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clinical medicine > Acneiform lesions > Flashcards

Acneiform lesions Flashcards

0
Q

What percentage of Americans does Acne affect?

A

60%–70% of Americans at some point in life
20% (1/5) will have severe acne, resulting in permanent mental and physical scarring
ACNE MOST COMMON SKIN DISEASE IN US
if 2 parents had it, 3 of 4 kids will
if 1 parents had it, 1 of 4 kids will

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1
Q

What are 4 acneiform lesions that resemble Acne Vulgaris?

A
  • comedones (plugged glands)
  • papulopustules
  • cysts
  • nodules
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2
Q

Age of acne presentation?

A

-newborns due to maternal hormones and higher adrenal gland androgen production
-adolescents (gonads produce androgen @ puberty)
-5% adults men + women at age 45
20% women and 5% men at age 25

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3
Q

What is the clinical presentation of acne?

A

comedones: closed (whiteheads) and open (blackheads)
Inflammatory papules, pustules
-due to Propionibacterium acnes (p. acne)

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4
Q

What are blackheads?

A

comedones–open

they have melanin, not dirt!

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5
Q

What are the social impacts of acne?

A

depression- freezes personality in adolescence during first development
anger, hostility, antisocial behavior

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6
Q

Describe acne grades I, II, III, IV

A

grade I: comedones open (blackheads)
grade II: comedones closed (white heads)
grade III: papulopustules lesions
grade IV: comedones open, closed, papulopustules cysts

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7
Q

What factors aggravate acne vulgaris?

A
  • cosmetics (for hair and face)
  • pregnancy may aggravate
  • medications: lithium, steroids, antiepileptics (for seizures), iodides
  • sunlight may make better or worse
  • occlusions (hats, hair, underwire bras)
  • congenital adrenal hyperplasia, polycystic ovary syndrome + other endocrine disorders associated with adrenal gland

-NOT DIET!! chocolate, sodas, junk food will not make acne worse

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8
Q

Treatment for acne

A
  • wash face 2x a day
  • non-comedogenic make-up/moisturizers
  • topical treatments (benzoyl peroxide, retinoids, adapalene, tazarotene), topical antibiotics, systemic antibiotics (tetracycline), systemic treatments (isotretinoin, oral contraceptives, spironolactone)
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9
Q

Describe all topical treatments for acne (topical GREAT FOR NON-INFLAMMATORY!!!)

A
  • benzoyl peroxide: effective against P. acne, comes OTC (soap, wash, lotion, gel, cream), use 1-2x a day, MAY cause irritant contact derm especially if used w/ tretinoin, RARELY causes allergic contact derm
  • retinoids: (include adapalene & tazarotene)- comedolytic, anti-inflammatory, normalize hyperproliferation & hyperkeratinization, can be used with other acne meds, use 1x a day or every other day, thins corneum, may cause redness, peeling, irritation, associated w/ sun sensitivity
  • Adapalene (Differin)- naphthoic acid derivative that binds to retinoic acid receptor to normal epidermal differentiation– ANTI-INFLAMMATORY!
  • Tazarotene (AVAGE, Tazorac)- retinoid prodrug that modulates proliferation & differentiation of epithelial tissue, may have anti-inflammatory and immunomodulatory properties
  • topical antibiotics: against P. acne, anti-inflammatory, includes erythromycin & clindamycin, NOT comedolytic, bacterial resistance possible but LESS LIKELY if used with benzoyl peroxide, apply 1-2x daily, gel & solutions may be more irritating than cream or lotions
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10
Q

Describe Isotretinoin aka Accutane (systemic treatment for acne)

A

-used in severe, recalcitrant (stubborn) acne cases
-normalizes epidermal differentiation
-decreases sebum excretion by 70%
-anti-inflammatory, reduces presence of P. acne
-cumulative dose of 120-150mg/kg, administer W/ STEROIDS at onset
in severe cases
-Teratogen!!! pregnancy must be avoided (2 neg. preg. tests before starting, contraception counseling mandatory)
-lower intermittent dose schedules (1 wk a month) not effective
-baseline labs: cholesterol, triglycerides, CBC, HCG, hepatic transaminase levels
-may heighten feelings of depression/suicidal thoughts
-FDA-mandated registry for all people prescribing, dispensing, taking (iPLEDGE online)
-risk of abnormal healing, development of excessive granulation tissue, elective procedures must be postponed up to a yr after finishing isotretinoin
-during medication, cannot get piercings, tattoos, leg waxing, etc

