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Dermatology > Acne Vulgaris > Flashcards

Acne Vulgaris Flashcards

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Dermatology Board Prep flashcards
1
Q

When does it usually occur?

A

80-90% of teenagers (60% of whom seek medical advice)

May persist beyond adolescence- 10-15% of female and 5% of males over 25 being affected

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2
Q

Describe the pathophysiology

A

Multifactorial

1) follicular hyperkeratinisation -> keratin plugs - made of dead keratinocytes, keratin and melanin.
2) increased sebum production by sebaceous glands (due to increased androgen production) . Contributes to blocking of follicles
3) colonisation by the anaerobic bacterium propionibacterium acnes
4) inflammation

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3
Q

What cause acne (simply put)

A

Hair follicles (pores) get blocked by particles like dead skin cells or oil

Once blocked, they form raised red bumps on skin

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4
Q

Why is it common among teenagers?

A

Due to skin changes that occur during puberty

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5
Q

What are the different types of acne?

A

Mild
Moderate
Severe

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6
Q

How does mild acne present?

A

Open and closed comedones (blackheads and whiteheads)
The occasional inflammatory lesion
Mainly facial

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7
Q

How does moderate acne present?

A

Inflammatory lesions - papules and pustules dominate

Face +/- torso

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8
Q

How does severe acne present?

A

Cysts and nodules
Scarring
Inflammatory papules and pustules

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9
Q

Where are sebaceous glands located?

A

Dermis of skin
They are connected to hair follicles
Secrete sebum via hair follicle or pores that open directly into skin surface

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10
Q

What is the role of sebum?

A

Transport nutrients and lubricate skin
Soften hair shaft
Prevent moisture loss
Slightly acidic

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11
Q

What causes an open comedone (blackhead)?

A

When there is an excessive of sebum or a keratin plug (or both) in hair follicle it can start to fill up the follicle (but not all the way). If it is still open to skin = an open comedone

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12
Q

Why do blackheads look black?

A

Melanin in keratin plug gets oxidised when exposed to air and becomes dark in colour

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13
Q

Does propionibacterium always live in the hair follicle?

A

Yes - part of normal skin flora

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14
Q

Why can bacterial overgrowth occur?

A

If hair follicle gets completely blocked up by sebum and keratin plug = closed comedone - propionibacterium can multiply with no place to go. This results in bacterial overgrowth.

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15
Q

What can the bacterial overgrowth attract?

A

Immune cells - result of bacteria and immune cells = white pus surrounding red inflammation

= a white head

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16
Q

What genetic and environmental factors can lead to acne?

A

Hyperkeratosis can have a genetic component
PCOS - increased androgen levels, which leads to more sebum
Psychological stress increases cortisol release - stimulates sebum secretion

Certain moisturisers and cosmetics can block pores
Wearing headband can irritate skin and block pores = contact acne
Excessive face washing - irritate skin surface
Low fat dairy and compounds in chocolate

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17
Q

What is another name for contact acne?

A

Acne venenata

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18
Q

Where on the body does acne vulgaris typically occur?

A

Face
Shoulders
Back
Chest

= sites of oil glands

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19
Q

Do most with acne have increased levels of androgens?

A

No - their sebaceous glands are more sensitive to androgens

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20
Q

How is mild acne treated?

A

Topical benzoyl peroxide 2.5, 5 or 10% (start with low strength)
OR
Topical retinoid (avoid in pregnancy and breastfeeding) e.g adapalene alone or with benzoyl peroxide
OR
Topical antibiotic e.g clindamycin 1% WITH benzoyl peroxide to prevent antibiotic resistance
OR
Azelaic acid 20%

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21
Q

When treating mild acne how long does it usually take for the effects to be seen?

A

8 weeks

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22
Q

How do you manage those with moderate acne, not responding to topical treatment?

A

If response to topical treatment inadequate, add an oral antibiotic - doxycycline, lymecycline, tetracycline, oxytetracycline are first line (erythromycin if pregnant) for max of 3 months

A topical retinoid or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce risk of resistance
Change to alternative antibiotic if no improvement after 3 months
Alternative to systemic antibiotics in women: COCP (plus topical)

23
Q

When should a referral to a dermatologist be made?

A

If not responding to 2 different courses of antibiotics, if they are starting to SCAR

24
Q

How is severe acne managed?

A

Isotretinoin - needs specialist prescribing

Marked benefit occurs in nearly all patients (permanent in 65%)

25
Q

What are the side effects of isotretinoin?

A

Teratogenic - contraception must be used during and for 1 month after
Skin and mucosal membrane dryness and flaky skin
Depression
Muscle or bone pain
GI disorders

26
Q

In acne vulgaris are several different types of acne lesions seen in each patient?

A

Yes

27
Q

Is drug induced acne often monomorphic?

A

Yes

Pustules are characteristically seen in steroid use

28
Q

What kind of management scheme is often used in the treatment?

A

Simple step up scheme

29
Q

How should tetracyclines be avoided in?

A

Pregnant and breastfeeding women

Less than 12 years old

30
Q

Should topical and oral antibiotics be used in combination?

A

No

31
Q

Why is Dianette (co-cyrindiol) sometimes used?

A

Has anti - androgen properties

32
Q

What does Dianette have an increased risk of compared to other COCPs?

A

Venous thromboembolism- should generally be used second line, only be given for 3 months, with appropriate counselling

33
Q

What influences the size and activity of sebaceous glands?

A

Genetics

Hormonal changes - puberty more androgen type hormones which cause sebaceous glands to enlarge and produce more sebum

34
Q

What occurs in follicular hyperkeratinisation?

A

The cells of the follicle become cohesive and do not shed as normal onto the skin surface - dead cells clumping together and blocking pores - blocking sebum in follicle

35
Q

What does P. acnes do when it is trapped in the follicle?

A

Converts the sebum into fatty acids - activate inflammation in nearby skin cells

36
Q

What are retinoids derived from?

A

Vitamin A

37
Q

How do retinoids work?

A

Main target = suprabasal keratinocytes

Enter cells and get converted to retinoic acid (biologically active form).
In nucleus, activates specific transcription factors - causing proliferation of basal keratinocytes and thickening the epidermis - promote shedding of keratinised dead cells at surface -> results in expulsion of comedones

38
Q

What types of topical retinoids are there?

A

Tretinoin
Adapalene
Tazarotene

39
Q

How does isotretinoin (oral retinoid) work?

A

Inhibits the proliferation and differentiation of sebum producing cells - shrinking sebaceous glands and decreasing sebum production

Also reduces co invasion with P. Acnes and the number of leukocytes that aggregate

40
Q

What are the side effects of topical retinoids?

A

Skin dryness, irritation, swelling, blistering

Sensitivity to sunlight

41
Q

What is the pilosebaceous unit?

A

The hair follicle and its associated oil gland

42
Q

What superficial lesions are there?

A

Open and closed comedones
Papules
Pustules

43
Q

What are papules?

A

Small, tender, red bumps

44
Q

What are pustules?

A

Elevated white or yellow topped lesions that contain pus

45
Q

What deeper lesions are there?

A

Nodules - large, painful red lumps lying under the skin

Pseudocysts

46
Q

What myths is it important to dispel?

A

It is not due to dirt/ lack washing
Not infectious or contagious
Diet has little or no effect

47
Q

What psychological problems is it associated with?

A

Depression
Anxiety
Social phobia

Important to ask about mood, effect on body image, self esteem and fears of social rejection

48
Q

What is acne fulminans?

A

Very severe acne associated with systemic upset e.g fever
Hospital admission required
Usually responds to oral steroids

49
Q

What secondary lesions can occur?

A

Excoriations - picked or scratched spots
Erythematous macules - red marks from recently healed spots
Pigmented macules - dark marks from old spots (mostly affects those with dark skin)
Scars of various types

50
Q

What causes acne scars?

A

Inflammation within the dermis - abnormal healing and dermal inflammation causes the scar

51
Q

What types of acne scars can occur?

A

Atrophic - loss of collagen from the healing response (most common type)

Hypertrophic - increased collagen content (uncommon)

52
Q

How does benzoyl peroxide work?

A

Releases free oxygen radicals into pores
P. Acnes can not survive in oxygen rich environment, so it gets killed by direct toxicity

Also has an anti inflammatory action and speeds up turnover of epithelial cells - promoting resolution of comedones

53
Q

What side effects of benzoyl peroxide are there?

A

Dryness
Redness
Itching
Burning

Dermatology (35 decks)

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