Acne & Rosacea Flashcards
Around what structure does the formation of an acne lesion occur?
formation of an acne lesion (spot) occurs around the pilosebaceous unit
this consists of the hair shaft, hair follicle and its attached sebaceous gland
Where are the highest numbers of acne lesions found and why?
- face
- chest
- back
- shoulders
these are the areas that have the highest numbers of pilosebaceous units
What does the skin feel like in most people with acne?
most people with acne tend to have oily skin
oil is produced in the sebaceous glands
What hormones are people with acne overly sensitive to?
Are they overproduced?
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)
What do the sebaceous glands do in response to androgens circulating in the blood?
the sebaceous glands swell and produce more oil
this passes in and around the hair follicle and onto the surface of the skin
What process is occurring at the same time as oil production and what does this produce?
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
What bacteria is involved in the pathogenesis of acne?
Where is this found?
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
What is the result of dead skin cells, extra oil and presence of P. acne?
the combination of dead skin cells, extra oil and P. acne leads to production of large amounts of inflammation
What is the difference between inflammatory and non-inflammatory lesions resulting from acne?
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
How do other aspects of skincare and lifestyle impact acne?
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
What is the typical clinical presentation of acne?
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)
What is meant by late onset acne?
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)
What is seborrhoea and how can it be measured?
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
What are comedones?
What are the 2 different types of comedones?
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
What are the 4 different types of inflammatory lesions?
- papules
- pustules
- nodules
- cysts
What is a potential complication of long-standing acne?
inflammatory acne that persists for a long time can lead to scarring
this is relatively irreversible
What are the 2 different types of scarring?
atrophic scars:
- dense indented scar
- icepick / rolling / boxcar scars
hypertrophic scars:
- raised nodular scars
- more common on the shoulders and back
How is acne graded?
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
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
How may someone with mild acne present?
- this is more comedonal acne with whiteheads and blackheads
- *
- there may be one or two inflammatory lesions
- no scarring
How does someone with moderate acne tend to present?
there are more inflammatory lesions present
if this is untreated, they are at risk of developing scarring
What does someone with severe acne present like?
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
What is the grading system usually used for more long-term acne?
Leeds Acne Grading System
this is numerical scale ranging from 1 to 12 and is based on photographs
What do OTC acne treatments tend to be used for?
Who are these suitable for?
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
What is the main problem with OTC acne treatments?
they are very expensive and people often try many unsuccessfully
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
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%)
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
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
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.
What are the 2 main topical retinoids used to treat acne?
adapalene and tretinoin
these are commonly used topical creams
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)
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
What is Epiduo?
Epiduo is a cream containing adapalene and benzoyl peroxide (BPO)
this is commonly prescribed for treating acne
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
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
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
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
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
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
What are 2 other systemic acne treatments used for their anti-androgen properties?
- spironolactone
- metformin
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
What 4 antibiotics are used as a systemic treatment for acne?
- erythromycin
- lymecycline
- doxycycline
- trimethoprim
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
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
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
How is isotretinoin prescribed?
it is prescribed and dosed based on body weight
it is prescribed as a 4-6 month course
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
Why are regular blood tests required for patients on isotretinoin?
isotretinoin can cause:
- elevated liver enzymes
- low neutrophils
- elevated lipids
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
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
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
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
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
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
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
What do rosacea and acne have in common?
They are both chronic inflammatory skin disorders
rosacea is not as common as acne
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
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
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
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
What is an important feature that distinguishes rosacea from acne?
in rosacea, there are NO COMEDONES
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
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
What is shown in this image?
blepharitis
inflammation around the eye commonly seen in ocular rosacea
What is shown in this image?
lymphoedema
chronic inflammation around the skin can present with swelling around the forehead and eyes
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
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
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