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11
Q

Describe systemic antibiotics (tetracycline group) for acne

A

effect against P. acnes & anti-inflammatory

  • lipophilic medications more effective (doxycycline & minocycline)
  • P. acnes resistance is becoming more common w/ antibiotics
  • subantimicrobial therapy or treatment with topical benzoyl peroxide may reduce emergent or resistant strains
  • other antibiotics: azithromycin, sulfamethoxazole, trimethoprim
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12
Q

Describe systemic treatments (oral contraceptives & Spironolactone) for acne

A

Oral contraceptives (OCP): increase sex hormone-binding globulin, decreasing circulating free testosterone, a requirement for many dermatologists before isotretinoin, combination (triphasic) birth control pills

Sprionolactone: reduces androgen production, could cause dizziness, breast tenderness, dysmenorrhea (painful menstrual cycle) which could be cured by taking birth control, periodic evaluation of blood pressure and potassium is appropriate, avoid pregnancy because of risk of feminization of male fetus while taking this med

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13
Q

What is a papulopustular drug reaction?

A

Not acne because NO COMEDONES! looks like acne
-patients have fever, have leukocytosis
caused by: penicillin & macrolides
others: co-trimoxazole, doxycycline, ofloxacin, chloramphenicol
*others on slide that produce acne-like eruption-don’t need to know?

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14
Q

What are eruptive vellous hair (peach fuzz/bum bluff) cysts?

A

many vellous (fine, non pigmented) hair follicles
mid-dermal epithelial cyst containing vellous hairs, keratinous material
may be hereditary
-cysts may spontaneously regress, form connection to epidermis, or be degraded by foreign body granulomatous reaction
-flesh colored papules
-face, thigh, chest, neck, groin, axillae, butt

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15
Q

What are treatments for vellous hair cyst?

A

incise & drain (risk of scarring)
CO2 laser ablation–difficult with large surface area
topical retinoids + 12% lactic acid preparations

16
Q

What is steroid acne?

A
  • caused by steroid use (ex: anabolic steroids)–topical or systemic steroid use, including intravenous and inhaled
  • monomorphous papulopustules
  • trunk, extremities
  • eruption resolves after STOPPING steroid
  • MAY respond to usual treatments of acne vulgaris!!
17
Q

What is chloracne?

A
  • cutaneous eruption of polymorphous comedones or cysts
  • possible pigmentary changes and xerosis
  • may cause nervous, ophthalmic, hepatic system effect, and possible oncogenic
  • due to exposure to halogenated aromatic hydrogen compounds (ex: chlorinated dioxins & dibenzofuranes)
  • inhalation, ingestion, or direct contact through foods or contaminated compounds
18
Q

Describe secondary syphilis (great pox)

A
  • papulopustules and nodules, some crusted
  • face, trunk, extremities
  • caused by: spirochete Treponema pallidum
19
Q

How is secondary syphilis diagnosed?

A
  • biopsy

- serologic tests and presents of spirochetes on darkfield microscopy

20
Q

What is erythematotelangiectatic (ETR) type rosacea?

A
  • central facial blushing
  • butterfly effect (across central face)
  • burning or stinging
  • redness spares periocular skin
  • triggers to flush include emotional stress, hot drinks, alcohol, spicy foods, exercise, hot or cold weather
  • burning or stinging exacerbated when topical agents applied
21
Q

Describe papulopustular rosecea (PPT)

A
  • more pronounced inflammation
  • more common in white women in 30-40 yrs of age
  • classic presentation of rosacea: red central portion of face containing small erythematous papules surmounted by pinpoint pustules
  • telangectasis hidden by surrounded erythema
22
Q

Describe phymatous rosacea

A
  • marked skin thickening

- irregular surface nodularities on nose, chin, forehead, ears, eyelids

23
Q

Describe ocular rosacea

A
  • ocular signs may precede rosacea by years or develop together
  • eyes: conjunctivitis, blepharitis (swelling of eyelids), meibomian glands, inflammation of lids, interpalpebral conjunctival hyperemia, conjunctival telangiectasias
  • symptoms of eye stinging, burning, dryness, irritation with light, feeling of foreign body in eye
  • -REQUIRES DERMATOLOGIST: antihistamine drops do not work
24
Q

Describe rosacea histopathology

A

lymphohistiocytic perivascular & perifollicular inflammation, ectatic (dilation of..) vascular channels, elastosis (accumulation of abnormal elastin in dermis), and hypertophy of connective tissue & sebaceous follicles

25
Q

How do you diagnose rosacea?

