Acne, Rosacea And Perioral Dermatitis

Question 1

Facts about acne

Answer 1

40-50 million people per year
- costs 2.5 billion a year

85% of people between 12-24 get this
- decreases with age but 20% of adults can still see acne

Women are more common than men

Is a chronic disease that is can be recurrent or relapsing.
- can vary with acute outbreaks or slow onset

Creates a psychological and social impact on patients

Question 2

What is the primary bacterium in acne?

Answer 2

P. Acnes (cutibacterium acnes)

• are gram positive rods that activates TLR-2 receptors and upregulates IL-1/8 and TNF-a upregulation
• **IL-8 is the big one since it increases neutrophil recruitment and release of lysosomal enzymes

Question 3

What are the most potent androgens

Answer 3

Dihydrotestosterone (DHT) and testosterone

- DHT is 5-10x greater than testosterone

Question 4

What enzyme catalzyes the conversion of testosterone to DHT?

Answer 4

5-alpha reductase

Question 5

Non inflammatory acne

Answer 5

Comedones

• open = black head
• closed = whitehead

Question 6

Inflammatory acne

Answer 6

Papules
Pustules
Cysts
Nodules

more likely to scar than non-inflammatory, but all types of acne can scar

Question 7

What is the follicular occlusion triad

Answer 7

1) dissecting cellulitis of the scalp
2) hidradentitis suppurativa
3) acne conglobata

if you have one of these, you are more likely to have the other town as well since these 3 often tied together

Question 8

Drug induced acne

Answer 8

Is monomorphic NOT heterogenous

Most common rugs

• **anabolic steroids
• **corticosteroids
• phenytoin
• lithium

Question 9

Epidermal growth factor receptor inhibitors causing acne

Answer 9

Produces acneiform eruptions
- NO comedomes and monomorphic papules/pustules

Erlotinib/cetucimab are most common

Question 10

Recalcitrant acne

Answer 10

These are actually angiofibromas that are treated as acne but will not respond to acne treatments

Question 11

Acne treatments

Answer 11

Combination therapy is first line
- topical retinoic acid and antimicrobials are #1

DONT use antibiotics as monotherapy

Avoid use of both topical and oral antibiotics without topical retinoids

Question 12

Isotretinoin has what black box warnings

Answer 12

Suicidal ideology (not really true)

Teratogenic

Question 13

What are the 4 major factors in pathogenesis of acne

Answer 13

1) alteration in the keratinization process
- formation of the micro commodore occurs here

2) sebum production
3) cutibacterium acne’s follicular colonization
4) release of inflammatory mediators

Question 14

Early vs late comedo

Answer 14

Early = hyperkeratosis and increased corneocyte cohesiveness in sebaceous follicles
- also increased sebum production via androgens

Late = accumulation of the shed keratin and sebum and formation of whirled lamellar concertions

• open commodes = black heads since the keratin plug darkens with oxidation
• closed commodes = white heads

Question 15

What are the three clinical findings of polycystic ovarian syndrome

Answer 15

Hyperandrogenism

Insulin resistance

Acanthosis nigricans

having POS increases risk for CAD and DM

Question 16

Doxycycline side effects

Answer 16

GI upset, photosensitivity

Demineralization and decoloration in teeth and bones (contraindicated in younger children)

Question 17

What is generally the antibiotic that has the highest rates of SJ syndrome and TEN?

Answer 17

TMP-SMX

note NOT the only one

Question 18

How long do you use antibiotics for acne?

Answer 18

3-6 months

Question 19

Oral contraceptives and acne

Answer 19

Are approved for acne treatment except progestin only

Question 20

Spironolactone in acne

Answer 20

Can be used in androgen specific acne (blocks 5 alpha reductase as a side effect)
- DONT use in men causes gynecomastia

Question 21

What are the most common acne treatments in pregnancy

Answer 21

Azelaic acid

Clindamycin and erythromycin

Blue light

Chemical peels (glycolic only)

Question 22

Rosacea

Answer 22

Peaks in 3rd-4th decades of life and less common in black people

Pathogenesis
- UV radiation, aberrant immune response, vascular changes, epidermal barrier dysfunction, neuogenic inflammation

• *very highly correlated with demodex folliculorum mite species**
• this species causes papulopustular rosacea

Question 23

Erythematotelangiectatic (vascular) rosacea

Answer 23

Is more common in skin photo types 1 and 2
-also typically shows excessive flushing

Triggers = stress, hot weather and alcohol are most common

Treatment = photoprotection and gentile cleansers as well as avoid triggers

Question 24

Papulopustular rosacea

Answer 24

Looks very similar to inflamed acne except there is NO COMEDONES present

Treatment = azelaic acid, metronidazole, sodium sulfacetamide

Question 25

Phymatous rosacea

Answer 25

Shows dilated pores on distal nose and preexisting rosacea

Treatment = excision or electrosurgery

Question 26

Perioral dermatitis

Answer 26

Looks similar to herpes except it is confined symmetrically around the mouth with 5mm clear zone from vermillion border

Produces an uncomfortable burning sensation and almost exclusively seen in women or children

Treatment = gentile skin care with 4-6 weeks of antibiotics

Question 27

Steroid rosacea

Answer 27

Caused by potent corticosteroids

If it develops, must initial weaning off steroids asap and move to topical calcineurin inhibitors

Question 28

Pyodermal faciale (rosacea fulminans)

Answer 28

Similar to acne fulminans but no comedomes are present and are NOT on the trunk

Treatment = oral steroids or low does calcineurin inhibitors