Acne

Question 1

what are the 3 pathophysiological processes involved in the development of acne

Answer 1

1. increase in sebum secretion
2. hypercornification of follicular lining leading to sebaceaous gland obstruction
3. overgrowth of p.acneus inside the pilosebaceous ducts leading to subsequent inflammation

Question 2

what do androgen hormones do to sebaceous gland production

Answer 2

increase it

Question 3

at what point do adrenergic surges happen

Answer 3

adrenarche (early puberty 10-14) and puberty

Question 4

are patients with acne hyper-adrenergic

Answer 4

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

Question 5

what causes artificial hyper-adrenergic states

Answer 5

anabolic steroids
PCOS
cushings

Question 6

what causes micocomedomes in acne

Answer 6

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

Question 7

what causes p.acneus proliferation in the sebum ducts

Answer 7

the bacteria love the sebum rich environment and proliferate, aggregating proinflammatory mediators through neutrophil activation and cytokine release

Question 8

what are blackheads and what causes them

Answer 8

open comedomes - they represent a distended pilosebaceous unit with a dilated orifice which is impacted with keratin and lipid

Question 9

what are whiteheads

Answer 9

closed comedomes

Question 10

what are the non-inflammatroy lesions of acne

Answer 10

closed and open comedomes

Question 11

what are the inflammatory lesions of acne

Answer 11

small papules
inflammatory nodules
cysts
abscesses

Question 12

why does a closed comedome bursting cause superficial irritation

Answer 12

it releases irritant fatty acids into the surrounding dermis and causes papules and pustules

Question 13

what type of acne causes cystic acne

Answer 13

acne conglobate

Question 14

when does acne cause scarring

Answer 14

usually post a large inflammatory period

Question 15

what are the 2 broad types of scarring

Answer 15

loss of collagen (hypotrophic)

too much collagen (hypertrophic)

Question 16

what are examples of hypotrophic scarring

Answer 16

ice-pick scars
macular atrophic scars
box car scars
rolling scars 
deep atrophic scars
depressed fibrotic scars

Question 17

what are examples of hypertrophic scars

Answer 17

keyloid scarring

Question 18

where is keyloid scarring more common and in what population

Answer 18

upper back/chest/shoulders and more common with people with darker skin

Question 19

what are some aggrevating factors for acne

Answer 19

oily cosmetics 
facial treatments - sauna/massage 
squeezing lesions
OCP
potent steroids

Question 20

what are the types of acne

Answer 20

acne vulgaris
cystic acne/acne conglobate
acne fulminans
Acne excoriee
neonatal acne
infantile acne
endocrine acne
occupational acne
tropical acne
cosmetic acne
medication acne

Question 21

what is the most common type of acne and by how much

Answer 21

acne vulgaris - 85% of 12-24 year olds with acne

Question 22

when is acne vulgaris more likely to persist

Answer 22

women

Question 23

what is acne fulminans

Answer 23

fulminant acne, a very serious but rare form occuring usually after a failure to treat cystic acne

Question 24

what is acne excoriee and who is more likely to have it

Answer 24

rare acne where the lesions have been compulsively squeezed/scratches

associated more with younger girls + those with mental health problems

Question 25

what are the features of infantile acne

Answer 25

2-12 months M>F usually facial

Question 26

what is used to treat infantile acne

Answer 26

erythromycin

Question 27

whats aspects of jobs are associated with occupational acne

Answer 27

working with hot oil/grease/tar

Question 28

what are the features of tropical acne

Answer 28

usually younger caucasians in hot climate, causing lesions on the trunk (usually back) - face is spared resolves on moving to a milder climate

Question 29

how is acne classified usually

Answer 29

number of lesions and type of lesions

Question 30

what is the classification for acne

Answer 30

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

Question 31

what is the first line treatment for mild/moderate acne

Answer 31

topical agents only (Benozyl peroxide/retinoid), topical Abx if required, 1-2 a week up to daily if required

Question 32

what is the first line treatment for moderate acne (worse than mild-moderate), or mild-moderate acne with treatment failure

Answer 32

systemic antibiotic for 3 months with co-prescribed topical agent - usually doxycycline/limecycline if no effect try another antibiotic (max 2)

Question 33

what happens if after 2 systemic antibiotics there is no resolution

Answer 33

dermatology referral (isotretinoin is probably required but only dermatologists can prescribe)

