Acne

Question 1

Describe the process of acne vulgaris

Answer 1

Basal keratinocyte proliferation in pilosebaceous follicles (Androgen and corticotropin releasing hormone driven)
Increased sebum production
Propionibacterium acnes colonization
Ifnalmmation
Comedones (white and black heads) blocking secretions
Hence papules, nodules, cysts and scars (face, neck and upper torso)

Question 2

What are features of acne vulgaris?

Answer 2

Comedones due to a dilated sebaceous follicle
If the top is closed a whitehead is seen
If the top opens a beachhead forms

Inflammatory lesions form when the follicle bursts releasing irritants: papules, pustules

Excessive inflammatory response may result in nodules, cysts

Sequnence causes scarring

Question 3

What is acne fulminans?

Answer 3

Very severe acne associated with systemic upset (fever)

Usually responds to oral steroids

Question 4

What is mild acne? Management?

Answer 4

Open and closed comedones with or without sparse infalmmatory lesions
Mainly facial comedones

Topical benzoyl peroxide
Or topical retinoid (avoid in pregnancy)
or Topical antibiotic alone

Treatment takes up to 8 weeks to be effective
If ineffective consider combination of topical antibiotic with benzoyl peroxide or topical retinoid

Question 5

What is moderate acne? Management?

Answer 5

Widespread lesions - numerous papules and pustules affecting face ± torso

Topical antibiotic combined with benzoyl peroxide or topical retinoid for ma 12 weeks

Oral antibiotic - tetracycline, doxycycline are first line
Erythromycin if pregnant or <12
Use for 4-6 months with topical benzoyl peroxide

Consider a standard COCP if contraception is required

Question 6

What is severe acne? Management?

Answer 6

Nodules, cysts, pitting, scarring, inflammatory papules and putules

Refer
Oral Isotretinoin (reduces sebum production and pituitary hormones)
- teratogenic

Question 7

What are options for treatment in acne?

Answer 7

Single topical therapy
Topical combination therapy (topical abx, benzoyl peroxide, topical retinoid)
Oral antibiotics for 3-4 months
Oral isotretinoin

Question 8

What is rosacea?

Answer 8

Chronic relapsing/remitting disorder of blood vessels and pilosebaceous units in central facial areas typically in fair-skinned people

Question 9

What are features of rosacea?

Answer 9

Pre-Rosacea features: flushing triggered by stress/blushing, alcohol and spice

Central facial rash (usually symmetrical) with erythema, telangiectasia, papules, pustules (without comedones) , inflammatory nodules ± facial lymphedema, belpharitis and conjunctivitis

Typically affects nose, cheeks and forehead
Flushing is often first symptom
Telangiectasia are common
Later develops into persistent erythema with papules and pustules
Rhinophyma
Ocular involvement: blepharitis

Question 10

What is management of mild rosacea?

Answer 10

Mild (limited number of papules and pustules) - topical metronidazole
Daily high factor sunscreen
Camouflage creams
Laser therapy for prominent telangiectasia

Question 11

What treatment for moderate/severe rosacea?

Answer 11

Moderate/severe - oral tetracycline or erythromycin for 4m
Daily high factor sunscreen
Camouflage creams
Laser therapy for prominent telangiectasia

Question 12

What is treatment for prominent telangiectasia in rosacea?

Answer 12

Laser therapy

Question 13

What are side effects of isotretinoin?

Answer 13

Dry mouth
Dry nose - epistaxis
Dry skin
Dry mood - low mood
Teratogenicity - must be on contraception

Intracranial hypertension esp. if with tetracycline so must be off tetracycline