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Acne & Rosacea Flashcards

1
Q

Around what structure does the formation of an acne lesion occur?

A

formation of an acne lesion (spot) occurs around the pilosebaceous unit

this consists of the hair shaft, hair follicle and its attached sebaceous gland

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2
Q

Where are the highest numbers of acne lesions found and why?

A
  • face
  • chest
  • back
  • shoulders

these are the areas that have the highest numbers of pilosebaceous units

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3
Q

What does the skin feel like in most people with acne?

A

most people with acne tend to have oily skin

oil is produced in the sebaceous glands

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4
Q

What hormones are people with acne overly sensitive to?

Are they overproduced?

A

people with acne are overly sensitive to their male hormones (androgens) which are present in both men & women

for most people, the circulating hormone level is entirely normal but we are overly sensitive to them

there are a few underlying medical conditions in which higher amounts of androgens are produced (e.g PCOS)

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5
Q

What do the sebaceous glands do in response to androgens circulating in the blood?

A

the sebaceous glands swell and produce more oil

this passes in and around the hair follicle and onto the surface of the skin

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6
Q

What process is occurring at the same time as oil production and what does this produce?

A

follicular hyperkeratosis is occurring, which is the build up of dead skin cells in and around the hair follicle

this forms a comedone plug

this results in blockage of the hair follicle

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7
Q

What bacteria is involved in the pathogenesis of acne?

Where is this found?

A

P . acnes

this is an entirely normal bacteria that lives on the skin and in and around hair follicles

it tends to grow in higher numbers in patients that produce extra oil

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8
Q

What is the result of dead skin cells, extra oil and presence of P. acne?

A

the combination of dead skin cells, extra oil and P. acne leads to production of large amounts of inflammation

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9
Q

What is the difference between inflammatory and non-inflammatory lesions resulting from acne?

A

inflammation, excess oil, P. acne and dead skin cells contribute to the formation of an acne spot

non-inflammatory lesions are called comedones (typical whiteheads / blackheads)

inflammatory lesions are papules, pustules, cysts & nodules and are contributed more to by P. acne

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10
Q

How do other aspects of skincare and lifestyle impact acne?

A

other lifestyle factors such as diet, skincare and medications contribute very little to acne

acne is NOT caused by having dirty or unclean skin

there is very little evidence about changes in the diet significantly impacting the skin

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11
Q

What is the typical clinical presentation of acne?

A

it is most common in the teens and early 20s

it occurs over the “T-zone” of the face

(across the forehead, around the nose and around the central cheeks)

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12
Q

What is meant by late onset acne?

A

a subset of patients have acne that persists or occurs for the first time in adulthood

this tends to occur around the “U-zone” of the face

(chin and jawline)

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13
Q

What is seborrhoea and how can it be measured?

A

seborrhoea is the presence of very oily skin

it can be tested for using test strips that are left on the skin for 10-15 minutes and measure the amount of oil being produced

this is measured as mild, moderate or severe

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14
Q

What are comedones?

What are the 2 different types of comedones?

A

comedones are non-inflammatory lesions

blackheads:

  • follicular opening onto the skin with the build up of oil and dead skin cells that have turned black upon exposure to oxygen

whiteheads:

  • the same lesion but covered with skin, forming a bump
  • these can be larger and are then macrocomedones
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15
Q

What are the 4 different types of inflammatory lesions?

A
  • papules
  • pustules
  • nodules
  • cysts
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16
Q

What is a potential complication of long-standing acne?

A

inflammatory acne that persists for a long time can lead to scarring

this is relatively irreversible

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17
Q

What are the 2 different types of scarring?

A

atrophic scars:

  • dense indented scar
  • icepick / rolling / boxcar scars

hypertrophic scars:

  • raised nodular scars
  • more common on the shoulders and back
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18
Q

How is acne graded?

A

it is graded as either mild, moderate or severe

it is graded on initial presentation and during treatment to see if the treatment is effective

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19
Q

acne is graded on initial presentation and during treatment to see if the treatment is effective

mild - more comedonal acne (whiteheads and blackheads) and maybe one or two inflammatory lesions

no scarring

A
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20
Q

How may someone with mild acne present?

A
  • this is more comedonal acne with whiteheads and blackheads
  • ​*
  • there may be one or two inflammatory lesions
  • no scarring
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21
Q

How does someone with moderate acne tend to present?

A

there are more inflammatory lesions present

if this is untreated, they are at risk of developing scarring

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22
Q

What does someone with severe acne present like?

