Acne, Actinic keratosis, Pityriasis rosea, Psoriasis, Rosacea Flashcards
Acne Vulgaris: What is it?
- most common skin condition in the U.S.
- begins during puberty and most common in adolescents
- increased androgen production leads to increases in sebum production which leads to:
* Comedones
* Pustules
* Papules
* Cystic nodules
* Scarring
Acne Vulgaris: Risk Factors
- genetics (50% have family history of acne)
- skin trauma
- milk consumption (skim and low-fat)
- high glycemic load diets
- insulin resistance
- low BMI
- worsens with stress and menses
- skin contact with chin straps, shoulder pads
- adolescents
- PCOS, adrenal hyperplasia, hormonal tumors
- white race
- hot, humid climates
Acne Vulgaris: Diagnostic Studies
- clinical exam
- If PCOS, investigate this further
Acne Vulgaris: Prevention
- avoid occupational irritants
- good hand/face hygiene
- frequent gentle cleansing of the skin
- rapid treatment for inflammatory and cystic acne
- avoid anabolic steroids
Acne Vulgaris: Non-Pharmacological Management
- address psychosocial concerns
- phototherapy
- laser therapy
- address stress
- mechanical extraction of comedones does not affect disease course, but may improve appearance
Describe Mild Acne
- scattered, small (< 5 mm), comedonal or inflamed papules or pustules without associated scarring
- limited skin involvement (involvement of one body area or relatively few lesions in more than one body area)
- absence of nodules
- absence of near confluent skin involvement
Describe Moderate-Severe Acne
- visually prominent acne consisting of many comedonal or inflamed papules or pustules
- presence of nodules
- involvement of multiple body areas with more than a few scattered lesions
- associated scarring
Mild Acne Management: Comedonal Lesions (first treatment)
Topical Retinoid:
1. Adapalene
2. Tazarotene
3. Tretinoin topical
4. Trifarotene
Mild Acne Management: Comedonal Lesions (if first treatment has unsatisfactory response)
- Increase concentration of topical retinoid or change to an alternate topical retinoid.
- If still has an unsatisfactory response, switch to treating as moderate or severe acne
Mild Acne Management: Papulopustular +/- Comedonal Lesions (first treatment)
Topical retinoid and benzoyl peroxide:
- if satisfactory response after 3-6 months, transition to topical retinoid therapy only
Mild Acne Management: Papulopustular +/- Comedonal Lesions (if first treatment has unsatisfactory response)
- add topical clindamycin or topical dapsone (to the existing topical retinoid and benzoyl peroxide treatment already in place)
* if this treatment is satisfactory after 3-6 months, then transition to topical retinoid therapy only - if unsatisfactory response, consider alternative topical therapies (clascoterone or minocyocline) or treat as moderate to severe acne
Moderate to Severe Acne Management: Papulopustular and/or nodular lesions are present
Treatment options include: (pick one)
1. Oral tetracycline
2. Combined estrogen-progestin OCP
3. Oral spironolactone
4. Oral isotretinoin
Moderate to Severe Acne Management: Papulopustular and/or nodular lesions are NOT present, comedones only
Treatment options include: (pick one)
1. Combined estrogen-progestin OCP
2. Oral spironolactone
3. Oral isotretinoin
* No tetracycline
Adapalene
- Topical retinoid
- apply daily at bedtime, after washing
- redness, dryness, scaling of skin common in first 2-4 weeks
- caution with other photosensitizing agents (tetracyclines, thiazides, sulfonamides, fluoroquinolones)
- do NOT use on broken skin
Tazarotene
- Topical retinoid
- apply thin film at bedtime, after cleansing
- caution with other photosensitizing agents (tetracyclines, thiazides, sulfonamides, fluoroquinolones)
- do NOT use on more than 20% of body surface
- women of childbearing potential: begin during normal menses
- do NOT use on broken skin
