Acne Flashcards
what are the 3 pathophysiological processes involved in the development of acne
- increase in sebum secretion
- hypercornification of follicular lining leading to sebaceaous gland obstruction
- overgrowth of p.acneus inside the pilosebaceous ducts leading to subsequent inflammation
what do androgen hormones do to sebaceous gland production
increase it
at what point do adrenergic surges happen
adrenarche (early puberty 10-14) and puberty
are patients with acne hyper-adrenergic
no, they have normal circulating levels but there may be a decrease in androgen binding globulins in the blood, or there is androgen hypersensitivity to normal levels
what causes artificial hyper-adrenergic states
anabolic steroids
PCOS
cushings
what causes micocomedomes in acne
kertinocytes lining the sebaceous gland become hyperkeratotic and start to shed causing duct occlusion - causing the ‘blocked pore’ , which is a build up of lipid-rich keratinous material
what causes p.acneus proliferation in the sebum ducts
the bacteria love the sebum rich environment and proliferate, aggregating proinflammatory mediators through neutrophil activation and cytokine release
what are blackheads and what causes them
open comedomes - they represent a distended pilosebaceous unit with a dilated orifice which is impacted with keratin and lipid
what are whiteheads
closed comedomes
what are the non-inflammatroy lesions of acne
closed and open comedomes
what are the inflammatory lesions of acne
small papules
inflammatory nodules
cysts
abscesses
why does a closed comedome bursting cause superficial irritation
it releases irritant fatty acids into the surrounding dermis and causes papules and pustules
what type of acne causes cystic acne
acne conglobate
when does acne cause scarring
usually post a large inflammatory period
what are the 2 broad types of scarring
loss of collagen (hypotrophic)
too much collagen (hypertrophic)
what are examples of hypotrophic scarring
ice-pick scars macular atrophic scars box car scars rolling scars deep atrophic scars depressed fibrotic scars
what are examples of hypertrophic scars
keyloid scarring
where is keyloid scarring more common and in what population
upper back/chest/shoulders and more common with people with darker skin
what are some aggrevating factors for acne
oily cosmetics facial treatments - sauna/massage squeezing lesions OCP potent steroids
what are the types of acne
acne vulgaris cystic acne/acne conglobate acne fulminans Acne excoriee neonatal acne infantile acne endocrine acne occupational acne tropical acne cosmetic acne medication acne
what is the most common type of acne and by how much
acne vulgaris - 85% of 12-24 year olds with acne
when is acne vulgaris more likely to persist
women
what is acne fulminans
fulminant acne, a very serious but rare form occuring usually after a failure to treat cystic acne
what is acne excoriee and who is more likely to have it
rare acne where the lesions have been compulsively squeezed/scratches
associated more with younger girls + those with mental health problems
what are the features of infantile acne
2-12 months
M>F
usually facial
what is used to treat infantile acne
erythromycin
whats aspects of jobs are associated with occupational acne
working with hot oil/grease/tar
what are the features of tropical acne
usually younger caucasians in hot climate, causing lesions on the trunk (usually back) - face is spared
resolves on moving to a milder climate
how is acne classified usually
number of lesions and type of lesions
what is the classification for acne
mild - <20 comedomes/<15inflammatory lesions/<30 both
moderate - 20-100 comedomes/15-50 inflammatory lesions/30-125 lesions
severe - >5 psuedocysts/>100 comedomes/>50 inflammatory lesions/>125 total
what is the first line treatment for mild/moderate acne
topical agents only (Benozyl peroxide/retinoid), topical Abx if required, 1-2 a week up to daily if required
what is the first line treatment for moderate acne (worse than mild-moderate), or mild-moderate acne with treatment failure
systemic antibiotic for 3 months with co-prescribed topical agent - usually doxycycline/limecycline
if no effect try another antibiotic (max 2)
what happens if after 2 systemic antibiotics there is no resolution
dermatology referral (isotretinoin is probably required but only dermatologists can prescribe)
what antibiotic tends to be avoided systemically, but it used in pregnancy
macrolides - such as erythromycin
apart from treatment failure, what other acne cases require a dermatology referral
any cases of severe acne ?acne conglobata/fulminans visible scars severe psychological distress - no matter the severity of acne unsure of diagnosis
what is the follow up reccomendation for acne treatment
follow up in 8-12 weeks
if acne clear - continue with topical treatment
Sufficient response = continue treatment for 12 weeks,
Insufficient response = consider adherence to treatment, adverse effects, progression to more severe acne, or use of comedongenic make up or face creams. Discuss a trial of an alternative formulation or move on to the next step in treatment if appropriate.
