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Medical dermatology Dan > Acne, Rosacea, HS etc > Flashcards

Acne, Rosacea, HS etc Flashcards

1
Q

What are indications for hormonal investigation in acne?

A 
Sudden onset acne
Late onset acne 
Pre-pubertal onset acne
Acne persisting into adulthood
Very severe acne
Therapy resistant acne or rapid relapse after isotretinoin
Unusual features;
 - Many comedones
 - Hyperseborrhoea
 - Periorifical distribution

Also in women only if signs of hyperandrogenism;
- Irregular menses
- Hirsuitism
- Alopecia
- Acanthosis nigricans
Extracutaneous signs of virilisation;
- Clitoromegally
- Increased muscle mass
- Deep voice
symptoms of;
Pituitary tumour – visual field defects, headache, galactorrhea
PCOS – obesity, oligomenorrhoea, infertility, insulin resistance
Cancer – Wt loss, abdominal distention, post-menopausal bleeding etc

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2
Q

T/F

skin with acne fluoresces under Woods lamp

A

True
due to porphyrins produced by P acnes
orange-red

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3
Q

What are the patho-aetiological factors in acne?

A

Increased sebum production (seborrhoea)
Hypercornification of pilosebaceous duct (results in comedones)
Abnormality of skin flora esp Propionibacterium Acnes colonization
Inflammation

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4
Q

What is ‘physiological acne’?

A

Some use this to mean mild teenage acne

Some authors include ongoing occasional acne spots in adults as physiological acne

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5
Q

What is late-onset acne?

A

acne adultorum or acne Tarda
begins after age 25
Affects 20% of women (mostly in 30s) and 10% of men
50% have FHx of late onset acne (acne adultorum or acne Tarda)
Men more likely to get late onset cystic, scarring or conglobate acne

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6
Q

What are the associations of acne?

A 
XYY syndrome
Aperts syndrome
SAPHO, PAPA and PAPASH syndromes
Acne keloidalis nuchae
Follicular occlusion tetrad
Dariers disease – may have nodular or conglobate acne
Hormonal imabalance;
 - PCOS
 - HAIR-AN
 - Late adrenal hyperplasia or adrenal tumour
 - Ovarian tumour
Depression
Seborrhoea alone linked to acromegally and Parkinsonism
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7
Q

Which factors trigger or exacerbate acne?

A 
Stress
Humidity
Sweating
Menstrual cycle
Androgen excess
Chemicals - oil, tar, asbestos, halogentaed hydrocoarbons
Drugs - cortocosteroids, anabolic steroids, acneiform rcns
Cosmetics/pomades
Detergents
Diet - milk, high GI, chocolate
Smoking - unclear
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8
Q

T/F

UV makes acne worse

A

False

no evidence for this

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9
Q

How are comedones classified?

A

Closed comedones have no visible skin opening – may need to stretch skin to see – about 1mm
‘sandpaper comedones’ – multiple very small whiteheads esp on forehead
Macrocomedones – large white/black heads bigger than 1mm diameter
‘submarine’ comdones – deep large closed comedones >5mm diameter – often become inflammatory nodules
‘secondary’ comedones part of acne due to an external factor

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10
Q

What hormone tests should be considered in unusal presentations of acne?

A 
Hormone profile – do at 8am on day 3 of menstrual cycle (not on OCP for at least 2 months)
o	Total and free testosterone
o	17(OH) progesterone
o	SHBG
o	DHEAS 
o	Androstenedione
o	Prolactin
o	LH and FSH
o	Oestradiol
o	TFTs
o	8am cortisol
If Cushings suspected order dexamethasone suppression test (alternative is 24hr urinary cortisol repeated x 2)
Oral glucose tolerance test – Identifies insulin resistance in PCOS, HAIR-AN or overweight pts
IGF1 – raised in acromegally
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11
Q

What tests other than hormones might be prudent in acne pts?

A

Baseline
- Lipid profile
- Fasting BSL
- FBC, ELFT (esp potassium if spironolactone planned)
If depression/fatigue symptoms;
TFTs, iron studies, vitamin-D to rule out organic cause
Imaging
USS ovaries if Raised testosterone/hirsuitism/AGA(MPHL)/irregular periods/raised LH
CT or MRI imaging of adrenals
MRI brain – if hyperprolacinaemia

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12
Q

What are DDs of acne?

