Acne and Related Conditions Flashcards
Acne facts
- Most common disease in America
- Affects 85% of Americans at some point in their lives
- 20% will have severe scarring disease
- Affects areas of dense sebaceous units: face, chest, and back
Acne Pathogenesis
***Multi-factorial
- Genetics
- The inclination towards follicular epidermal hyperproliferation is inherited
- Androgen hormones
- PCOS in women or adrenal gland hyperplasia
-Inflammation
- P. acnes infection
- Excessive sebum
Formation of acne
***Occurs in pilosebaceous units
- Microcomedone is formed
- The follicle is distended. Then, the follicular opening becomes dilated, and an open comedone results.
- The follicular wall thins, and ruptures.
- Inflammation and bacteria may be evident, with or without follicular rupture.
- Dense inflammatory infiltrate occurs throughout the dermis.
Acne Pathogenesis
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Clinical Manifestations of Acne
- pain, tenderness, and pruritis occasionally
- Systemic symptoms are usually absent except with Acne Fulminans
- Psychological symptoms
- Physical: comedones, papules, pustules, and nodules in a sebaceous gland distribution.
- Face may be the only involved skin surface, but the chest, back, and upper arms are often involved
Classification of Acne
(Grades I-IV)
Grade I: multiple open comedones, no inflammatory lesions present
Grade II: multiple closed comedones and few papules and pustules
Grade III: mostly papules and pustules
Grade IV: multiple open and closed comedones, papulopustules, and cysts
Classification of Acne
(mild, moderate, severe)
-Mild acne
-comedones and a few papulopustules
-Moderate acne
-comedones, inflammatory papules, and pustules. Greater numbers of lesions are present.
-Severe acne“nodulocystic acne”
-comedones, inflammatory lesions, and large nodules around 5 mm in diameter. Scarring is often evident.
DDX for Acne
-Rosacea
-Folliculitis
-Perioral Dermatitis
-Keratosis Pilaris
-Steroid-induced acne
If you don’t see comedones, it is not acne!!!
-have to see open comedones (black-heads)
Important things to remember when choosing
Acne Vulgaris Therapy
-Treatment should target all causes of acne
-follicular hyperproliferation, excess sebum, P acnes, and inflammation
-Use the grade or severity to determine course of action
*Remember to always use a benzoyl peroxide wash or topical to prevent bacterial resistance when using topical or oral abx
Topical Treatment for Acne
(agents and MOA)
Topicals:
-Retinoids: comedolytic and anti-inflammatory
adapalene, tazarotene, tretinoin
-Antibiotics: fights P. acnes and maybe anti-inflammatory
erythromycin, clindamycin
-Benzoyl Peroxide: fights P. acnes and reduces bacterial resistance
-Dapsone: Provides anti-inflammatory and anti-sebum benefits
**when patients have dry skin, use a moisturizer as well
Systemic treatments
(agent and MOA)
◦Antibiotics
-doxycycline, minocycline: 1st line therapy lipophilic and anti-inflammatory properties
-trimethoprim, azithromycin: broad spectrum benefits for failed doxy/mino
-avoid unless needed, due to side effects
-tetracycline, erythromycin: less effective than newer abx due to resistance and newer design
◦Hormonal
◦Isotretinoin
Systemic Antibiotics:
Dosing and side effects
-Tetracycline: 400mg BID; age 12y.o.>
◦Use for those unable to swallow pills
-EES: 250-500mg BID-QID; no age restriction
◦S.E.- GI upset, rash
-TMP/SMX: DS BID; >2 mos
◦S.E.- SJS, TEN, photosensitivity, vag. candida
-Azithromycin: 250-500mg TIW; >6 mos
◦S.E.- GI upset, dizziness, rash
-Doxycycline: 50-100mg QD-BID; age 12y.o.>
◦S.E.- GI upset, photosensitivity
-Minocycline: 50-100mg QD-BID; age 12y.o.>
◦good affinity for back acne
◦S.E.- *can be dangerous, neuro side effects, dizziness, headache, blue dyspigment, serum sickness, lupus-like drug eruption, hepatitis, hypersensitivity rxn.
