Acne Vulgaris, Impetigo, Herpes

Question 1

Pathophysiology of acne vulgaris

Answer 1

1. increased sebum prdtn will increase sensitivity of sebaceous gland2. formation of microcomedones due to abnormal differrentiation and proliferation of follicle and sebaceous gland3. Cutibacterium acnes within microcomedones4. Perifollicular inflammation of commendone to papule, pustule or nodule

Question 2

Types of comedones

Answer 2

1. open comedones/black heads2. closed comedones/white heads3. giant comedones

Question 3

Clinical presenation of acne vulgaris

Answer 3

inflammation, redness, papules, some pustules located at cheeks and face, not pruritic

Question 4

What are the differential diagnosis of acne vulgaris?

Answer 4

1. Rosacea: butterefly morphology on cheek, comedones usually not present, may be caused by bacteria and is not linked to androgensAggravating factors: alcohol, spicy food, alot of caffeine, overexposure to sunlight, extreme heats, irritating cosmetic, topical CS, friction2. Perioral dermatitis: more often in women, assoc with cosmetic makeup or creams, CS can also cause this, excessive saliva from drooling3. Folliculitis (gram -ve): inflammatory cyst

Question 5

What is the European Union Guidelines Clinical Classification of Acne Vulgaris?

Answer 5

I : comedonal acne (mainly comedones)II : mild to moderate papulopustular acneIII : severe papulopustular acne, moderate nodular acneIV : severe nodular acne, conglobate acne I and II : pri careIII and IV: refer

Question 6

Clinical presenation of acne conglobata (nodulocystic acne) & acne fulminans

Answer 6

severe acne and inflammation. risk of permanent scarring and pigmentation for life

Question 7

Non-pharm measures for prevention and tx of acne vulgaris

Answer 7

1. low glycemic load diet2. avoid skim milk3. cleansing skin4. do not squeeze pimple -> leads to scarring5. do not touch face6. cleanse face BD7. Use oil free creams and cosmetics

Question 8

What is an example of evidence based choice of cleanser?

Answer 8

• Generally there is limited efficacy due to the short period of contact with the skin* Chlorhexidine gluconate 4% solution in a detergent base is as effective as benzoyl peroxide washes but evidence base is weak and irritation a possible side effect,* Glycolic 1%, an alpha-hydroxy acid (AHA), causes desquamation bydecreasing basal corneocyte cohesion and limiting follicular occlusion* Most are ineffective but clorhexidine gluconate is most effective

Question 9

What are the basic goals of pharmacotherapy of acne vulgaris?

Answer 9

1. alleviate clinical smx 2. prevent scarring and PIH3. reduce psychological stress

Question 10

Type of scarring assoc with acne vulgaris

Answer 10

1. ice pick scars2. hypertrophic scars3. atrophic scars

Question 11

Which part of the acne pathogensis does drug act on

Answer 11

P. acnes proliferation: benzoyl peroxide (cheap, TOP, effective), TOP/PO ABs, Isotretinoin (for sev acne)Abnormal keratinisation of follicle: salicylic acid, benzoyl peroxide, TOP retinoids, IsotretinoinInflammatory response: Intralesional/PO CS, TOP/PO ABsAbnormal sebum: antiadrogens (for women), isotretinoin, TOP/PO ABs, CS, estrogens

Question 12

Types of topical pharmacotherapy for acne vulgaris

Answer 12

1. retinoids2. benzoyl peroxide3. salicylic acid4. azelaic acid

Question 13

What is the use of topical retinoids: Adapalene (Differin)?

Answer 13

• Third generation (poly-aromatic) retinoid, stable, fast acting anti-acne treatment with both significant anti-inflammatory and comedolytic properties* Adapalene release from lotions and hydro-alcoholic gels is more effective than from creams and aqueous gels and a microsphere gel formulation may be less irritating 1* Adapalene is generally regarded as the topical retinoid of first choice for both treatment and maintenance therapy, as it is as effective but less irritating than other topical retinoids* It is available in fixed-dose combinations in specialised gel vehicles with benzoyl peroxide to increase the efficacy in comparison with monotherapy [Epiduo Topical Gel TM]* First line of tx for maintenance + treatment for mild acne. commonly used with benzoyl peroxide

Question 14

What to monitor for adapalene?

Answer 14

SE: erythema, xerosis, burning and desquamationLess irritation than other retinoidsPhotoirritation or sensitisation.Degree and/or changes in S&S of irritancy to skin (subsides w time). Skin changes in areas of sun exposure (avoid sunlight!)

Question 15

What is the use of topical antimicrobial agent: Benzoyl peroxide?

Answer 15

• antimicrobial, anti-comedonal and anti-inflammatory- can be used concomittantly with topical retinoids and antibiotics (prevent resistence)- sunscreen is rec with use- for mild or mod acne

Question 16

What to monitor for benzoyl peroxide?

