related as classically flares before menses
Distributed on lower face/mandible

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Acne inflammatory lesions

Papules
Pustules
Nodules

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Acne noninflammatory lesions

Closed and open comedones

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Inflammatory Acne grading

Mild: just papules and or pustules (up to 20 pustules)
Moderate: can have nodules
Severe: many nodules
Other factors: scaring, persistent drainage, sinus tracts

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Acne treatment: mild non inflammatory acne

Start with retinoid-> should work in 1-2 mo-> can add BPO/topical antibiotic combo and increase tretinoin strength
-initially can alternate the tretinion and BPO/antibiotic wash at night and increase to tretinoin at night and BPO in am as tolerated

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Acne treatment: mild inflammatory

Start with retinoids +/- topical antibiotic/BPO
Can add oral antibiotic (3mo trial)
If female and still need more tx: can add spironolactone

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Acne tx moderate inflammatory

Start with topical antibiotics (drying agent) with BPO (can add oral antibiotic as well)
If not controlled in 2 months, can add retinoid
If still flaring, can consider acutane or spironolactone

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Acne tx severe inflammatory

If minimal scaring: try conventional topical and oral before acutane
If significant scaring:
Can go straight to acutane

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Notes on doxycycline

Photo toxicity
Dyspepsia (can take with food)
Don’t use in kids under 12

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Notes on minocycline

Dizziness/vertigo
Blue grey skin staining
Hepatotoxicity
Lupus-like syndrome
Not to use in kids under 12
Can cause pseudotumor cerebri

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Bactrim notes

Good alternative for severe inflammatory acne if acutane contraindicated
Can cause SJS
Okay for use in kids over 2mo

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Erythromycin notes

Useful in pediatric population

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Which acne treatments act by normalizing the pattern of follicular keratinization

Tretinion

Acutane

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Which acne treatments act by inhibiting sebaceous gland function

OCPs
Low dose oral steroids
Acutane
Spironolactone

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Which acne treatments act by anti inflammatory effect

Intralesional steroids
NSAIDs
Oral steroids (high dose)
Antibiotics by preventing neutrophil chemotaxis

Which acne treatments act by antibacterial effect

BPO
Topical and oral antibiotics
Accutane

What type of bacteria is p. Acnes

Anaerobic diptheroid

How to differentiate between a closed comedone and small pustule

Closed comedowns can typically be accentuated with skin stretching

Types of nodulocystic acne

Pyoderma faciale
Localized/Diffuse cystic acne
Acne conglobata
Acne fulminans

Pyoderma faciale

Confined to face of adult women
Rapid onset
Spontaneous purulent drainage from cysts

Acne fulminans

Ulcerative form
Acute onset with systemic symptoms: arthralgias and severe muscle pain
MC seen in adolescent white males
Can see fever and weight loss

Acne conglobata

Chronic condition
Involved areas with double comedones, communicating cysts, and draining sinus tracts
Sometimes associated with hidradenitis suppurativa and dissecting cellulitis of the scalp

Special actions of specific retinoids azalaic acid and adapalene

Azalaic acid: strong antibacterial potency

Adapalene: anti inflammatory activity

Tretinoin time course/what to expect

1-4 weeks: redness/irritation which should resolve in a month 3-6 weeks: May see new papules or pustules due to comedone irritation After 6 weeks: should see improvement by 9-12 weeks

Four main topical retinoids

Tretinoin Tarazotene Adapalene Azelaic acid

Gram negative acne

Can be seen when new pustules/cysts develop after long term antibiotic use

Ampicillin in acne

Can be used for gram negative acne | Can be used in pregnancy/breastfeeding

When to consider hormone labs in acne

Women with rapid onset acne, hirsutism, androgenic alopecia or other virilization signs or if concerned for Cushings: Labs to check: total and freetestosterone, prolactin, LH, FSH, lipid profile, glucose tolerance, and DHEAS

Hormonal acne treatments and indication

OCPs: failed antibx, free testosterone elevated Spironolactone: failed antibx Dexamethasone/Prednisone: DHEAS elevated or no response to the previous two

Isotretinoin dosing

Cumulative dose of 120-150mg/kg which determines remission rate Goal of 1mg/kg/day unless patients are older (especially men) Start with lower dosages and titrate up Usually treat for 4 to 5 months

Isotretinoin efficacy

39% relapse rate 23% require antibiotics 17% require additional isotretinoin

Very “greasy” acne treatment

A good add on therapy is sulfacetamide/sulfur lotion to dry skin out

Who relapses on Isotretinoin

Younger patients (14-19) More severe acne Truncal acne

Side-effects of Isotretinoin

``` Teratogenicity Increased triglycerides Asymptomatic bone spurs Cheilitis Acute conjunctivitis Muscle pains Exuberant granulation tissue at severe acne sites ```

Steroid acne

Sudden onset of uniformly sized, symmetrically distributed papules and pustules on the neck, chest, and back No scarring

Infantile vs neonatal acne

Neonatal: caused by maternal androgens and common Infantile: rare with male predominance, inflammatory pattern. Typically takes 18 months to clear

Acne mechanica

Acneiform eruption at sites of mechanical pressure (chin straps, etc)