Hormonal Therapy
(Agents and MOA)
-Oral contraceptives: increase sex hormone–binding globulin, resulting in an overall decrease in circulating free testosterone
◦Yasmin, Yaz and Ortho-tricyclen in particular
◦May take 2-3 months for efficacy
-Spironolactone: anti-HTN that binds to the androgen receptors and reduces androgen production
◦May cause dizziness, breast tenderness, and dysmenorrhea (use OCP to help this)
◦Causes feminization of male fetus-must avoid pregnancy
◦Monitor blood pressure
Upcoming Therapies for Acne
Sarecycline- Phase 3 trial
◦improved anti-inflamm activity
◦more narrow spectrum
◦hope to improve efficacy and decrease unwanted side effects/tolerability issues
Topical Minocycline- Phase 2 trial
◦Foam formulation
◦Indication- mod-severe acne
Isotretonoin
(MOA, Dosing, Side effects, Labs)
-Oral retinoid/vitamin A derivative
-MOA:
-normalization of epidermal differentiation
- decreases sebum excretion by 70%
- anti-inflammatory
- reduces the presence of P. acnes
- Used for severe, persistent nodulocystic acne and recalcitrant acne
-Dosing: approx. 1 mg/kg/day x 20-24 weeks
- Can be curative (60%)
- Brand Accutane no longer available
◦Amnesteem, Myorisan, Zenatane, Asorbica, and Claravis are the substitutes
-TERATOGENIC!!!! Causes severe birth defects
◦Must agree to use 2 forms of birth control
◦sign consent forms
-Side effects: Extreme dryness, photosensitivity, headache, nausea/vomiting, joint pain, vision change, paronychia, fatigue, acne flare, mood changes, pseudotumor cerebri (esp. if taken w/ TCN)
-Serologically: Increased TG and LFTs, leukopenia
-Labs: CBC, CMP, TG, total Chol, CK total, HCG quant. (for females)
◦Must have baseline HCG 30 days prior to start of med
Variations of Acne
- Childhood acne
- Neonatal
- Infantile
- Early-onset
Neonatal Acne
-Appearance: multiple raised red papules and pustules on the cheeks, chin and forehead
- Typically caused by hormonal change
- Does not result in scarring
- Resolves spontaneously, but may use a mild retinoid to combat milia
- Affects children during 1st month of life
- Usually mild, related to glandular development
- 20% of newborns
-Males > Females
Infantile Acne
-Affects children 3-16 months of age
-Usually resolves within 3 years
- Can be more severe than neonatal acne and can result in scarring
- always on the FACE, not the body
- Occurs less often than neonatal acne
- Typically caused by hormonal change
- May be treated with gentle cleansing and topical benzoyl peroxide and occasionally a topical antifungal for secondary infection
- For serious cases, oral antibiotics may be used (EES usually first line)
Early onset acne
-Usually seen in acne prone families
-Begins age 6 or 7 years
****Particularly extensive or inflammatory acne in children should alert clinicians to the possibility of an underlying virilizing disorder
-Cannot use tetracycline derived abx due to age restriction
Acne Rosacea
-inflammatory disease that closely resembles acne
-Etiology: Unknown
◦Increased blood flow to facial vessels
◦Harsh climate exposure (trigger)
◦Dermal matrix degeneration
◦Spicy foods, hot bev, caffeine, certain meds (amiodarone, topical steroids, B-12)
◦Inflammation perifollicular or perivascular
◦Demodex organism
◦Release of free iron causing oxidative stress to the skin
◦Reactive Oxygen Species- causes inflammation assoc. with rosacea
Demodex organisms
- mites that normally inhabit human hair follicles
- can cause inflammation
Presentation of Rosacea
- Persistent erythema centrofacially lasting >3 months plus flushing, papules, pustules, and telangiectasias on the convex surfaces
- Other characteristics are:
burning, stinging, edema, plaques, a dry appearance, ocular involvement, and phymatous changes
-The prevalence of these findings designates the subclassification of the presentation and the therapeutic options
Rosacea Stages I-IV