A

Rosacea (older pts, flushing, no comedones, nodules, cysts or scarring) Possible to have acne and rosacea
Periorificial dermatitis (itchy, dry, no comedones)
Acne excoriee
Pityrosporum folliculitis (esp upper trunk)
Candida folliculitis
Staph epidermidis folliculitis
Demodex folliculitis
Milia
Plane warts
DH can present as vesiculopustular facial eruption – v itchy
Linear IgA may rarely present as popular facial rash, no comedones
Acne agminata (light brown lesions, apple jelly diascopy)
Adenoma sebaceoum (tuberous sclerosis)
Micropapular facial sarcoid
Zinc deficiency facial eruption (esp after prolonged TPN)
Acne necrotica (varioliformis) – see below
Behcets disease
Acneiform drug eruptions
Dental sinus
Cervicofacial actinomycosis
Can be acneiform lesions with giant comedones in folliculotropic MF/follicular mucinosis
Inflamed epidermoid cyst

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13
Q

What are poor prognsotic factors for acne?

A 
Fam Hx
Early onset
Hyperseborroea
Site – truncal acne
Scarring
Persistant/ resistant to Rx
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14
Q

How can acne be graded?

A 
Can use an assessment tool
Otherwise at least document
o	Inflammatory or non-inflammatory
o	Comedonal
o	Nodular (‘nodulocystic’)
o	Mild/mod/severe
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15
Q

T/F

Retinoids are important for all types of acne

A

True
as they act on microcomedones – precursors of comedones and inflammatory lesions
topical retinoid options;
Tretinoin cream/gel 0.025-0.1% (Retin-A, Stieva-A); 1st gen
Isotretinoin 0.05% gel (Isotrex); 1st gen
Tazarotene 0.1% cream (Zorac); 3rd gen (may be more effective than adapalene)
Adapalene 0.1% cream/gel (Differin); 3rd gen

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16
Q

T/F

Topical retinoids in early pregnancy are high risk for birth defects

A

False
2015 BJD Rw confirms no evidence of birth defects or any other pregnancy problem in women exposed to topical retinoids in first trimester – can reassure women exposed by accident
but should still avoid if preg/planned preg

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17
Q

Which antibiotics can be used for acne?

A

Tetracyclines 1st line
Doxycycline 50-200mg/day - 50mg just as good as higher doses
Minocycline 100-200mg/day - not much used as AEs
Erythro 1st line if age under 12/pregnant/breast feeding
- EES 400/800mg BD or 500mg erythro BD
Trmethoprim 3rd line 400-600mg/day in divided dose
Cepahlexin ??500mg TDS
Co-trimoxazole - side effects limit use
Azithromycin 250mg 3x per week - not used much as resistance could be problematic
Ciprofloxacin - not used much as resistance could be problematic
Dapsone 100-300mg daily hase some evidence

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18
Q

What are the indications for hormonal treatments in women with acne?

A

Failed antibiotics or CIs/AEs to antibiotics
Significant premenstrual flares
Clinical or laboratory hyperandrogenism (after investigation)
Want menstrual control or contraception as well as acne Rx
o Isotretinoin not appropriate

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19
Q

T/F

All women on spironolactone need monitoring for hyperkalaemia

A

False
Recent paper suggests Routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne
Only need to monitor for hyperkalaemia if age>50, renal, liver or cardiac impairment or also taking OCP containing drosepirenone

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20
Q 
T/F
3mg drospirenone (as in Yaz/Yasmin) is eqial to 1mg CPA or 25 mg spironolactone
A

True

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21
Q

Which pts are at risk of a poor response to isotretinoin for acne?

A 
Younger pts
Adult women
Males
Extensive truncal Dx
Severe disease
macrocomedones
Unusual variants
Staph colonization
Poor absorption – degree of cheilitis is good indicator of absorption (dose-dependent)
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22
Q

What are the indications for oral steroid use in acne?

A

Settling severe acne while starting isotretinoin
Settling acne fulminans prior to starting isotretinoin
Managing early flare on isotretinoin
Treating acne due to or flared by a hyperactive hypothlamus-pituitary-adrenal axis – e.g. Adrenal hyperplasia, functional adrenal hyperplasia due to chronic stress

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23
Q

T/F

ILCS can be used for active acne

A

True
good for nodules less than 7 days old
Triamcinolone 2.5mg/ml (A10 diluted 1:4)
Inject 0.025-0.1 ml into middle of lesion

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24
Q

T/F

Cryotherapy can be used for active acne

A

True

15-30sec DFTC good for nodules older than 7 days

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25
T/F | PDT can be used for active acne
True Up to 68% improvement demonstrated Can us ALA or metvix with red light Painful. Can be oedema, crusting, pustular eruption and pigment change Topical ALA and broadband (?daylight) light may also help
26
T/F | Chemical peels can be used for active acne
False | no good evidence for them
27
T/F Treatment with oral antibiotics (with exception of rifampicin) does not increase pregnancy rates under co-administration of OCPs
True
28
T/F | Drugs which inhibit CYP450 3A4 can stop OCP from working
False | Inducers of CYP450 3A4 can stop OCP from working
29
How can you test for use of exogenous testosterone?
Urine testosterone:epitestosterone ratio | – ratio>6 strongly suggest exogenous testosterone
30
What are predictors of good or poor adherence to therapy in acne?
``` Good adherence predictors; Older/more mature female married Good Dr-Pt relationship Shame, embarrassment Once daily drug Gel formulation Isotretinoin ``` ``` Poor adherence risks; Smoking, alcohol, unemployment Younger age, single, male Psychosocial morbidity – low DLQI, anxiety, depression High cost treatments Dosing more than once a day ```
31
What causes should you consider if there is a poor response to acne therapy?
``` Poor pt education by Dr Poor adherence – may be intolerance or AEs to treatment or not pts preferred Rx Inadequate dose Resistant P. Acnes Development of gram neg folliculitis Wrong diagnosis Refractory subtype consider if unerlying trigger factor that hasnt been addressed eg anabolic steroids, fats, tars ```
32
Other than changing meds what else can you do to try to improve reponse to acne Rx?
``` Consider if wrong diagnosis consider if unerlying trigger factor that hasnt been addressed Try to establish if there is adherence Improve Dr-pt relationship address psychiatric issues Involve pts partner/family consider need for physical Rx of stubborn comedones simplify treatment/reduce dosing change formulation address AEs Increase dose Lower cost treatments ```
33
What general measures are important in acne Rx?
``` Need thorough Hx and work up plan Mx Discuss pt QoL/psychosocial issues and their expectation of treatment Need good education o Treatments are slow to show effect o Need to stick to treatment to see response o There is a ladder of treatment Diet - low GI, low dairy, no chocolate Advise Oil free wash or non-foaming cleanser Non comedogenic sunscreen light make up Avoid pomades, greases etc Ibuprofen can help if inflammatory Zinc gluconate 200mg/day may be of benefit ```
34
T/F | acne in adult women is usually late onset acne
False | 80% persistent, 20% late onset
35
T/F | acne in adult women always needs a hormone assessment
True do hormone screen and pelvic USS in all pts and investigate further if clinical features of hyperandrogenism or other indications
36
T/F | 1st generation retinoids can be used with BPO
False Inactivated by BPO so dont use together e.g. Tretinoin (Retin-A, Stieva-A), topical isotretinoin okay to use retinoid at night and BPO mane also good at night as retinoid may be degraded by UV and causes photosensitivity. Tretinoin and BPO like this good for adult womens acne
37
What active topicals are available for acne?
