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Acne and Follicular Disorders Flashcards

1
Q

What are the 5 disorders under the Acne and Follicular disorders umbrella?

A
  1. Acne Vulgaris
  2. Rosacea
  3. Perioral Dermatitis
  4. Folliculitis
  5. Hidradenitis
    Suppurativa
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2
Q

Define Acne Vulgaris

A

A common disorder that affects the pilosebaceous unit of folliclesand can be characterized by both noninflammatory and inflammatory lesions

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3
Q

What are the epidemiological facts about acne vulgaris?

A
  1. 85% of people ages 12-24 yrs old have acne
  2. 100% pubertal boys
  3. 90% pubertal girls
  4. Women develop acne earlier and are more likely to have it in adulthood
  5. Men suffer severe disease 10x more freq
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4
Q

What are the psych consequences of acne vulgaris?

A

Emotional distress associated with acne can exacerbate the condition in a positive-reinforcement loop.
Low self-esteem, social phobias and/or depression relatedto acne-associated cosmetic changes can aggravate adolescent-related psychosocial stressors.
Acne may serve as a focus of complaint in patients with primary psychiatric disorders such as obsessive-compulsive disorder.

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5
Q

What are the physical and psych consequences of acne?

A

Untreated acne vulgaris can have serious physical and psychological consequences
Permanent scarring and disfigurement
Depression and anxiety
Lowered self-esteem
Lowered professional expectations and employability
Social inhibition
Increased risk of suicide or suicidal ideation

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6
Q

What are some reasons for acne treatment failure?

A
  1. Suboptimal medication adherence
  2. Patients unmotivated to adhere to treatment regimens during maintenance phase
  3. Underlying affective disorders (e.g., depression)
  4. A multifactorial approach combining non-pharmacologic interventions and effective, well-tolerated, and simplified drug regimens appears to be associated with the greatest success.
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7
Q

What is acne vulgaris caused by?

A
  1. Sebum secretion
  2. Follicular epidermal hyperproliferation and hyperkeratinization
  3. Proliferation of Propionibacterium acnes
  4. Inflammation and immune response
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8
Q

What is the pathogenesis of acne vulgaris?

A
  1. The primary acne lesion, the microcomedo, is caused by the obstruction of the sebaceous follicle and is the result of follicular epidermal hyperproliferation and hyperkeratinization.
  2. This obstruction occurs when an androgen-induced overproduction of sebum combines with follicular hyperkeratosis and keratotic debris.
  3. Microcomedones may progress to either “open” or “closed” comedones, which create an environment suitable for Propionibacterium acnes (P. acnes) growth.
  4. Proliferation of P. acnes converts sebum to free fatty acids, which produce pro-inflammatory mediators that diffuse through the follicle wall – leading to the development of inflammatory acne lesions.
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9
Q

Where is acne vulgaris most proliferative?

A

Acne affects the areas of the body with the densest population of
sebaceous follicles:
face, neck, back, chest, & shoulders

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10
Q

What are the inflammatory forms of acne vulgaris?

A
  1. Papular/Pustular

2. Nodular/Cystic

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11
Q

What are the non-inflammatory forms of acne vulgaris?

A

Comedonal

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12
Q

What is acne graded by?

A

Lesion counts

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13
Q

What is mild acne?

A

Comedones and a few scattered papules and/or pustules

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14
Q

What is moderate acne?

A

Comedones with many papules and pustules, few nodules

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15
Q

What is severe acne?

A

Numerous papules, pustules, and nodules

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16
Q

What lesions are present in non-inflammatory acne vulgaris?

A
  1. Open blackhead comedomes

2. Closed whitehead comedomes

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17
Q

What are the topical retinoid/comedolytic treatment options for mild comedomal acne?

A
  1. Differin – Mildest, Synthetic that can be used with BPO’s
  2. Retin A – Comes in less irritating microgel vehicle
  3. Tazorac – Strongest, more irritant rxn’s, very few pts can tolerate it
  4. Azelex Acid – Antibx & Comedolytic, Hypopigments: good to reduce hyperpigmentation in darker skinned pts after acne clears
  5. Hydroxy Acids – Alpha’s (Glycolic/Lactic Acids) or Beta’s (Salicytic Acid)
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18
Q

What are the benzoyl peroxide treatment options for mild comedomal acne?