Tretinoin Topical
- Topical retinoid
- apply sparingly to affected areas at bedtime
- improvement may not occur before week 12
- within 2 weeks: peeling, redness in treated areas
- At 3-6 weeks, there could be new blemishes; continue to use
- caution with other photosensitizing agents (tetracyclines, thiazides, sulfonamides, fluoroquinolones)
- do NOT use on broken skin
Trifarotene
- Topical retinoid
- apply thin layer to affected areas of face and/or trunk once a day, in the evening on clean, dry skin
- most common adverse reactions: skin irritation, pruritus, and sunburn
- specifically indicated to treat acne on face and trunk
Benzoyl Peroxide
- initial daily wash, may increase to BID or TID as tolerated
- may bleach fabric or hair
- avoid unnecessary sun exposure and use sunscreen
Actinic Keratosis
- AKA solar keratosis
- usually presents on sun-exposed areas as scaly, red papules or plaques
- may progress to squamous cell carcinoma
Actinic Keratosis: Risk Factors
- common in middle ages and older adults
- more common in men
- more common in those with fair skin or chronic sun exposure, tanning bed use
Actinic Keratosis: Assessment Findings
- round or oval, raised, scaly papules or plaques
- flesh-colored, red, pink, brown, or black
- 2 mm to 5 mm
Actinic Keratosis: Diagnostic Studies
- clinical exam
- possibly a skin biopsy
Actinic Keratosis: Prevention
- sunscreen and protective clothing
- lip balm
Actinic Keratosis: Treatment on Head and Neck (one or a few isolated lesions)
- Flat: cryotherapy (preferred) or curettage and electrodessication
- Hypertrophic:
- if clinically suspicious for cancer, then surgical excision and patho
- if not suspicious for cancer, then cryotherapy with 2 freeze-thaw cycles OR shave removal plus electrodessication
Actinic Keratosis: Treatment on Head and Neck (multiple lesions)
- Discrete, hypertrophic lesions present, then cryotherapy followed by topical fluorouracil
- Discrete, hypertrophic lesions NOT present, then field therapy with topical fluorouracil (preferred)
Actinic Keratosis: Treatment on other body sites such as dorsal hands, forearms, and/or legs
- Cryotherapy followed by topical fluorouracil
OR - gentle curettage followed by photodynamic therapy (PDT)
Actinic Keratosis: When to Refer
- Refer to dermatologist if AK lesions appear with frequency; may require biopsy of lesions or more intensive treatment
- Any lesion unresponsive to topical therapy warrants referral
Fluorouracil
Antineoplastic Treatment for Actinic Keratosis
- apply with fingertips BID, wash hands afterward
- contraindicated in women who are or may become pregnant
- use for 2-6 weeks usually
Pityriasis Rosea: What is it?
- AKA Christmas tree rash
- idiopathic, self-limiting skin disorder characterized by papulosquamous lesions distributed over the trunk and proximal extremities
- cause is unknown, but may be viral or autoimmune
Pityriasis Rosea: Risk Factors
- more common in patients with atopic dermatitis
- slightly more common in females
- more common in older children and young adults
Pityriasis Rosea: Diagnostic Tests
- usually a clinical diagnosis
- may look like ringworm, so may need to do a KOH test on the scales
- if sexually active, do a VDRL/RPR test (to rule out syphilis)
Pityriasis Rosea: Assessment Findings
- “Herald” patch 1-2 weeks before the generalized rash
- salmon-colored oval plaques with fine scales
- mild pruritus
Pityriasis Rosea: Treatment
- Topical antipruritic - calamine lotion
- Oral antihistamines - 1st gen (Benadryl); 2nd gen (Zyrtec, Claritin)
- Medium potency topical steroids (Groups 4 & 5); apply 2-3 times daily for 2-3 weeks (thin layer)
- If severe or not getting better after several weeks, then REFER
Pityriasis Rosea: Topical Corticosteroids
- Betamethasone
- Fluocinolone
- Fluticasone
- Hydrocortisone
- Mometasone
- Triamcinolone
Psoriasis: What is it?