``` Anti-inflam and anti P.acnes - BPO - 2-5% - Azelaic acid 15% - Salicylic acid 2% Antibiotics - Clindamycin gel - Clindamycin+BPO (Duac) - Erythromycin 2% compounded Retinoids - esp 3rd gen - Adapalene, Tazarotene - also 1st gen - tretinoin, isotretinoin Others sometimes used - astringents if lots of seborrhoea - acetone, alcohol wash - Glycolic acid or AHA products - tea tree oil - nicotinamide - sulphur - dapsone - topical steroid ```
38
T/F | acne in adult women has more comedones an fewer inflammatory lesions
false other way around and mainly affects lower jaw, chin, cheeks - U zone
39
What is Postmenopausal/ perimenopause acne?
Occurs in first 2 years after last menstruation Rare Most prevalent in mediterraneans with thick dark skin (lifelong sun exposure), rare in type 1 skin Usually have other menopause symptoms Often minimal Hx of acne in earlier life Due to loss of oestrogen secretion by ovaries but continued androgen secretion by ovaries and adrenals Small closed comedones visible on stretching skin Large pores esp on nose cheeks Often have postmenopausal hirsuitism
40
T/F | adapalene is the topical treatment of choice in adult female acne
False Tretinoin is use at night w/ azalaic acid or BPO in morning
41
T/F | isotretinoin is always 1st choice in adult female acne
False | often first but if alopecia or hirsuitism or any CI to isotretinoin then use hormonal Rx - OCP, CPA, spironolactone
42
How is isotretinoin used in adult female acne?
Can do course(s) in same way as usual If ongoing Rx needed intermittent dose often used e.g. 0.5mg/kg daily for 1 week in every 4 for 6 months
43
What are the grades of acne scars?
Grade I: Abnormally coloured, macular disease Grade II: Mildly abnormally contoured disease Mild atrophy or hypertrophy that may not be obvious at social distances of ≥50 cm and may be adequately camouflaged with make-up, the normal shadow of a shaved beard in males or normal body hair if extra-facial Grade III: Moderately abnormally contoured disease scarring that is obvious at social distances of ≥50 cm and is not covered easily but flattens by manual stretching of the skin (if atrophic) Grade IV: Severely abnormally contoured disease scarring that is obvious at social distances >50 cm, is not covered easily. Manual skin stretching cannot flatten it
44
How are macular erythematous acne scars treated?
topical retinoids e.g. retrieve Topical antinflammatories e.g. Azelaic acid Vascular laser - 595nmPDL, 532nmKTP Fractionated non-ablative laser - 1540nm Er:glass, 1550nm diode-pumped erbium laser (Fraxel SR)
45
How is acne PIH treated?
Sun protection Bleaching agents - hydroquinone etc Light chemical peel Fractionated non-ablative laser - 1927nm thallium laser
46
How are macular hypopigmented acne scars treated?
Sun protection Can use bleaching agents on normal skin to minimise contrast Fractionated non-ablative laser - 1540nm Er:glass, 1550nm diode-pumped erbium (Fraxel SR), 1927nm thallium laser Pigment transfer procedures – minigrafting, epidermal suspensions
47
How are mild and severe rolling acne scars treated?
``` Mild; Needling or rolling Fractional non-ablative resurfacing Non-Fractional non-ablative resurfacing Dermal or superficial dermal fillers Mod-severe; Can try above but may need; Subcision +/- filler - 1st line Fractional ablative resurfacing - 2nd line Non-fractional ablative laser Fractional radiofrequency treatment Plasma skin resurfacing Dermabrasion Chemical peel Dermal fillers BoTox ```
48
How are mild and severe papular acne scars treated?
``` Mild; Fine wire diathermy ILCS 5FU injections (2nd line) Mod-severe; Can try above but may need; Vascular laser silicon sheeting ```
49
How are boxcar scars treated?
``` Same as mod-severe rolling scars; Subcision Fractional ablative resurfacing - 1st line Non-fractional ablative laser Fractional radiofrequency treatment -1st line Plasma skin resurfacing Needling Dermabrasion Chemical peel Dermal fillers BoTox If deep may need; TCA peel or CROSS Fractional resurfacing+ CROSS punch excision punch elevation if base okay ```
50
How are ice pick scars treated?
TCA CROSS - 1st line Fractional resurfacing+ CROSS punch excision Fractional radiofrequency treatment
51
How is severe atrophic acne scarring treated?
Fat transfer | Volumetric filling w/ HA, hydroxyapatite, stimulatory filler or silicon
52
How are hypertrophic and keloidal acne scars treated?
``` Vscular laser (Nd:YAG, Alex, diode) +/- ILCS - 1st line ILCS 5FU injections 5FU + vascular laser fractional ablative laser ```
53
How are Bridge or tunnel dystrophic acne scars managed?
Excision
54
What does CROSS stand for?
Chemical Reconstruction Of Skin Scars Use 60-100% TCA +/- other techniques (subcision etc) to raise depressed scars Usually followed by ablative CO2 or Er:YAG laser resurfacing
55
What is acne conglobata? How is it treated?
Rare severe eruptive form of nodulocystic acne without systemic manifestations chronic if untreated persists to age 40-50 often trunk>face Multiple inflammatory papules, tender nodules, macrocomedones, and abscesses which commonly coalesce to form draining sinuses; lead to hypertrophic scars Assoc - follicular occlusion tetrad, PAPA syndrome and SAPHO syndrome Pred and erythro to start – can start roac at same time or can delay by few weeks. Pred about 0.5mg/kg
56
T/F | Disssecting cellulitis of scalp is largely due to infection
False Follicular hyperkeratosis rather than infection is thought to play a primary role in pathogenesis but bacterial superinfection can occur
57
What are the features of Disssecting cellulitis of scalp? | What is the treatment?
Young black men; rarely Caucasians and women Multiple, firm scalp nodules on mid-posterior vertex and upper occiput which rapidly develop into interconnecting, boggy, fluctuant, oval and linear ridges that eventually discharge purulent discharge; little pain Rx; ILCS Oral doxy/mino, trimethoprim Isotretinoin (0.5-1.5 mg/kg daily until 4 months after clinical remission) – relapses are common TNF-alpha inhibitors Surgery – Incision and drainage to excision with grafting
58
What are the features of acne fulminans? | What is the treatment?
Abrupt development of nodular and suppurative acne lesions in association with systemic manifestations Primarily adolescent boys aged 13-16 yrs of age usually have mild-mod acne before lesions on face, neck, chest, back and arms, coalescence into painful, oozing, friable plaques with hemorragic crusts fever, arthralgias, myalgias, severe malaise erythema nodosum hepatosplenomegaly osteolytic bone lesions can be part of SAPHO syndrome elevated ESR, protineuria, leucocytosis, anaemia Rx EES Pred 0.5-1 mg/kg/day – decreasing slowly over 2-3 months Isotreitnoin - start low after inflammation settled and slowly increase NSAIDs for fever, myalgia, arthralgias Second line: dapsone, oral antibiotics, TNF-alpha inhibitors
59
What is Acne excoriee (acne des jeunes filles)? | What is the treatment?
Variant of neurotic excoriation esp in women around age 30 jawline, hairline, forehead, chin, preauricular May be personality disorder (immature/ narcissistic) anxiety, OCD white atrophic scarring often Rx can try topical antibiotics - often dont tolerate BPO or retinoid Doxy good often isotretinoin psychotherapy antidepressants
60
What is solid facial oedema?
Rare and disfiguring complication of acne or rosacea Distortion of the midline face and cheeks due to soft tissue swelling Woody induration +/- erythema Impaired lymphatic drainage and fibrosis in setting of chronic inflammation Does not usually resolve spontaneously Treatment: Isotretinoin (0.2-1mg/kg/day) alone or in combination with the antihistamine, ketotifen (1-2mg/day) or prednisone (10-30mg/day) for 4-5 months
61
Which drugs can cause acne-like eruptions?
``` BE SOLID B12 vitamin EGFR or MEK inhibitors (Rx w/ doxy, topical ABs) Steroids (Corticosteroids (topical, IV, PO), Androgens (anabolic steroids eg Danazol), ACTH) OCP (progestins) Lithium Isoniazid, Iodides (Bromide) Dilantin (phenytoin) ```
62
What is neonatal acne?
Same as neonatal cephalic pustulosis 20% of healthy newborns Appear about 2 wks age and generally resolve within 3 months Small, inflamed papulopustules (but typically not comedones) on cheeks and nasal bridge (also forehead, chin, neck, upper trunk can also be involved) Thought to be inflammatory response to Malassezia spp. Treatment: Topical ketoconazole 2% cream
63
What is infantile acne?