A

Gels/washes qd to BID

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19
Q

What are the benzoyl peroxide treatment for mild comedomal acne used in combo with?

A

Used in combo with topical antibx – no resistance to BPO’s - Duac

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20
Q

What are the topical abx treatment options for mild comedomal acne?

A
  1. Topical Antibiotics QD to BID
    A. Erythromycin – older, more resistance has been seen
    B. Clindamycin or Sulfer products a better choice
    -Exert a bacteriostatic or bactericidal effect on P. acnes, depending on the concentration of the drug at the site of infection
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21
Q

What are the characteristics of papular inflammatory acne?

A 
Inflamed lesions (less than 0.5 cm in diameter) that appear as small, pink to red bumps on the skin
Can be tender to the touch
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22
Q

What are the characteristics of pustular inflammatory acne?

A

Dome-shaped lesions containing pus (a mixture of white blood cells, dead skin cells and bacteria)
These lesions are fragile and may rupture
may progress to cysts

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23
Q

What are the treatment options for moderate acne?

A
  1. Topical Retinoid Therapy QHS
  2. Benzoyl Peroxide Products (gels/washes) QD to BID
  3. Topical Antibiotics QD to BID
  4. Systemic Antibiotics (taper once improved)
  5. Antiandrogenic (Hormonal) Therapy if Female
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24
Q

What are the topical abx options for moderate acne?

A
  1. Drug of Choice: Clindamycin (used >20 yrs, Effective and well-tolerated)
    A. Available in gel, solution, lotion, &pledget forms Now available in a foam
    B. This antibx is able to modulate the release of pro-inflammatory cytokines
  2. Combination products ideal (Duac) - Simplifies Tx plan and Improves compliance
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25
Q

What are the systemic abx options for moderate acne?

A
  1. Tetracycline 250-500mg BID (photosens, not for Preg, GI)
  2. Doxycyline 100mg BID (photosens, not for Preg, GI)
  3. Minocycline 100mg BID (photosens, not for Preg, GI, Vertigo, Grey)
  4. Erythromycin 250-500mg BID (safe in Preg, GI upset, drug interactions)
  5. Septra DS BID (if all else fails, many side effects - allergic rashes and SJS)
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26
Q

What are the anti androgen options for moderate acne?

A
  1. OCP’s – Yasmin, OrthoTricyclen, Estrostep (low androgenic progestin’s)
  2. Spironolactone – Old K+ sparing
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27
Q

What are the characteristics of nodular inflammatory acne?

A

Large solid lesions that are lodged deep within the skin and frequently result in scarring
May be very painful

28
Q

What are the characteristics of cystic inflammatory acne?

A

Sac-like lesions containing pus
Progressed from unresolved pustules
Often painful and result in scarring

29
Q

What are the treatment options for severe acne?

A
  1. Topical Retinoid Therapy QHS
  2. Benzoyl Peroxide Products (gels/washes) QD to BID
  3. Topical Antibiotics QD to BID
  4. Systemic Antibiotics (taper once improved)
  5. Antiandrogenic Therapy if Female
    OR
  6. ISOTRETINOIN Therapy
30
Q

What is isotretinoin therapy?

A

Used for Moderate Acne failed Meds or Severe Acne with Scarring
Produces Remission, Rule of 1/3’s, 5mo Tx course w/ labs monitored
Very $$$, Teratogen (Class X), Common SE’s, ?Depression SE?,
Dosed at 0.5mg – 2.0mg/kg per day (start 1mg/kg)

31
Q

What are the general topical tx options for acne?

A

Hydroxy Acids
Retinoids
Benzoyl Peroxide (BPO)
Antibiotics

32
Q

What are the general systemic tx options for acne?

A

Antibiotics
Retinoids (Isotretinoin)
Hormonal Therapy

33
Q

What are the general adjunctive tx options for acne?

A

Comedo Extraction andDraining of Cysts
Intralesional Corticosteroids
Ultraviolet Light (PDT)
Microdermabrasion

34
Q

What are the general adjunctive tx options for acne scars?