Answer 16

• dryness, erythema, burning, pruritis, irritation/irritant dermatitis (assoc with conc)- start with low strength of 2.5% gel first then once tolerance achieved, increase to 5%. if start too strong can cause severe redness.- redness, and stinging will subside after 1st week- risk of photosensitisation

Question 17

What is the use of exfoliants: salicylic acid?

Answer 17

• Salicylic acid, a beta-hydroxy acid, is a comedolytic agents that is available over the counter in 0.5% to 2% strengths* Clinical trials demonstrate the efficacy or safety of salicylic acid on acne are limited* Salicylic acid is a mild irritant and may cause some degree of local skin peeling and erythema* Salicylic acid products are often used as first-line therapy for mild acne because of their wide availability [e.g. Comedone LotionTM-R&D Pharmaceuticals]

Question 18

What is the use of anti-inflammatory agents: azelaic acid?

Answer 18

• Dicarboxylic agent has mildly effective as a comedolytic, anti-bacterial, and anti- inflammatory agent* Agents has been used in patients with sensitive skin or of Fitzpatrick skin type IV or greater because of the lightening effect on dyspigmentation* Possesses activity against all four pathogenic factors that produce acne* Azelaic acid 20% cream [SkinorenTM] is used in the treatment of mild to moderate inflammatory acne* Azelaic acid has been shown to be effective with topical 2% erythromycin, topical 5% benzoyl peroxide gel, and topical 0.05% tretinoin cream in the treatment of mild to moderate inflammatory acne. However, the agent has limited efficacy when compared with other acne treatments

Question 19

What to monitor for azelaic acid?

Answer 19

mainly pruritis, stinging, burning.others: erythema, dryness, rash, dermatitis, irritation

Question 20

What is the use of topical antibacterials?

Answer 20

• Topical antibiotics work through antibacterial effects (the primary mechanism for efficacy in acne) and anti-inflammatory mechanisms.* These agents are best used in combination with benzoyl peroxide (wash off or leave on) which increases efficacy and decreases the development of resistance [e.g. Clindoxyl Once DailyTM]* Monotherapy with topical antibiotics in the management of ace is not recommended because of the development of resistance.* Gel is usually used as it is less oily

Question 21

What to monitor for clindamycin?

Answer 21

erythema, peeling, itch, dryness and burning

Question 22

What are the types of oral therapy for acne vulgaris?

Answer 22

• oral ABs- hormonal therapy- isotretinoin

Question 23

What is the use of oral ABs for acne vulgaris?

Answer 23

• The use of oral antibiotics is reserved for patients with moderate-to-severe inflammatory Acne Vulgaris (Type III onwards)* Tetracyclines are considered first-line therapy, while macrolides and trimethoprim/sulfamethoxazole are acceptable alternative agents* It is recommended that oral antibiotics be prescribed with concurrent topical therapy for improved efficacy and to combat antibiotic resistance -> the use of ABs here is different from acute infection. These are used for extended durations of min. 3months so there is concern of resistence, hence must be used tgt with benzoyl peroxide. Furthermore, therapeutic effect not evident in ST so might have adherence issues* Oral antibiotics used in the treatment of acne may have unintended effects on nontarget bacteria, and the clinical implications of this warrant further considerations* Avoid use with retinoids.

Question 24

What to monitor for oral ABs in acne vulgaris?

Answer 24

For tetracyclines: GI intolerance, vaginal candidiasis, photosensitivity. For doxycycline: GI upset, photosensitivty.Both CI in pregnant women or <9y/o

Question 25

What is the use of hormonal therapy - COCs

Answer 25

• The mechanism of action of combination COCs in the treatment of Acne Vulgaris is based on their anti-androgenic properties* Cyproterone acetate combined with ethinyl estradiol (in the form of an oral contraceptive is approved by the HSA1 for the treatment of Acne Vulgaris in females [e.g. Estelle-35 EDTM]* COCs are equivalent to antibiotics at 6monthsin reducing acne lesions and may be a betterfirst line alternative to systemic antibiotics forlong term acne management in women

Question 26

What to monitor for anti-sebum/COC in acne vulgaris?

Answer 26

• breakthrough bleeding, headache- serious: venous thromboembolism, hepatotoxicity

Question 27

What is the use of oral isotretinoin therapy?

Answer 27

• shrinks oil glands- reduces acne bacteria- helps prevent clogs- reduces inflammation- acts on all 4 pathological factors of acne vulgaris

Question 28

What is the safety and efficacy of oral isotretinoin in asian population?

Answer 28

• > 10% develop hyperlipidemia hence freq blood tests must be done to ensure safety.- usually 5-10% will get side effects

Question 29

What to monitor for oral isotetinoin in acne vulgaris?