A

there are many inflammatory lesions with a large number of cysts and nodules

there is very severe scarring affecting anywhere across the face, chest, shoulders and back

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23
Q

What is the grading system usually used for more long-term acne?

A

Leeds Acne Grading System

this is numerical scale ranging from 1 to 12 and is based on photographs

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24
Q

What do OTC acne treatments tend to be used for?

Who are these suitable for?

A

these tend to come in the form of creams and facewashes

mild acne can be kept under control with these

anyone with moderate to severe acne or is developing scarring should see their GP for prescription acne treatment

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25
What is the main problem with OTC acne treatments?
they are very expensive and people often try many unsuccessfully
26
How can diet be changed to help improve acne?
* generally, excluding any particular type of food will not significantly improve skin * not a single change will clear the skin * overall, a good diet for general health is a good diet for the skin
27
28
What is one of the main topical treatments for acne?
**benzoyl peroxide (BPO)** this comes in the form of a gel, cream or a wash it can be prescribed in a number of strengths (2.5% - 10%)
29
What is the main benefit of using benzoyl peroxide (BPO)?
it is both **antibacterial** and **anti-inflammatory** this means that it is effective against P. acnes it also contributes to unblocking and opening of the pores
30
How often should benzoyl peroxide be used? How should usage change over time?
it should be applied once a day, usually in the evening initially it is irritating on the skin advice to patients is to put it on 3 nights a week initially for an hour or two and then wash it off this can then be built up over time until it can be left on overnight
31
What are the 2 main drawbacks of using benzoyl peroxide?
it causes **skin irritation** it is **bleaching** so will stain if it touches towels, bed linen etc.
32
What are the 2 main topical retinoids used to treat acne?
**adapalene** and **tretinoin** these are commonly used topical creams
33
What are the benefits of using topical retinoids to treat acne?
* **anti-inflammatory** * **comedolytic** (unblock the comedones) * **skin tone regulator** (after having an acne lesion there is often some hyperpigmentation of the skin and retinoids speed up the resolution of this)
34
What are the drawbacks of using topical retinoids?
* they irritate the skin (use more infrequently and build up use) * they cause the skin to become more photosensitive * they cannot be used in pregnancy
35
What is Epiduo?
Epiduo is a cream containing **adapalene** and **benzoyl peroxide** (BPO) this is commonly prescribed for treating acne
36
Why might topical antibiotics be prescribed for acne?
acne is not an infective problem the antibiotics are mainly being used for their anti-inflammatory properties
37
What topical antibiotics are commonly used to treat acne?
topical antibiotics tend to be in combination with anti-inflammatory ingredients * erythromycin + zinc - **Zineryt lotion** * clindamycin + benzoyl peroxide - **Duac**
38
How long should topical antibiotics be used for in the treatment of acne?
They should be used daily for at least 3 months before any improvement is seen They can then be used on a long-term basis as required
39
Why might a systemic treatment be used to treat acne?
a systemic treatment (i.e. a tablet) may be considered for: * patients who have not responded to topical creams or antibiotics * patients with moderate to severe acne
40
Why is the combined oral contraceptive pill prescribed as a systemic acne treatment?
**anti-androgen effects** anti-androgen effects on the sebaceous glands tries to reduce the amount of oil they produce
41
What is the name of the combined oral contraceptive pill that is usually used as a systemic treatment for acne? What risks are associated with this?
**Dianette** (co-cyprindiol) any COCP can be used but Dianette is recommended this is only used in patients with acne as it carries a small risk of developing breast cancer and blood clots
42
What are 2 other systemic acne treatments used for their anti-androgen properties?
* spironolactone * metformin
43
Why might systemic antibiotics be used to treat acne?
they are not used because acne is infective, but because acne is an inflammatory disorder and antibiotics can have anti-inflammatory properties
44
What 4 antibiotics are used as a systemic treatment for acne?
* erythromycin * lymecycline * doxycycline * trimethoprim
45
What should patients be warned about before starting systemic antibiotics for treatment of acne?
they should not be expecting to see an improvement within the first week or two of use usually antibiotics need to be used for at least 12 weeks before an improvement is seen
46
What are the contraindications for using systemic antibiotics to treat acne?
they should not be used if patients are currently or planning on becoming pregnant or breastfeeding drug to drug interactions should also be checked
47
What type of treatment is isotretinoin? In which patients is this used?
it is an oral retinoid it is only used in severe acne it may be used in a small subset of patients with mild-to-moderate acne but with a high psychological burden due to their acne
