Acneiform Eruptions

Question 1

What is the pathophysiological mechanism of inflammation in acne?

Answer 1

1. Hyperkeratosis occurs due to hyperproliferation of ductal keratinocytes or reduced separation of ductal corneocytes which leads to blockage of pilosebaceous duct
2. Sebum excretion increases via androgen stimulation and builds up
3. Propionibacterium acnes overpopulates duct along with shed keratin and sebum
4. Stimulates inflammatory mediators

Question 2

How does sebum excretion rate change in acne?

Answer 2

Increases (androgen stimulates it)

increases in puberty

Question 3

What are the 2 types of comedones?

Answer 3

Open (blackheads)

Closed (whiteheads)

Question 4

What are blackheads?

Answer 4

Dilated keratin filled follicles which appear as black papules due to keratin debris

Question 5

What are whiteheads?

Answer 5

Accumulation of sebum and keratin deeper in the pilosebaceous ducts

Question 6

What is the most common peak age for acne vulgaris?

Answer 6

15-18yrs (90% of teens)

Question 7

What happens to the squamous epithelium in acne?

Answer 7

Hypercornification/hyperkeratinisation - develops into tough protective layers

Question 8

What are the 3 variants of acne?

Answer 8

Mild
Moderate
Severe

Question 9

How is mild acne described?

Answer 9

Non-inflammatory
Open + closed comedones
Lesions <30; <15 inflammatory

Question 10

How is moderate acne described?

Answer 10

Inflammatory (papules, pustules, nodules, cysts)
20-100 comedones
Lesions 30-125; inflammatory 15-50

Question 11

What can early treatment of moderate acne prevent?

Answer 11

Scarring

Question 12

How is severe acne described?

Answer 12

> 5 pseudocysts
Comedones >100
Lesions >125; Inflammatory >50

Question 13

Severe acne is difficult to treat, may need lasers, but what is left once it is treated?

Answer 13

Permanent scarring and post-inflammatory pigmentation

Question 14

Give 3 acne variants

Answer 14

Acne Fulminans
Drug induced acne
Acne excoriee

Question 15

How is acne fulminans characterised?

Answer 15

Most severe form of cystic acne

Abrupt onset of nodular and suppurative acne with systemic manifestations

Question 16

What systemic manifestations accompany acne fulminans?

Answer 16

Fever
Arthralgias
Myalgias
Hepatosplenomegaly

Question 17

What medications cause drug induced acne?

Answer 17

Anabolic steroids
Corticosteroids
Phenytoin
Lithium
Isoniazid

Question 18

What is the cause of acne excoriee?

Answer 18

Neurotic excoriation of papules and comedones leaving crusted lesions which may scar

Question 19

Why might you enquire about menstrual history in acne?

Answer 19

Polycystic Ovary Syndrome

Question 20

What are some topical treatments for acne?

Answer 20

Topical retinoids
Benzoyl peroxide
Topical abx (clindamycin/erythromycin)
Azelaic acid

Question 21

What are some oral treatments for acne?

Answer 21

Abx tablets (lymecycline, tetracycline)
Combined oral contraceptive pill in women
Isotretinoin (last resort)

Question 22

What populations is rosacea most common in?

Answer 22

3rd and 4th decades of life

Fair-skinned

Question 23

Is there a known pathogenesis of rosacea?

Answer 23

No; in contrast to acne it is not associated with sebhorrhoea

Question 24

What is increased in rosacea?

Answer 24

Sensitivity to noxious stimuli

Question 25

What is the mite which is increased in number in rosacea?

Answer 25

Demodex folliculorum

Question 26

Describe a common presentation of rosacea

Answer 26

Central convex areas of face affected Episodic flushing with no sweating Erythema/burning sensation triggered by minor irritants Persistent tissue thickening due to oedema, fibrosis + glandular hyperplasia

Question 27

What can be present in more advanced rosacea?

Answer 27

Papules and pustules (NO COMEDONES)

Question 28

What are some triggers for rosacea?

Answer 28

Stress Hot drinks Alcohol Spices

Question 29

Give the 2 features of vascular rosacea

Answer 29

Recurrent blush | Telangiectasis (initially in nose)

Question 30

Give some (4) features of inflammatory rosacea

Answer 30

Small papules/pustules Absence of comedones Deeper red colour compared to acne Soft/solid facial oedema

Question 31

Describe phymatous rosacea

Answer 31

Overgrowth of sebaceous glands Skin swollen and smoother; pores more apparent Lumpy surface gradually develops (nose)

Question 32

What is the incidence of ocular rosacea?

Answer 32

50% of rosacea patients

Question 33

What are some possible symptoms of ocular rosacea?

Answer 33

``` Dryness/tired eyes Oedema Tearing Pain Chalazia Corneal damage ```

Question 34

What are the topical treatments for rosacea?

Answer 34

Metronidazole cream/gel (major therapy) Azelaic acid cream/gel Ivermectin cream

Question 35

What are the non-topical treatments for rosacea?

Answer 35

Tetracyclines most common Avoidance of obvious vasodilators/irritants Surgery for rhinopymas