Answer 29

• dryness (give lubricant eyedrops and emollients), teratogenic, depression and suicide, sun sensitivity- must test for pregnancy twice before starting- contraceptive meausres must be started 1month prior

Question 30

Summary of care plans for Acne types I - IV

Answer 30

Type I: mainly comedones with occasional small inflamed papule or pustule, no scarring -> topical retinoids. can consider benzoyl peroxide or azelaic acid or salicylic acidType II: Comedones and more numerous papules and pustules (mainly facial), mild scarring -> fixed dose combi (adapalene and benzoyl peroxide) or benzoyl peroxide or topical retinoid or azelaic acid. if more severe, fixed dose combi preferred w or w/o hormonal therapy and/or AB, particularly if trunk is involvedType III: Numerous comedones, papules and pustules, spreading to back, chest and shoulders, with an occasional cyst or nodule, moderate scarring -> fixed dose combi w an oral AB is preferred, oral isotretinoin or oral hormonal therapy can also be addedType IV: numerous large cysts on face, neck, and upper trunk, severe scarring -> for males, monotherapy w oral isotretinoin or a retinoin fixed combi or oral ABs. for females, oral isotretinoin + antiandrogenic hormonal therapy is preferred or fixed combi retinoid with oral ABs (consider high dose) and/or antiandrogenic hormonal therapy

Question 31

Global Alliance Consensus Recommendations for management of Acne Vulgaris

Answer 31

1. Retinoids have an essential role in treatment of acne. For most patients with inflammatory acne, comedonal acne, or both, a topical retinoid plus benzoyl peroxide is first-line therapy.2. The role of antibiotics in acne therapy has changed. Neither topical nor systemic antibiotics should be used as monotherapy for acne treatment.3. Oral isotretinoin should be first-line therapy for very severe (cystic and conglobate) acne.4. Oral isotretinoin therapy should proceed until full clearance of acne. Additional studies are needed5. Acne flare with oral isotretinoin can be minimized by initiating therapy at a low dose.6. Most patients with acne should receive maintenance therapy with a topical retinoid.7. Azelaic acid cream 20% or gel 15% is a useful acne treatment in pregnant women and patients with acne and PIH.8. At present, devices that use laser, intense pulsed light, or photodynamic therapy should not be considered first-line treatment for inflammatory acne.9. A minority of women 25 years of age have acne lesions localized only to the lower face. Topical retinoids with or without benzoyl peroxide are important components in therapy of adult acne.10. Early and effective treatment is important to minimize potential risk for acne scarring

Question 32

Clinical presentation of impetigo

Answer 32

• mostly face and common in children. usually from trauma, scratches, mosquito bites. its a bacterial infection- smx: pruritis is common, weakness/fever/diarrhoea occasionally seen with bullous form, minimal systemic smx of infection- signs: non bullous-> lesions start as small, fluid filled vesicles and rapidly develop into pustules that rupture readily, purulent discharge dries to form golden yellow crusts. bullous -> lesions start as vesicles that rapidly progress into bullae containing clear yellow fluid. bullar soon rupture, forming thin light brown crusts. regional lymph nodes may be enlarged

Question 33

What topical AB treatment for impetigo?

Answer 33

• Topical mupirocin 2% or retapamulin ointment* Penicillinase-resistant penicillins (dicloxacillin)* First generation cephalosporins (e.g. cephalexin)

Question 34

Clinical presentation of herpes simplex labialis

Answer 34

• on the lips - painful- lesions, blisters- prodrome smx: tingling sensation is felt around the lips before anything shows up

Question 35

Hx taking questions to ask for herpes simplex labialis

Answer 35

• Appearance: pts with cold sores will often experience prodromal smx before the skin eruption, whereas no warning signs are present with impetigo or angular cheilitis- Location: cold sores usually occur around mouth, may also occur around and inside nose but is less common. impetigo also occur in same areas but is more prone to spread to other areas of face or move to other parts of body like arms. angular cheilitis occurs at corners of mouth and may be mistaken for cold sores due to similar locations.- trigger factors: stress, sunlight, viral infection (common cold), menstruation, ill health.

Question 36

What topical antiviral treatment for herpes simplex labialis?

Answer 36

• acyclovir 5% cream (Zovirax 2g)

Question 37

What are the trigger points and when to refer for cold sores?

Answer 37

• duration >14days: unlikely to be cold sores- cold sores located in mouth- severe and widspread lesions- lesions that spread away from the lips and onto face: imeptigo is more likely

Question 38

What are the complications of HSV1 infection?

Answer 38

• dendritic ulcer: infection in eye- eczema herpeticum- erythema multiforme

Question 39

What is the differential diagnosis of herpes simplex labialis?

Answer 39

angular cheilitis: more common at corner of mouth, no prodrome, no blisters, caused by saliva (might be due to breathing from mouth due to sinus) or wound, painful when pt opens mouth, can be crusty,