- a chronic, pruritic, inflammatory skin disorder characterized by rapid proliferation of epidermal cells
- frequent remissions and exacerbations
- plaque psoriasis is more common
Psoriasis: Risk Factors
- more common in adults
- men and women affected equally
- strep infection
- family history
- genetics
- low vitamin D
- stress
- smoking, obesity, alcohol
- Drugs: beta blockers, lithium, anti-malarial drugs, systemic steroids
Psoriasis: Assessment Findings
- silvery, white scale on erythematous base
- pruritus
- Positive Auspitz sign (pinpoint bleeding when lesions scraped)
- Koebner phenomenon (when skin lesions appear on healthy skin following a skin injury)
- Pitted nails (particularly common in psoriatic arthritis)
- common distribution on elbows, knees, scalp, gluteal cleft, fingernails, toenails, palms, and soles of feet
Psoriasis: Diagnostic Tests
History and physical exam
Psoriasis: Non-Pharmacologic Treatment
- warm soaks
- moisturizers and emollients
- oatmeal baths
- UV lamps/sunlight
Psoriasis: Pharmacologic Treatment
- Topical steroids
- Systemic treatments
** Limit use of steroids with high potency to less than 2 weeks
Psoriasis: Treatment if able to tolerate topical therapy
- Topical corticosteroid (high or ultra-high potency) not on the face or other sensitive area
WITH or WITHOUT - Vitamin D analog (calcipotriene ointment)
** If good response after 4 weeks, switch to vitamin D analog only
** If suboptimal response, adjust topical therapy or add intralesional corticosteroid injections
** If still unsatisfactory response, switch to systemic therapy
Psoriasis: Treatment if topical therapy is not feasible
- Phototherapy
* If satisfactory response after 3 months, taper the phototherapy
Psoriasis: Treatment if topical therapy and phototherapy is not feasible or effective
- Systemic therapy which includes
- biologic agents
- small molecule agents
- other nonbiologic agents
** Usually managed by a specialist
Guttate Psoriasis
- AKA Eruptive psoriasis
- more common in children and young adults
- associated with strep throats and may occur several weeks following the infection
- may become a chronic condition, but usually resolves spontaneous over several months
- may occur on any part of the body
- treat with mild steroids and sunlight (Avoid sunburns)
Rosacea: What is it?
- a common chronic disorder of the skin characterized by redness, flushing, and other cutaneous findings, such as telangiectasis and roughened skin
- primarily affects the central face, including the cheeks, chin, nose, and central forehead
- may also experience watery or irritated eyes
- characterized by periods of remission and exacerbation
Rosacea: Risk Factors
- fair skin
- warm temperatures, hot baths, hot drinks
- females over 30
- sunlight, exercise
- alcohol, spicy food
- emotional stress
- hot flashes
Rosacea: Assessment Findings
- erythema
- telangiectasias
- papules and pustules
- burning or stinging with episodes of flushing and extremely cosmetic intolerant skin
- facial distribution
- may also have ophthalmic disease: blepharitis, keratitis, chalazion
Rosacea: Diagnostic Studies
Usually a clinical diagnosis
Rosacea: Non-Pharmacologic Treatments
- avoidance of triggers
- sunscreen
- cool compresses
- frequent skin moisturization
- laser or intense pulsed light therapy
Rosacea: Pharmacologic Treatment for Facial Erythema
- Topical brimonidine tartrate 0.33% gel
- Topical oxymetazoline
** Monitor for hypotension (affects vasodilation)
Rosacea: Pharmacologic Treatment for Papulopustular Disease (mild to moderate)
- Topical metronidazole
- Topical azelaic acid
- Topical ivermectin
Rosacea: Pharmacologic Treatment for Papulopustular Disease (moderate to severe)
- Oral tetracycline
- Oral doxycycline
- Oral minocycline
** May need to combine with a topical therapy
Rosacea: Pharmacologic Treatment for Papulopustular Disease (refractory)
Oral Isotretinoin (teratogenic)
