Acne Vulgaris

Question 1

Cause of acne?

Answer 1

Obstruction of the pilosebaceous follicle with keratin plugs which results in comedones, inflammation and pustules.

Question 2

What are the 4 major factors that contribute to the formation of acne lesions?

Answer 2

1) Follicular hyperkeratinisation

2) Increased sebum production

3) Propionibacterium acnes colonisation

4) Inflammation

Question 3

What is follicular keratonisation?

Answer 3

An abnormal keratinization process within the follicle leads to the formation of a keratinous plug, known as a microcomedone.

This creates an environment conducive to the proliferation of Propionibacterium acnes (P. acnes).

Question 4

What hormone stimulates sebaceous gland activity, leading to increased sebum?

Answer 4

Androgens

Question 5

Sebum & P. acnes?

Answer 5

Sebum serves as a nutrient source for P. acnes and contributes to the formation of a favorable anaerobic environment.

Question 6

What is P. acnes?

Answer 6

commensal bacterium in sebaceous follicles

Question 7

P. acnes and acne?

Answer 7

P. acnes produces lipases, proteases, and chemotactic factors that contribute to inflammation

Question 8

What is a comedone?

Answer 8

A blocked sebaceous follice

Question 9

What are the 2 types of comedones?

Answer 9

1) If the top is closed –> whitehead

2) If the top is open –> blackhead

Question 10

Inflammatory lesions form when the blocked sebaceous follicle bursts, releasing irritants.

What are 2 inflammatory lesions?

Answer 10

1) papules
2) pustules

An excessive inflammatory response may result in:
1) nodules
2) cysts

Question 11

What are the 2 types of acne scars typically seen?

Answer 11

1) ice pick scars
2) hypertrophic scars

Question 12

What is acne fulminans?

Answer 12

Very severe acne associated with systemic upset (e.g. fever). Hospital admission is often required.

Question 13

Mx of acne fulminans?

Answer 13

oral steroids

Question 14

1st line mx of mild-mod acne?

Answer 14

12 week course of topical combination therapy:

1) a fixed combination of topical adapalene with topical benzoyl peroxide

2) a fixed combination of topical tretinoin with topical clindamycin

3) a fixed combination of topical benzoyl peroxide with topical clindamycin

N.B. topical benzoyl peroxide may be used as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic

Question 15

Which macrolide can be used during pregnancy?

Answer 15

Erythromycin

Question 16

What should a topical retinoid or benzoyl peroxide always be co-prescribed with?

Answer 16

An oral antibiotic, to reduce the risk of antibiotic resistance developing.

Question 17

What COCP can be used to help with acne?

Answer 17

Co-cyprindiol (due to anti-androgen effects)

Question 18

Key side effect of co-cyprindiol?

Answer 18

Increased VTE risk –> only give for 3 months

Question 19

What is a macule?

Answer 19

A flat mark on the skin

Question 20

What is a papule?

Answer 20

A raised lump on the skin

Question 21

What is a pustule?

Answer 21

Small lump containing yellow pus

Question 22

What is a comodone?

Answer 22

skin coloured papules representing blocked pilosebaceous units

Question 23

Role of topical benzoyl peroxide in acne?

Answer 23

Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria

Question 24

Role of topic retinoids in acne?

Answer 24

Slow the production of sebum

Question 25

What vitamin are retinoids related to?

Answer 25

Vitamin A (contraindicated in pregnancy)

Question 26

Give an example of topical abx used in acne

Answer 26

Clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance)

Question 27

What is the last line option for severe acne?

Answer 27

Oral retinoids (i.e. isotretinoin) AKA roaccutane

Question 28

How long must patients wait to get pregnant after stopping isotretinoin?

Answer 28

at least a month

Question 29

Side effects of isotretinoin?

Answer 29

1) Dry skin and lips

2) Photosensitivity of the skin to sunlight

3) Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment.

4) Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis