Acne, Rosacea, HS etc Flashcards
What are indications for hormonal investigation in acne?
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
T/F
skin with acne fluoresces under Woods lamp
True
due to porphyrins produced by P acnes
orange-red
What are the patho-aetiological factors in acne?
Increased sebum production (seborrhoea)
Hypercornification of pilosebaceous duct (results in comedones)
Abnormality of skin flora esp Propionibacterium Acnes colonization
Inflammation
What is ‘physiological acne’?
Some use this to mean mild teenage acne
Some authors include ongoing occasional acne spots in adults as physiological acne
What is late-onset acne?
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
What are the associations of acne?
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
Which factors trigger or exacerbate acne?
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
T/F
UV makes acne worse
False
no evidence for this
How are comedones classified?
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
What hormone tests should be considered in unusal presentations of acne?
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
What tests other than hormones might be prudent in acne pts?
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
What are DDs of acne?
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
What are poor prognsotic factors for acne?
Fam Hx Early onset Hyperseborroea Site – truncal acne Scarring Persistant/ resistant to Rx
How can acne be graded?
Can use an assessment tool Otherwise at least document o Inflammatory or non-inflammatory o Comedonal o Nodular (‘nodulocystic’) o Mild/mod/severe
T/F
Retinoids are important for all types of acne
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
T/F
Topical retinoids in early pregnancy are high risk for birth defects
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
Which antibiotics can be used for acne?
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
What are the indications for hormonal treatments in women with acne?
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
T/F
All women on spironolactone need monitoring for hyperkalaemia
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
T/F 3mg drospirenone (as in Yaz/Yasmin) is eqial to 1mg CPA or 25 mg spironolactone
True
Which pts are at risk of a poor response to isotretinoin for acne?
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)
What are the indications for oral steroid use in acne?
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
T/F
ILCS can be used for active acne
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
T/F
Cryotherapy can be used for active acne
True
15-30sec DFTC good for nodules older than 7 days
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
T/F
Chemical peels can be used for active acne
False
no good evidence for them
T/F
Treatment with oral antibiotics (with exception of rifampicin) does not increase pregnancy rates under co-administration of OCPs
True
T/F
Drugs which inhibit CYP450 3A4 can stop OCP from working
False
Inducers of CYP450 3A4 can stop OCP from working
How can you test for use of exogenous testosterone?
Urine testosterone:epitestosterone ratio
– ratio>6 strongly suggest exogenous testosterone
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
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
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
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
T/F
acne in adult women is usually late onset acne
False
80% persistent, 20% late onset
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
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
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
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
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
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
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
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
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
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)
How is acne PIH treated?
Sun protection
Bleaching agents - hydroquinone etc
Light chemical peel
Fractionated non-ablative laser - 1927nm thallium laser
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
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
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
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
How are ice pick scars treated?
TCA CROSS - 1st line
Fractional resurfacing+ CROSS
punch excision
Fractional radiofrequency treatment
How is severe atrophic acne scarring treated?
Fat transfer
Volumetric filling w/ HA, hydroxyapatite, stimulatory filler or silicon
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
How are Bridge or tunnel dystrophic acne scars managed?
Excision
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
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
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
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
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
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
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
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)
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
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!!
T/F
Cyclosporin can trigger acne keloidalis nuchae
True
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
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
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
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
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
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
What is Naevus sebaceous syndrome?
Type of epidermal naevus syndrome
association of naevus sebaceous with occular, CNS, and skeletal abnormalities
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
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
T/F solar comedones (Favre-Racouchot syndrome) and comedone naevus are terated in the same way
True
Comedone extractor
Topical retinoid
gentle electrocautery
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
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
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
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
