Acneiform and Verrucous lesions

Question 1

Acne Vulgaris

Answer 1

● Acne is an extremely common, usually self-limited, chronic inflammatory condition of the
pilosebaceous unit

Question 2

Pathogenesis of Acne vulgaris

Answer 2

● The pathogenesis involves four factors:
○ Increased sebum production
○ Follicular hyperkeratinization
○ Proliferation of the bacterium Cutibacterium acnes (C. acnes)
○ Inflammation

Question 3

Acne is most commonly found on areas with the _____, such as the face, back, and upper chest

Answer 3

greatest density of sebaceous follicles

Question 4

Mild Acne treatment

Answer 4

○ Benzoyl Peroxide 2.5% - 5% (OTC)
○ Topical Antibiotics
■ Clindamycin
■ Dapsone (Aczone)
■ Minocycline
■ To reduce antibiotic resistance, topical antibiotics are best used with benzoyl peroxide
○ Topical Retinoids
■ Adapalene (Available OTC as Differin Gel)
■ Tretinoin (0.025%-0.1% applied QHS)
■ Tazarotene (0.05%-0.1% applied QHS)

Question 5

Moderate Acne treatment

Answer 5

○ Oral Antibiotics- Courses should be limited to 3-4 months
■ Doxycycline, Minocycline, Tetracycline
■ May consider amoxicillin if patient cannot tolerate a tetracycline
■ Isotretinoin (more on next slide)
○ Oral antibiotics should be combined with topical treatments for moderate acne

Question 6

Hormonal Acne treatment

Answer 6

○ Topical clascoterone 1% cream (Winlevi)- an androgen receptor inhibitor
○ Oral contraceptives
○ Spironolactone- Only appropriate for use in females
■ May cause gynecomastia in men
■ Monitoring of women over 45 for hyperkalemia is recommended

Question 7

Severe Acne treatment

Answer 7

○ Isotretinoin (Accutane) (Vitamin A derivative)

Question 8

Rosacea

Answer 8

● Rosacea is a common, chronic inflammatory
condition with a relapsing-remitting course

Question 9

Rosacea Pathology

Answer 9

○ Involves dysregulation of immune and neurocutaneous
mechanisms. These may include-
■ Cutaneous vascular changes
■ Ultraviolet (UV) exposure
■ Microbial exposure
■ Disruption of the epidermal barrier
■ Genetics

Question 10

Two Subtypes of Rosacea

Answer 10

Erythematotelangiectatic Rosacea
Papulopustular Rosacea

Question 11

Erythematotelangiectatic Rosacea

Answer 11

● Persistent erythema of the central
face with intermittent flushing
● Telangiectasias are present due to
persistent dilation of blood vessels
● Patients often mention stinging or
burning sensations on the skin
● Most common subtype

Question 12

Papulopustular Rosacea

Answer 12

● Presence of acneiform papules and
pustules
● Variable intensity of central facial
erythema
● Sparing of the periocular areas

Question 13

Management of Erythematotelangiectatic Rosacea

Answer 13

● Avoid known triggers, including spicy
foods, alcohol, chocolate, stress, hot
beverages, extremes of temperature
● Use broad-spectrum sunscreens
● Mirvaso (brimonidine gel)
● Rhofade (oxymetazoline cream)
● Pulsed dye laser

Question 14

Management of Papulopustular Rosacea

Answer 14

● Topical metronidazole
● Azelaic acid gel
● Erythromycin or clindamycin lotion
● Ivermectin cream (Soolantra)
● Low dose doxycycline
● Isotretinoin
● Topical medications are significantly more
effective in the treatment of
papulopustular rosacea

Question 15

Perioral Dermatitis etiology

Answer 15

○ Exacerbated by external factors (irritants and topical
steroids) that break down the skin’s protective barrier
○ Oral contraceptives, inhalers, and fluoride have also been
implicated in perioral dermatitis
○ Masks

Question 16

Perioral Dermatitis presentation

Answer 16

○ Multiple small (1-2mm), clustered inflammatory papules with
or without scale around the mouth, nose, or eyes
○ Often resembles acne or rosacea
○ Usually spares a narrow area around the vermilion border of
the lip
○ May be accompanied by stinging or burning sensations

