Acne, Rosacea, and Hidradenitis

Question 1

What is the pathogenesis of acne?

Answer 1

1. Adolescence leads to increased androgens, which causes hyperproliferation of sebaceous glands.
2. Keratin and sebum plug the hair follicle
3. P. acnes bacteria proliferates in follicle, releasing inflammatory cytokines
4. Inflammatory response leads to red, inflamed cysts.

Question 2

Who tends to get severe vs persistent acne?

Answer 2

Severe - more frequent in men

Persistent - women, with periodic flare-ups before menstrual periods

Question 3

What is a blackhead vs a whitehead?

Answer 3

1. Open comedone - blackhead - where pore is plugged with keratin debris and oxidation turns it black
2. Closed comedone - whitehead - the black part becomes hidden and skin grows overtop. Note, NOT a pustule.

Question 4

What is the progression of acne after whitehead? How will scarring occur?

Answer 4

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

Question 5

Does diet play a factor in acne?

Answer 5

High-glycemic carbohydrate diets worsen acne

Milk hormones can worsen acne

Question 6

What are the three classifications of acne?

Answer 6

1. Comedonal - open and closed comedones predominate
2. Inflammatory - papules and pustules predominate
3. Cystic - nodules and cysts predominate

Question 7

What are some OTC topic agents used for acne treatment? How do they work?

Answer 7

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

Question 8

What antibiotics are typically used for acne treatment and at what doses?

Answer 8

Doxycycline, minocycline

Use as submicrobial doses for their anti-inflammatory effect

Question 9

What are the side effects of concern for doxycycline and minocycline?

Answer 9

Doxycycline - divalent cation binding, photosensitivity, GI upset

Minocycline - lupus drug reaction, hyperpigmentation of scars and teeth

Question 10

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?

Answer 10

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.

Question 11

What is hormonal acne and what are two treatments for it?

Answer 11

Acne developing in adult females, usually along the jawline, which is secondary to hormonal effects

1. Spironolactone - antiandrogen by blocking 5alpha reductase
2. Oral contraceptives -> inhibits LH and thus androgen production

Question 12

What is rosacea also known as and who tends to get it? What are very general features of it?

Answer 12

“Adult acne” - inflammatory facial skin disorder characterized by erythematous papules, pustules, and telangiectasia.

Tends to occur in white people >age 30.

Question 13

What are the four major subtypes of rosacea?

Answer 13

1. Erythematotelangiectatic
2. Papulopustular
3. Phymatous
4. Ocular

Question 14

What is erythematotelangiectatic rosacea characterized by?

Answer 14

Flushing, usually triggered by emotion, hot beverages, caffeine, etc, as well as persistent facial erythema with or without telangiectasia.

Question 15

What is papulopustular rosacea characterized by?

Answer 15

Persistent facial erythema with transient papules / pustules

-> inflammatory type rosacea

Question 16

What is phymatous rosacea characterized by? Why does it occur?

Answer 16

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

Question 17

What characterizes ocular rosacea? Why does it occur?

Answer 17

Ocular photosensitivity, blurred vision, telangiectasia of the sclera, foreign body sensation in the eye
-> occurs because oil blands and tear ducts get blocked

Question 18

What are the cosmetic treatments for rosacea?

Answer 18

Sunscreens - disease often sun-aggravated

Special concealers to hide redness

Avoidance of triggers

Question 19

What is the prescribed therapy used for rosacea? Are steroids effective?

Answer 19

Typically oral antibiotics as antiinflammatories and some immunosuppressives
-> taper to minimum effective dose

Steroids are NOT effective and may exacerbate disease

Question 20

What does perioral dermatitis look like and who tends to get it?

Answer 20

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

Question 21

What is the treatment for perioral dermatitis and what makes it worse?

Answer 21

Made worse by steroids (like rosacea), treatment is antibiotics like doxycycline

Question 22

What is the proper name for “Acne inversa” and why is it called this?

Answer 22

Hidradenitis suppurativa (inflammation of sweat glands)

Called this because it is in the same places as inverse psoriasis -> intertriginous areas.

Question 23

What are common areas for hidradenitis suppurativa and who tends to get it? Describe the lesions as well.

Answer 23

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.

Question 24

What is the hallmark lesion of hidradenitis suppurativa (HS)? What is inflamed in this disease?

Answer 24

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

Question 25

What are the treatments for small and large cysts in HS?

Answer 25

Small - inject steroids

Large - incise and drain, will usually be sterile cysts

Question 26

What are the immunotherapies used in HS?

Answer 26

Anti-inflammatory antibiotics (not due to infection)

Adalimumab - immunosuppressive