A

usually clinical– biopsies can be performed but are not usually

26
Q

What is the etiology of rosacea?

A

unknown
triggered by alcohol, hot foods, hot water, high dose vitamin B supplements, weather extremes (temp & wind), & demodex folliulorum mites

27
Q

What are the treatments for rosacea?

A

sunscreens
topical antibiotics (metronidazole)
retinoids- regulate cell proliferation, epithelial growth
oral tetracyclines (erythromycin)
contraceptives
tacrolimus ointment (protopic/elidel)-immunosuppressives
dapsone -antibiotic
laser (for remodeling of connective tissue)

28
Q

What is hidradenitis suppurativa?

A

disorder of terminal follicular epithelium in apocrine areas of skin

  • comedo-like follicular occlusion
  • chronic inflammation
  • progressive scarring
  • mucopurulent discharge (secretion of fluid containing mucous and pus)
29
Q

Who gets hidradenitis suppurativa?

A

frequency 1-2%, but probably underdiagnosed
female:male - 2-5:1
usually black people because more apocrine glands
average age 23 years (typically 11-50 yr old but not usually before puberty or postmenstrual)

30
Q

What is histopathology of hidradenitis suppurativa?

A

same as acne vulgaris–hyperkaratosis of infundibulum (where hair follicle grows), creating comedo-like horny lesions

31
Q

What are symptoms of hidradenitis suppurativa?

A
  • pruritic, erythematous, local hyperhidrosis (abnormal sweating)
  • lesions become painful
  • secondary complications: scarring, rare squamous cell carcinoma
  • arthropathy variable (ranges from asymmetric to pauciarticular arthritis to symmetric polyarthritis)
32
Q

How is hidradenitis suppurativa diagnosed?

A
  1. Typical lesions: papules->nodules->abscesses->contractures
  2. characteristic distribution: milk line, axilla and groin, may involve perianal or areola (like Crohn’s disease), plus scalp, auditory meatus, back of neck, shoulders
  3. One of the following: active -1 or more lesions, or inactive lesions (fredenberg said don’t need to memorize other details about this)
33
Q

What are the stages of hidradenitis suppurativa?

A

Stage 1: solitary abscess (looks like carbuncle, epidermoid cyst, or lymphadenitis)
Stage 2: recurrent abscesses (single or multiple lesions with sinus tract formation and scarring
Stage 3: scar tissue and bridging fibrosis develop, many sinus tracts, abscesses common, diffuse or broad spreading

34
Q

What is the treatment for hidradenitis suppurativa?

A
  • local hygiene, loose fitting clothing
  • weight loss in obese people
  • ordinary soaps, deoderant, & antiperspirant agent (aluminum chloride)
  • warm NaCl compresses or with Burow solution
  • anti-inflammatory or anti-androgen therapy (tetracycline or finasteride, which inhibits enzyme for testosterone->hihydrotestosterone)
  • retinoids (isotretinoin)-anti-proliferative, immunomodulator
  • antibacterial therapy (tetracycline/doxycline, erythromycin)
  • surgery (sine qua non treatment)
35
Q

What is perioral dermatitis?

A
  • chronic
  • papulopostular
  • eczematous
  • facial dermatitis
  • resembles rosacea
  • most common in women
  • burning and tension, ITCHING RARE!
36
Q

What causes perioral dermatitis?

A
  • unknown
  • facial use of topical steroids often precedes
  • neurogenic inflammation a possible cause
37
Q

What is the treatment for perioral dermatitis?

A
  • doxycline, tetracycline, or minocycline
  • if granulomatous: oral isoretinoin
  • individualized topical therapy in kids/women
  • anti-inflammatory agents (erythromycin) with nongreasy base
  • In steroid induced cases: pimecrolimus cream
  • other topical anti-acne meds (adapalene)
  • greasy ointments should be avoided
38
Q

In perioral dermatitis, what is zero-therapy?

A

ceasing all topical meds and cosmetics (as possible causative factors)

  • limited to compliant individuals (often over-treated)
  • worsening expected initially during beginning of withdrawal
  • with those addicted, steroid weaning with .5-1% hydrocortisone cream

clinical medicine (12 decks)

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