Acne presenting at 3-12 months of age Comedone formation is prominent (in contrast to ‘neonatal acne’) Pitted scarring can develop, deep cystic lesions and suppuratives nodules occasional Due to androgen production intrinsic to this stage of development. NOT due to maternal hormones Resolves 1-2 yrs of age Rx Topical retinoids, benzyl peroxide Oral antibiotics (e.g. erythromycin, azithromycin) No Doxy for kids under 9!!
64
T/F | Cyclosporin can trigger acne keloidalis nuchae
True
65
What is the aetiology of acne keloidalis nuchae?
Multifactorial; androgens, inflammation, trauma, ingrowing hairs, and secondary infection NB Commonest form of scarring alopecia occurring in African males
66
What are the treatments for acne keloidalis nuchae?
Don’t cut hair very short Avoid rubbing collars Treat early in disease course to avoid scarring Tetracyclines as for acne TCS, ILCS, sometimes course of oral pred Cryo/surgery/laser (may be laser then secondary intention healing) Excision - Secondary intention healing has good cosmetic result, sometimes excision and grafting performed Radiotherapy post surgery has been used
67
What are the external/physical acne triggers?
``` CRAP DOTS Cosmetics (acne cosmetica) Radiation acne Friction (Acne mechanica) Pomade acne Detergent acne - excess washing of face Occupational acne - Chloracne, Oil/tar/pitch acne Tropical acne - heat/ heat and humidity Steroid acne ```
68
What is chloracne?
Due to exposure to chlorinated aromatic hydrocarbons found in electrical conductors and insulators, insecticides, fungicides, herbicides, and wood preservatives develops after several weeks of exposure; multiple comedones inflammatory lesions are not always evidentusually head and neck but may also affect axillae, scrotum, extremities, trunk and buttocks
69
What is radiation acne?
Comedo-like papules occurring at sites of previous exposure to therapeutic ionizing radiation Begins to appear as the acute phase of radiation dermatitis starts to resolve Ionizing rays induce epithelial metaplasia within follicle, creating adherent hyperkeratotic plugs that are resistant to expression
70
T/F | pts with Turner's syndrome get severe acne
False Apert's syndrome assoc w/ severe acne Early-onset nodulocystic acne with more widespread distribution (entire extensor aspects of arms, buttocks, thighs); highly resistant to therapy other than isotetinoin
71
What is Naevus sebaceous syndrome?
Type of epidermal naevus syndrome | association of naevus sebaceous with occular, CNS, and skeletal abnormalities
72
What are the most common lesions to arise in a sebaceous naevus?
``` Trichoblastoma - most common benign lesions BCC - most common malignant lesion Syringocystadenoma papilliferum Trichilemmoma Other adnexal tumours ```
73
What is Phacomatosis pigmentokeratotica?
Type of epidermal naevus syndrome naevus sebaceous is combined with a speckled lentiginous nevus in a checkerboard pattern w/ associated hyperhidrosis, muscular weakness, dysaesthesia, many other abnormalities
74
``` T/F solar comedones (Favre-Racouchot syndrome) and comedone naevus are terated in the same way ```
True Comedone extractor Topical retinoid gentle electrocautery
75
Who is at risk of gram negative foliculitis?
Pts on long-term oral, or less frequently, topical antibiotic therapy used to treat acne Often causes inflammatory pustules on face Discontinue current antibiotic Commence either ampicillin/amoxicillin (250mg qid) or Bactrim DS (1 bd) Isotretinoin is best treatment
76
What are the treatments of sebaceous hyperplasia?
``` Gentle cautery LN cryotherapy Trichloroacetic acid CO2 and pulsed dye laser Oral isotretinoin Antiandrogens (e.g. OCP) PDT ```
77
what is aperts syndrome?
rare AD disease with major cranial and other bony deformities and high risk of nodulocystic acne - craniosynostosis - early fusion of skull bone results in skull vault deformity Also get fair skin and/or hair so on DD list for diffuse hypopigmentation syndromes
78
what is pseudoacne of the transverse nasal crease?
onset before puberty line of small cysts, milia or comedones along junction of nasal bones and tip cartilages not responsive to hormonal therapy leave or use other topicals or physical Rx

Medical dermatology Dan (41 decks)

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