Acne, Rosacea, and Hidradenitis Flashcards
What is the pathogenesis of acne?
- Adolescence leads to increased androgens, which causes hyperproliferation of sebaceous glands.
- Keratin and sebum plug the hair follicle
- P. acnes bacteria proliferates in follicle, releasing inflammatory cytokines
- Inflammatory response leads to red, inflamed cysts.
Who tends to get severe vs persistent acne?
Severe - more frequent in men
Persistent - women, with periodic flare-ups before menstrual periods
What is a blackhead vs a whitehead?
- Open comedone - blackhead - where pore is plugged with keratin debris and oxidation turns it black
- Closed comedone - whitehead - the black part becomes hidden and skin grows overtop. Note, NOT a pustule.
What is the progression of acne after whitehead? How will scarring occur?
Closed comedone -> papule -> pustule (with marked inflammatory infiltrate) = pimple -> nodule / cyst, when the pimple bursts and inflammatory infiltrate is let into the epidermis -> will lead to a scar
Does diet play a factor in acne?
High-glycemic carbohydrate diets worsen acne
Milk hormones can worsen acne
What are the three classifications of acne?
- Comedonal - open and closed comedones predominate
- Inflammatory - papules and pustules predominate
- Cystic - nodules and cysts predominate
What are some OTC topic agents used for acne treatment? How do they work?
Benzoyl peroxide - Antibacterial, anti-inflammatory, and anticomedonal -> opens up pores for more effectiveness
Topical retinoids - apadelene, tazoretene - reduce keratin production and should be used with benzoyl peroxide
-> best anticomedonal
What antibiotics are typically used for acne treatment and at what doses?
Doxycycline, minocycline
Use as submicrobial doses for their anti-inflammatory effect
What are the side effects of concern for doxycycline and minocycline?
Doxycycline - divalent cation binding, photosensitivity, GI upset
Minocycline - lupus drug reaction, hyperpigmentation of scars and teeth
What is the most effective treatment for cystic acne resistant to treatment which is most effective? Side effects? What is needed before it can be prescribed?
Oral isotretinoin
Dryness, chapped lipds, elevated liver enzymes, hypertriglyceridemia (predisposition can be unmasked)
Also highly teratogenic and contraindicated in pregnancy. 2 forms of contraception are required before prescription.
What is hormonal acne and what are two treatments for it?
Acne developing in adult females, usually along the jawline, which is secondary to hormonal effects
- Spironolactone - antiandrogen by blocking 5alpha reductase
- Oral contraceptives -> inhibits LH and thus androgen production
What is rosacea also known as and who tends to get it? What are very general features of it?
“Adult acne” - inflammatory facial skin disorder characterized by erythematous papules, pustules, and telangiectasia.
Tends to occur in white people >age 30.
What are the four major subtypes of rosacea?
- Erythematotelangiectatic
- Papulopustular
- Phymatous
- Ocular
What is erythematotelangiectatic rosacea characterized by?
Flushing, usually triggered by emotion, hot beverages, caffeine, etc, as well as persistent facial erythema with or without telangiectasia.
What is papulopustular rosacea characterized by?
Persistent facial erythema with transient papules / pustules
-> inflammatory type rosacea
What is phymatous rosacea characterized by? Why does it occur?
Phyma = growth. This is characterized by thickened skin, irregular surface nodularities, and enlargement.
Frequently associated with rhinophyma (irreversible hypertrophy of the nose).
-> occurs due to sebaceous gland enlargement + scar tissue formation
What characterizes ocular rosacea? Why does it occur?
Ocular photosensitivity, blurred vision, telangiectasia of the sclera, foreign body sensation in the eye
-> occurs because oil blands and tear ducts get blocked
What are the cosmetic treatments for rosacea?
Sunscreens - disease often sun-aggravated
Special concealers to hide redness
Avoidance of triggers
What is the prescribed therapy used for rosacea? Are steroids effective?
Typically oral antibiotics as antiinflammatories and some immunosuppressives
-> taper to minimum effective dose
Steroids are NOT effective and may exacerbate disease
What does perioral dermatitis look like and who tends to get it?
Papules and pustules confined to chin and nasolabial folds, but SPARING a clear zone around the lips. Lesions often appear adjacent to nostrils.
-> primarily in young women, resembles acne
What is the treatment for perioral dermatitis and what makes it worse?
Made worse by steroids (like rosacea), treatment is antibiotics like doxycycline
What is the proper name for “Acne inversa” and why is it called this?
Hidradenitis suppurativa (inflammation of sweat glands)
Called this because it is in the same places as inverse psoriasis -> intertriginous areas.
What are common areas for hidradenitis suppurativa and who tends to get it? Describe the lesions as well.
Chronic suppurative scarring of axilla, anogenital regions, and under the breast (where alot of sweat is produced)
Tends to be in post-pubertal obese smokers.
Lesions can be many morphologies, including cysts, comedones, scars, and sinus tracts.
What is the hallmark lesion of hidradenitis suppurativa (HS)? What is inflamed in this disease?
Double or triple comedone -> a blackhead with two or sometimes several surface openings that communicate under the skin
Disease is thought to be due to inflammation of apocrine sweat glands or hair follicles
What are the treatments for small and large cysts in HS?
Small - inject steroids
Large - incise and drain, will usually be sterile cysts
What are the immunotherapies used in HS?
Anti-inflammatory antibiotics (not due to infection)
Adalimumab - immunosuppressive