Question 17

Perioral Dermatitis diagnosis

Answer 17

● Diagnosis is usually clinical based on presentation and history
○ Spares the skin around the vermilion border of the lip
○ Coexisting features of eczema
○ Burning/stinging sensation
○ Recent topical, nasal, or inhaled corticosteroid use
○ History of flares after corticosteroid withdrawal
○ Absence of comedones (if comedones are present, think acne)

Question 18

Perioral Dermatitis treatment

Answer 18

○ Treatment: Discontinue topical corticosteroids, avoid topical products that may exacerbate
condition
○ Mild PD (small area of involvement without much emotional distress)- try for 8 weeks
■ Topical erythromycin gel (improvement in 4-8 weeks)
■ Topical metronidazole gel for at least 8 weeks
■ Topical Calcineurin inhibitors
● Pimecrolimus 1% cream, tacrolimus 0.1% ointment
○ Moderate to Severe PD (or treatment resistant PD with topicals)- try for 8 weeks
■ 1st line: Oral tetracyclines (tetracycline, doxycycline, minocycline)
● Best results seen with concurrent use of Pimecrolimus

Question 19

Hidradenitis Suppurativa

Answer 19

● Is a chronic destructive inflammatory disorder of the follicular epithelium in apocrine gland-bearing regions
○ Follicular occlusion leads to trapping of follicular contents, rupture, and inflammation of the dermis, with bacterial superinfection in
some cases

Question 20

Hidradenitis Suppurativa RFs

Answer 20

○ Genetics
○ Friction/pressure on intertriginous skin and other areas (beltlines,
bra straps, etc)
○ Obesity
○ Smoking
○ Hormones (rare before puberty, can flare during pregnancy)

Question 21

Hidradenitis Suppurativa Presenting Features

Answer 21

○ The primary lesions are inflammatory nodules, often in the intertriginous area.
○ Can be insidious starting with occasional solitary painful nodules that can last days to months.
○ The nodules often progress to form an abscess that may open to the skin surface spontaneously
with drainage.
○ Sinus tracts are a typical findings.
○ Comedones appear in chronic HS
○ Scarring is common. May be atrophic or keloidal.
○ This is usually a chronic condition

Question 22

Hidradenitis Suppurativa staging

Answer 22

○ Stage 1 (most common): abscess formation (single or multiple) without sinus tracts
○ Stage 2: Recurrent abscesses with sinus tracts and scarring
○ Stage 3: Diffuse or almost diffuse involvement with multiple interconnected sinus tracts

Question 23

Hidradenitis Suppurativa treatment

Answer 23

■ Weight loss- reduction of sugar intake
■ Topical clindamycin (only used with Stage 1 or mild disease)
■ Oral tetracyclines (ie Doxycycline 100mg BID)
■ Antiandrogenic drugs (spironolactone) and metformin
■ Humira (Adalimumab)
○ Acute lesions:
■ Intralesional corticosteroids
■ I&D

Question 24

Skin Tag (Acrochordon) presentation

Answer 24

Pedunculated lesions on narrow stalks

Question 25

Skin Tag (Acrochordon) treatment

Answer 25

○ Removal with forceps and scissors (may need 1% lidocaine with epi for large lesions) ○ Liquid Nitrogen ○ Bleed easily after removal, use aluminum chloride or cautery

Question 26

Epidermal Cyst

Answer 26

● Most common cutaneous cyst. Can occur anywhere on the body

Question 27

Epidermal Cyst presentation

Answer 27

○ Usually present as asymptomatic, skin-colored dermal nodules, often with a visible central punctum ○ Size ranges from a few mm to several cm in diameter ○ Can become infected by normal skin flora. They will be larger, erythematous, and more painful

Question 28

Epidermal Cyst diagnosis

Answer 28

usually clinical based on appearance ○ Discrete cyst or nodule, often with a central punctum, that is freely movable on palpation.