A

Microdermabrasion

Laser Skin Resurfacing

35
Q

What are the characteristics of rosacea?

A
  1. Chronic Skin Disease
  2. Usually symmetrical on Convex areas
    nose, cheeks, forehead and chin
36
Q

What is the etiology of rosecea?

A

?Genetic factors (MC Celtic vs AA)

37
Q

What are the symptoms of rosecea?

A

Symptoms of “flush/blush”, “sensitive skin”, and “pimples”

Certain “Triggers” exacerbate Sx’s

38
Q

What are the characteristics of vascular rosacea?

A
  1. Flusing and Blushing (erythema) +/- telangiectasis
  2. May be Intermittent or Persistent
  3. Triggered by Stress, UVR, Heat (external or internal), or ETOH
39
Q

What is the treatment for intermittent vascular rosacea?

A

No effective therapy other than avoidance of triggering factors

40
Q

What is the treatment for persistent vascular rosacea?

A

“Erythematotelangiectasia” may be effectively treated with Laser Therapy (PDL, CYN)

41
Q

What are the characteristics of papulopustular/inflammatory rosacea?

A
  1. Infl papules and pustules
  2. +/- vascualr sx’s such as persistent central facial erythema
  3. NO COMEDONES!!!
42
Q

What are the tx options for papulopustular/inflammatory rosacea?

A
  1. Metronidazole: Gold standar
  2. Azelaic acid
  3. Sulfacetamide sodium
  4. tretinoin
  5. Tetracycline
  6. Doxycycline: good se profile
  7. Minocycline
  8. Isotretinoin: low dose for years, need pregnancy tests every month
43
Q

What are the characteristics of sebaceous hyperplasia/phymatous rosacea?

A
  1. Chronic deep facial lymphedema secondary to sebacous hypertrophy
  2. Thickening skin, irregular surface nodularities and enlargement. May occur on chin, forehead, cheeks or ears
  3. Rhinophyma describes these severe late stage changes that can occur on the nose
  4. Not caused by ETOH
44
Q

What is the treatment for sebaceous hyperplasia/phymatous rosacea?

A
  1. Treatment consists of treating the inflammatory component
  2. The best Tx for phymatous changes is Plastic Surgical paring, Electrosurgery, or CO2 Laser Surgery
45
Q

What are the characteristics of ocular rosacea?

A
  1. Conjunctival hyperemia, usually bilateral
  2. Telang of the eyelids
  3. Recurring Blephartitis and Chalazions
  4. Think of ocular rosacea when Allergic Conj continues to fail Tx
  5. FB sensation in eye, burning, stinging, dryness, itching, blurred vision, periorbital edema
46
Q

What are the tx options for ocular rosacea?

A
  1. Treated best with Systemic Rosacea Tx, not topical
47
Q

What are the characteristic sof granulomatous/variant rosacea?

A

Firm, brown, yellow, or red cutaneous papules or nodules of uniform size

48
Q

Define perioral dermatitis

A
  1. Thought to be variant of Rosacea
  2. Distinctive asymptomatic chronic eruption around mouth, eyes, and nose (spares vermillion border)
  3. Periorificial term used more presently b/c of multi orifice involvement in some cases
  4. Seen MC in young females
  5. Relapse is common
49
Q

What is the etiology of perioral dermatitis?

A

Etiology unknown - believed to be secondary to heavy emoillents or Topical Cortical Steroid misuse

50
Q

What is the tx of perioral/periorificial dermatitis?

A
  1. Systemic Rosacea Antibx
    A. Tetra/Doxy/Minocycline
    B. Clears in 2-4wks
  2. Topical Rosacea meds for maintenance
  3. Avoid prolonged use of strong TCS to face
  4. Gentle Skin Care, avoiding heavy emoillents
51
Q

Define Folliculitis

A
  1. Infl of hair follicles MC due to Staph Aureus
  2. Usually an abrupt eruption
  3. Spread by trauma, shaving
  4. Distributed over hair bearing areas
52
Q

What are the types of folliculitis?

A

Bact x 2, Hot Tub, PFB, AKN, Occlusion, Mechanical, Steroidal, Gram-Neg, Eosinophilic, Fungal

53
Q

What are the two bacterial forms of folliculitis?