Question 34

what antibiotic tends to be avoided systemically, but it used in pregnancy

Answer 34

macrolides - such as erythromycin

Question 35

apart from treatment failure, what other acne cases require a dermatology referral

Answer 35

``` any cases of severe acne ?acne conglobata/fulminans visible scars severe psychological distress - no matter the severity of acne unsure of diagnosis ```

Question 36

what is the follow up reccomendation for acne treatment

Answer 36

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.

Question 37

what are retinoids

Answer 37

Vitamin A derivatives

Question 38

what are retinoids best against + why

Answer 38

comedomes, as they remove the keratin plug unblocking pores and allowing drainage, and they also have a secondary action that prevents new lesions forming

Question 39

what are side effects of retinoids

Answer 39

They're teratogenic irritation photosensitivity erythema

Question 40

what is benozyl peroxide

Answer 40

topical antibacterial agent

Question 41

what is benozyl peroxide best against

Answer 41

pustular/inflammatory/cystic acne

Question 42

what are side effects of retinoids

Answer 42

irritation erythema bleaching of clothes

Question 43

what are common topical antibiotic agents for acne (excluding benozyl peroxide)

Answer 43

erythromycin + clindamycin

Question 44

what must all topical antibiotics be prescribed with

Answer 44

benozyl peroxide

Question 45

what are first line systemic antibiotic agents for acne + what is the usual dose/course

Answer 45

doxycycline - 100mg O.D lymecycline - 408mg O.D max 3 months

Question 46

what are side effects of doxycycline/limecycline for systemic acne treatment

Answer 46

abnormal bone growth in foetus | teeth disclolouration

Question 47

who is doxycycline/lymecycline for systemic acne treatment contraindicated for

Answer 47

pregnant women breastfeeding women children under 12

Question 48

what is often used off-license as a 3rd line systemic antibiotic for acne treatment

Answer 48

trimethoprim

Question 49

how long should you continue an antibiotic with no effect

Answer 49

up to 6 weeks - if no change after 6 weeks change to another Abx

Question 50

what should you do when prescribing systemic and topical antibiotics for acne

Answer 50

make sure they are the same to prevent resistance

Question 51

when is hormonal treatment used for acne

Answer 51

mostly in women

Question 52

what is the hormonal option for acne

Answer 52

dianette pill - oral contraceptive containing oestrogen and an anti-androgen (cyproterone-acetate)

Question 53

when is hormonal treatment used for acne

Answer 53

in women with moderate-severe acne that failed to respond to systemic antibiotics, or women with hyperandrogenism

Question 54

when is hormonal treatment contraindicated for acne

Answer 54

pregnancy breast feeding PMH/FH of idiopathic thromboembolism known/current thrombosis/emoblic disorder

Question 55

what is isotretinoin

Answer 55

retinoid used as last line result for acne

Question 56

what are the indications for isotretinoin

Answer 56

Severe acne Active acne with scarring Resistant disease Rapid relapses Psychiatric/psychological distress

Question 57

what does isotretinoin require if being taken by females

Answer 57

that they be on two forms of contraception - they can refuse but they have to sign a waiver

Question 58

what are the side effects of isotretinoin

Answer 58

Mood disturbance Dry skin Cracked lips, Nose bleeds Hair loss Alteration of liver and lipid enzymes High Teratogenicity

Question 59

what mandatory tests are required before commencing isotretinoin + during its course

Answer 59

FBC LFT pregnancy test if female fasting lipids done before starting then 1 month in

Question 60

how is isotretinoin used as an acne treatment

Answer 60

monotherapy - all other therapies should stop

Question 61

how long is an isotretinoin course

Answer 61

4-6 months

Question 62

whats the effectiveness of isotrerinoin

Answer 62

70-78% effective

Question 63

whats the typical dose for isotretinoin

Answer 63

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.

Question 64

when should you treat acne scarring

Answer 64

when the disease has settled

Question 65

what are options for treating acne scars

Answer 65

``` Microdermabrasion Dermabrasion Laser resurfacing - atrophic scars Punch biopsy Intralesional steroids - keyloid scarring ```

Question 66

what are disadvantages of laser resurfacing treatment for atrophic acne scars

Answer 66

may cause pigment change | no nhs funding

Question 67

when are punch biopsies used for acne scar treatments

Answer 67

mainly for large ice pick scars