what are retinoids
Vitamin A derivatives
what are retinoids best against + why
comedomes, as they remove the keratin plug unblocking pores and allowing drainage, and they also have a secondary action that prevents new lesions forming
what are side effects of retinoids
They’re teratogenic
irritation
photosensitivity
erythema
what is benozyl peroxide
topical antibacterial agent
what is benozyl peroxide best against
pustular/inflammatory/cystic acne
what are side effects of retinoids
irritation
erythema
bleaching of clothes
what are common topical antibiotic agents for acne (excluding benozyl peroxide)
erythromycin + clindamycin
what must all topical antibiotics be prescribed with
benozyl peroxide
what are first line systemic antibiotic agents for acne + what is the usual dose/course
doxycycline - 100mg O.D
lymecycline - 408mg O.D
max 3 months
what are side effects of doxycycline/limecycline for systemic acne treatment
abnormal bone growth in foetus
teeth disclolouration
who is doxycycline/lymecycline for systemic acne treatment contraindicated for
pregnant women
breastfeeding women
children under 12
what is often used off-license as a 3rd line systemic antibiotic for acne treatment
trimethoprim
how long should you continue an antibiotic with no effect
up to 6 weeks - if no change after 6 weeks change to another Abx
what should you do when prescribing systemic and topical antibiotics for acne
make sure they are the same to prevent resistance
when is hormonal treatment used for acne
mostly in women
what is the hormonal option for acne
dianette pill - oral contraceptive containing oestrogen and an anti-androgen (cyproterone-acetate)
when is hormonal treatment used for acne
in women with moderate-severe acne that failed to respond to systemic antibiotics, or women with hyperandrogenism
when is hormonal treatment contraindicated for acne
pregnancy
breast feeding
PMH/FH of idiopathic thromboembolism
known/current thrombosis/emoblic disorder
what is isotretinoin
retinoid used as last line result for acne
what are the indications for isotretinoin
Severe acne
Active acne with scarring
Resistant disease
Rapid relapses
Psychiatric/psychological distress
what does isotretinoin require if being taken by females
that they be on two forms of contraception - they can refuse but they have to sign a waiver
what are the side effects of isotretinoin
Mood disturbance
Dry skin
Cracked lips,
Nose bleeds
Hair loss
Alteration of liver and lipid enzymes
High Teratogenicity
what mandatory tests are required before commencing isotretinoin + during its course
FBC
LFT
pregnancy test if female
fasting lipids
done before starting then 1 month in
how is isotretinoin used as an acne treatment
monotherapy - all other therapies should stop
how long is an isotretinoin course
4-6 months
whats the effectiveness of isotrerinoin
70-78% effective
whats the typical dose for isotretinoin
500 micrograms/kg daily in 1–2 divided doses, increased if necessary to 1 mg/kg daily for 16–24 weeks, repeat treatment course after a period of at least 8 weeks if relapse after first course; maximum 150 mg/kg per course.
when should you treat acne scarring
when the disease has settled
what are options for treating acne scars
Microdermabrasion Dermabrasion Laser resurfacing - atrophic scars Punch biopsy Intralesional steroids - keyloid scarring
what are disadvantages of laser resurfacing treatment for atrophic acne scars
may cause pigment change
no nhs funding
when are punch biopsies used for acne scar treatments
mainly for large ice pick scars