Stage I: Persistent erythema w/ telangiectasias
Stage II: Persistent erythema, telangiectasias, papules, tiny pustules
Stage III: Persistent deep erythema, dense telangiectasias, papules, pustules, nodules; rarely persistent “solid” edema of the central face
Stage IV: Persistent deep erythema with rhinophyma
Rosacea Subclassifications
- Erythematotelangiectatic Rosacea (ETR)
- Papulopustular Rosacea (PPR)- Classic
- Phymatous Rosacea
- Ocular Rosacea
Erythematotelangiectatic Rosacea (ETR)
Erythematotelangiectatic Rosacea (ETR)
◦Central facial redness
◦Burning/stinging dry inflamed skin that cannot tolerate topical agents
◦Flushing due to exercise, hot shower, red wine, spicy food etc
Papulopustular Rosacea (PPR)
Papulopustular Rosacea (PPR)- Classic
◦Red central face with papules and small pustules
◦Telangiectasias present but not as visible beneath red background
◦Flushing due to triggers
Phymatous Rosacea
Phymatous Rosacea
◦Skin thickening and irregular nodularities along skin surface
◦Affects nose, chin, forehead, ears and/or eyelids
◦Can treat with isotretinoin and laser ablation
Rosacea Treatment
- Identify and avoid triggers- UV light #1 trigger
- Gentle cleanser, moisturizer and sunscreen
*Avoid sodium lauryl sulfate in moisturizers
-Laser therapy- only way to remove telangiectasias
◦potassium-titanyl-phosphate laser (KTP), pulsed-dye laser
-Medications:
◦Topical metronidazole 1% QD- 1st line
◦Topical azelaic acid BID or retinoids QHS
◦Topical sulfacetamide lotion or wash QD-BID
◦Topical or oral dapsone, brimonidine gel, botox?
◦Ivermectin 1% cream
◦Oral doxycycline: 40mg-200mg QD
**Less than 50mg of doxy is not antimicrobial, only anti-inflammatory- perfect for rosacea
Rosacea DDX
DDx:
◦Discoid Lupus
-persistent sun-sensatized, no blemishes
◦Acne Vulgaris
◦Seborrheic Dermatitis
◦Perioral Dermatitis
Perioral Dermatitis
-A common disorder consisting of redness and papules affecting the area around the mouth
-Young women 16-45 y.o.
-Physical exam: small, red papules, pustules and mild peeling affecting the naso-labial folds, chin and sides of the lips
-Occasionally periorbital area is involved
-Symptoms: itch, sting, burn
-Cause: Unknown
◦Form of rosacea? Sunlight-worsened seborrheic dermatitis?
◦Strong steroids can induce perioral dermatitis
◦Whitening or tartar control toothpaste may play a role
◦Cinnamon flavored gum
-Treatment:
◦Oral doxycycline or oral minocycline x 2months
◦Topical metronidazole 1% QD
Periorbital Dermatitis DDX
DDx:
◦Rosacea
◦Seborrheic Dermatitis
(distribution rarely under mouth/lips)
◦Acne Vulgaris
“Inflammatory Triad” - these can often present together
Pseudofolliculitis Barbae (PFB)
- “shaving bumps”, not assoc. w/ acne
- Occurs when a tightly curved hair re-enters the skin causing a foreign body inflammatory rxn
Affects: Post-pubescent black males (most common), hirsuit black women, and some white men
-Close shaving is the predisposing factor
-NOT painful
Pseudofolliculitis Barbae Treatment
-Treatment:
- Chemical depilatories: barium sulfide powder or calcium thioglycolate preparations used TIW
- Hair removal laser: Diode laser safe for dark skin
- Topical tretinoin eases hyperkeratinization
-Triluma- helps w/ inflammation, hyperkeratinization and hyperpigmentation
-Mild steroid creams and low potency intralesional triamcinalone (2.5mg/cc)
If pustules or abscesses are present-
◦Topical abx: clinda+BPO
◦Oral abx: doxycycline 100mg BID
Pseudofolliculitis Barbae DDx
DDx
◦Staphylococcal infection
◦Tinea Corporis- steroid induced
◦Herpes Simplex
-PAINFUL
Gram-Negative Folliculitis
-Seen in patients treated with long-term antibiotics (tetracycline)
-Seen commonly around buttox…yoga-pants….
-Physical exam: superficial 3-6mm pustules, flare from anterior nares (colonized)
Culture: gram neg., Escherichia coli, Klebsiella, Proteus
Treatment:
◦Isotretinoin: clears acne and colonization
◦amoxicillin or TMP-SMX