A
  1. Superficial form:
    Follicular Impetigo
  2. Deep form:
    Sycosis Barbae
54
Q

What are the physical characteristics of folliculitis?

A
  1. Small 1-3mm
  2. Erythematous Halo’s
  3. Papules/Pustules
  4. +/- Excoriations/Crusting
  5. Arranged Perifollicularly
  6. Distributed to hairy areas such as scalp, arms, legs, axilla, and trunk
55
Q

How is folliculitis diagnosed?

A
  1. Culture (MC due to Staph A.
  2. KOH (r/o dermatophyte)
  3. Good history to determine type
56
Q

How is folliculitis treated?

A
  1. Minimize heat, friction, occlusion
  2. Antibacterial Soaps (OTC or BPO’s)
  3. Localized Superficial type – Bactroban
  4. Generalized &/or Deep – Oral Antibx
    A. Dicloxacillin 500mg BID x 10 days
    B. Keflex 500mg BID x 10days
  5. Antifungal Tx for Dermatophyte inf.
57
Q

What subtypes cause hot tub folliculitis? When does it occur?

A
  1. P. aeruginosa serotypes 0:9 & 0:11

2. Occurs 1-3 days after exposure

58
Q

How is hot tub folliculitis treated? How is it prevented?

A
  1. Self limited disease 7-10days
  2. Severe or recurrent – Oral Antibx
    A. Cipro 500mg BID x 5-10days
  3. Prevent by proper hot tub care
    A. Frequent draining q4-8wks
    B. Maintain proper chemical levels
    C. Clean Filters routinely
59
Q

Define Psuedofolliculitis

A
  1. Papular/Pustular foreign body rxn
    A. Affects MC curly haired pt’s who shave closely on a regular basis (Military)
    B. African American – 50 –75%, Caucasian – 3-5%
    C. Most severly affected site is the neck
    D. Chr problem unless shaving’s avoided
    E. Can result in scarring and hyperpig.
60
Q

What is the treatment for Pseudofolliculitis?

A

Treatment aimed at dislodging imbedded hair shaft, proper shaving instruction, and meds used to try and soften hairs to prevent ingrown

61
Q

Define Acne Keloidalis Nuchae

A
  1. Form of scarring alopecia
  2. MC in young AA men
  3. Folliculocentric keloidal papules on the occipital-nuchal region
  4. Papules may coalesce to form giant scarring plaques
62
Q

What is the treatment of Acne Keloidalis Nuchae?

A
  1. Thought best to prevent by minimizing trauma to area (Avoid close cuts, Hats, Collars)
63
Q

Define Hidradenitis Suppurativa

A
  1. A chronic, suppurative, recurring scarring inflammatory disease
  2. Affects apocrine gland follicles
  3. Axilla and Groin MC sites (Perineum, Buttocks, Neck and Scalp also affected)
  4. MC in females and in Obesity
  5. Begins after puberty
64
Q

How is Hidradenitis Suppurativa diagnosed?

A
  1. Diagnosed clinically
    A. Skin Biopsy if in doubt
    B. Diff Dx – Acne, Furuncle/Carbuncle
65
Q

What are the physical sxs of Hidradenitis Suppurativa?

A
  1. Varied in sizes
  2. Inflammatory
  3. Nodules/Abscesses with sinus tract formation
  4. Double open comedones
  5. Hypertrophic Scarring (cordlike bands crisscrossing)
  6. Grouped or Coalescing
  7. Distributed to Axilla, Groin, or Buttocks
66
Q

What are the tx options of Hidradenitis Suppurativa?

A 
1. Reduce friction and decrease moisture
A. lose wt, loose clothes, Zeasorb powder, Al+ chloride
2. Minimize I&D to only Large fluctuant cysts 
A. Reduces sinus tract and scar 
3. IL Steroid injections
A. Chronic nodules/smaller cysts
4. Topical Antibx 
A. Clindamycin or BPO
5. Longterm PO Antibx
A. Tetracylines
B. Macrolides
C. Sulfonamides

Gen Med: Dermatology (10 decks)

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