Question 29

Epidermal Cyst treatment

Answer 29

○ If stable and unifection, not necessary unless desired by patient ○ Inflamed, ruptured cysts that aren’t infected may resolve spontaneously but tend to recur. ○ Can injection with Triamcinolone acetonide (3mg/mL for face, 10mg/mL for trunk) to hasten the resolution if actively inflamed ○ If lesion is fluctuant, I&D indicated ○ Excision is best when the lesion is not inflamed, less likely to rupture. ○ If infected or signs of surrounding cellulitis, treatment with PO antibiotics, culture if drainage is present

Question 30

Lipoma presentation

Answer 30

○ Can occur on any part of the body, usually superficial in the subcutaneous tissue. Rarely involve fascia or deeper muscle. ○ Soft, painless subcutaneous nodules ranging from 1 to >10cm. ○ Most commonly on trunk and upper extremities. ○ Can be round, oval, or multilobulated

Question 31

Lipoma diagnosis

Answer 31

● This is a largely a clinical diagnosis ○ Look for a subcutaneous mass with no overlying color change ○ Lipomas have a soft and fluctuant feel and are often lobulated ○ Ultrasound can be helpful to differentiate from a cyst

Question 32

Lipoma treatment

Answer 32

○ Surgical removal of the fat cells and fibrous capsules (often done in clinic) ○ Recurrence of an fully excised lipoma is not common ○ Side effect risks of removal include scarring, seroma, and hematoma

Question 33

Actinic Keratosis (AK)

Answer 33

● A common lesion caused by proliferation of atypical keratinocytes ● AK’s are are early representation on a continuum with SCC and can progress to SCC

Question 34

Etiology/Risk factors of Actinic Keratosis (AK)

Answer 34

○ Chronic sun exposure/UV exposure/history of sunburn ○ Fair skin tone ○ Immunosuppressed patients

Question 35

Actinic Keratosis (AK) presentation

Answer 35

○ Erythematous, scaly papule(s) in sun exposed areas (scalp, face, lateral neck, upper extremities) ○ Skin adjacent to AKs usually show signs of sun damage (yellow/pale color, hyperpigmentation, telangiectasias, or xerosis)

Question 36

Actinic Keratosis (AK) diagnosis

Answer 36

○ Usually a clinic diagnoses based on symptoms (touch and visual inspection). ○ Will feel rough in texture ○ Can biopsy if unsure (shave). Will show atypical keratinocytes ■ Lesions that are tender, ulcerated, or rapidly growing are suspicious for SCC ■ Lesions >1 cm in diameter ■ Lesions that fail to respond to treatment (do not resolve in 8-12 weeks after treatment)

Question 37

Actinic Keratosis (AK) treatment

Answer 37

○ Can regress on its own ○ We typically treat given AKs serve as a marker for chronic sun damage and therefore an increased risk for development of skin cancer (SCC) ○ Cryotherapy (liquid nitrogen)- Most Common ○ Topicals ■ Fluorouracil (5% cream) and Photodynamic Therapy (Blu Light)

Question 38

Actinic Keratosis (AK) prevention

Answer 38

Sun protection

Question 39

Seborrheic Keratosis (SK)

Answer 39

● Common epidermal tumors of benign proliferation of immature keratinocytes

Question 40

Risk Factors/Etiology of Seborrheic Keratosis (SK)

Answer 40

○ Usually develop after age 50, but can appear in young adulthood ○ Genetics most common factor ○ UV exposure also a risk factor

Question 41

Presentation of Seborrheic Keratosis (SK)

Answer 41

○ Well-demarcated, round or oval lesions with a stuck-on appearance ○ Generally asymptomatic but if irritated due to friction can cause pruritus, pain, or bleeding ○ Vary in color from light brown, dark brown, or black

Question 42

Seborrheic Keratosis (SK) diagnosis

Answer 42

● Diagnosis is largely clinic based on appearance ○ Usually presents as a stuck-on, warty, well-circumscribed, often scaly hyperpigmented lesion located most commonly on the trunk, face, or upper extremities ○ Dermoscopy ○ Biopsy is only necessary if there is uncertainty or concern for malignancy

Question 43

Seborrheic Keratosis (SK) Treatment

Answer 43

○ Generally not required ○ If symptomatic or cosmetically desired ■ Cryotherapy (liquid nitrogen) (Most common) ■ Curettage/shave excision after 1% lidocaine ■ Electrodesiccation ○ Risks of treatment ■ Post inflammatory hypo- or hyperpigmentation ■ Scarring