48
How is isotretinoin prescribed?
it is prescribed and dosed based on body weight it is prescribed as a 4-6 month course
49
What is the biggest risk associated with isotretinoin? What procedures are put in place to monitor this risk?
it has a high teratogenic risk with 90% chance of causing birth defects all females of childbearing age and potential MUST be on contraception they are invited back to clinic every month for a pregnancy test even though they are on contraception
50
Why are regular blood tests required for patients on isotretinoin?
isotretinoin can cause: * elevated liver enzymes * low neutrophils * elevated lipids
51
What are the common adverse effects associated with oral retinoids?
* the most common side effects are **dry lips and skin** * headaches * joint aches these side effects tend to settle down with treatment so patients are started on a very low dose which is gradually increased
52
What must patients be screened for before starting a course of isotretinoin?
**depression** isotretinoin is thought to have a depression / suicide risk so everyone is screened for features of depression when they first come to clinic PHQ9 questionnaire can be revisited and monitored at every appointment
53
Can someone with a previous history of depression still take isotretinoin?
YES previous history of depression doesn't exclude patients from taking isotretinoin, however they must be stable and on some form of treatment
54
When might **intra-lesional steroid injections** be used as an extra treatment for acne?
if someone has a particularly large nodule or cyst that is not responding to treatment it can be injected with a steroid this can be repeated every couple of months until the area settles down
55
When might **oral steroids** be given as a treatment for acne?
a short course of oral steroids may be used in patients with particularly inflammatory acne they are used at the same time as the patient is started on conventional treatment, such as antibiotics
56
What is **hyfrecation of comedones** and when is it used?
it is used to treat macrocomedones around the forehead and cheeks that are more resistant to conventional therapies small electrocautery is used to zap macrocomedone and this tends to clear them up
57
When might laser treatment be used in acne?
this is used to treat post-acne scarring it is usually private and not available on the NHS
58
What do rosacea and acne have in common?
They are both chronic inflammatory skin disorders rosacea is not as common as acne
59
What is involved in the underlying pathogenesis of rosacea?
it is poorly understood but is thought to be a multifactorial disease with contributions from: * sun damage * immune system * inflammatory response * genetics * Demodex mites
60
What are Demodex mites and how are they involved in rosacea?
they are small mites that live on the skin and within hair follicles patients with rosacea, particularly those resistant to conventional treatment, have more demodex mites on their skin
61
Who is more likely to be affected by rosacea?
* more common in **middle-aged** people (4th & 5th decades) * more common in **women** * much more common in **fair-skinned** individuals
62
Which sites of the body are more commonly affected by rosacea?
it is found on sun-exposed sites it is most common on the face, but can be found on the chest
63
What is an important feature that distinguishes rosacea from acne?
in rosacea, there are **_NO COMEDONES_**
64
How can rosacea be classified into 4 categories?
rosacea can be classified into 1 of 4 clinical phenotypes **erythema & telangiectasia:** * very red face * tends to affect the midline of the face * intermittent flushing until erythema becomes more permanent **papules & pustules:** * presence of more inflammatory lesions **rhinophyma:** * enlargement and thickening of the skin around the nose **ocular:** * inflammation in and around the eyes
65
What is shown in this image?
**rhinophyma** involves an increase in the number of oil secreting cells in the skin and chronic inflammation this leasd to thickening of the skin of the nose
66
What is shown in this image?
**blepharitis** inflammation around the eye commonly seen in ocular rosacea
67
What is shown in this image?
**lymphoedema** chronic inflammation around the skin can present with swelling around the forehead and eyes
68
What is the first stage in treating rosacea, before topical treatments are given?
patients tend to have very sensitive skin and their rosacea tends to have a number of triggers which need to be avoided * sun * alcohol * spicy food * changes in extremes of temperature anything that irritates the skin should also be avoided
69
What are the topical treatments available for rosacea?
* sun cream (used every day for at least spring/summer months) * ivermectin 1% (soolantra) * brimonidine gel (mirvaso gel) * azelaic acid * metronidazole gel in ocular rosacea, the importance of lid hygiene and washing with boiled cooled water & cotton wool is discussed
70
What are the systemic and physical treatments for rosacea?
**systemic:** * lymecycline * doxycycline * low dose isotretinoin (in those who have not responded to abx) **physical:** * laser treatment
71

Dermatology (Y3) (12 decks)

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