CHAPTER 13: ACNE Flashcards
What is the primary lesions of acne
Comedo
are usually 1-mm yellowish papules that may require stretching of the skin to visualize.
Closed com- edones (whiteheads)
Types of acne scars
Ice pick- temples and cheeks
Box car
Rolling
Anetoderma type (atrophic)
Hypertrophic
Most neonatal acne remit by age ___
1 year
Acne onset from what age is considered as preadolescent acne?
7-12y
The combination of these 3 elements in acne formation leads to the release of proinflammatory mediators➡️ formation of inflammatory lesions
Keratin
Sebum
Microorganisms- propionibacterium acnes
Screening tests to exclude a virilizing tumor for severe acne resistant to therapy, relapse quickly or sudden onset
Serum dehydroepiandrosterone (DHEAS)
Serum testosterone
2 weeks before onset of menses
Most common cause of treatment failure in acne
Lack of adherence
Treatment for mild comedonal acne
1st line: topical retinoid + physical extraction
2nd line: alternate retinoid, salicylic, azelaic acid
Treatment for mild papular/pustular acne
- Topical antimicrobial combination + topical retinoid, benzoyl peroxide wash if mild truncal lesions (first line)
- Alternate antimicrobials + alternate topical retinoids, azelaic acid, sodium sulfacetamide–sulfur, salicylic acid (second line)
Treatment for moderate papular/pustular acne
1st line: Oral antibiotics + topical retinoid + benzoyl peroxide
2nd line: alternate antibiotic, topical retinoid, benzoyl peroxide
Women: spironolactone + OCP + topical retinoid +/- topical antibiotic and/or benzoyl peroxide
Isotretinoin- relapse quickly off oral antibiotics, does not clear or scars
Treatment for severe acne
Nodular/conglobate
Isotretinoin
Oral antibiotic + topical retinoid + benzoyl peroxide
Women: spironolactone + OCP + topical retinoid +/- topical or oral antibiotic and/or benzoyl peroxide
Preferred agents in maintenance therapy of acne
retinoids
Oral antibiotic for pregnant women with acne
Amoxicillin 500mg TID
side effects of dapsone treatment for acne
Hemo- lytic anemia
Oral antibiotic for pregnant women with acne
Amoxicillin 500mg TID
Known side effect of clindamycin that limits its use
150mg TID
Pseudomembranous colitis
Antiandrogen treatment prescribed in combination with OCP in the treatment of acne
Spironolactone 100mg ODHS
Dose of isotretinoin for severe acne
0.5-1mg/kg/day OD or BID
Starting: 20-40mg/day
When taking isotretinoin, women should not become pregnant until stopping medication for at least _______
1 month
To ensure excellent absorption, isotretinoin should be taken with
high fat meal
Follicular occlusion triad
- Hidradenitis sup- purativa
2.dissecting cellulitis of the scalp - with acne conglobata,
A second course of isotretinoin may be done in acne conglobata if resolution does not occur after a rest period of _______
2 months
Rare form of extremely severe cystic acne that occurs in teenage boys
Highly inflammatory nodules and plaques that undergo swift suppurative degeneration
Fever, arthralgia, myopathy
acne fulminans
Treatment of acne fulminans
Prednisone, 40–60 mg, is necessary during the initial 4–8 weeks to calm the dramatic inflammatory response of acne fulminans.
After 4 weeks 10–20 mg of isotretinoin is added. This should be slowly increased to standard doses and contin- ued for a full 120–150 mg/kg cumulative course. Large cysts may be opened and the contents expressed.
Intralesional cor- ticosteroids will aid their resolution. Infliximab and dapsone are alternatives if isotretinoin is contraindicated.
SAPHO syndrome meaning
Synovitis
Acne
Pustulosis,
Hyperostosis, and
Osteitis.
Most potent acneiform inducing agents
The most potent acneiform- inducing agents are the polyhalogenated hydrocarbons, notably dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin).
Occurs in px who have had long periods of moderate acne and have been treated with long term antobiotics (tetracycline)
gram negative folliculitis
Treatment of choice for gram negative folliculitis
isotretenoin
2nd line/ if isotret is contraindicated:
amoxicillin
TMP-SMX
Primarily a cicatricial alopecia variant
Persistent folliculitis of the back and neck
Fibrosis with coalescence of papules into plaques over time
May have sinus tracts
acne keloidalis
Recurrent abscess formation within the folded areas of skin that contain terminal hairs and apocrine glands
hidradenitis suppurativa
Primary site of inflammation in hidradenitis suppurativa
terminal hair
Most frequently affected site in hidradenitis suppurativa
axilla
Treatment of hidradenitis suppurativa
- intralesional steroid therapy, which may be used initially in combination with topical Cleocin or oral doxycycline or minocycline.
- topical daily cleansing with chlorhexidine gluconate (Hibiclens) solu- tion or benzoyl peroxide wash is an important preventive measure.
- laser hair removal,
- Antibiotics : tetra- cyclines amoxicillin, TMP-SMX DS, or dapsone. etra- cyclines amoxicillin, TMP-SMX DS, or dapsone, IV ertapenem
5.Isotretinoin and acitretin
- TNF antagonists: infliximab and adalimumab
- Photodynamic therapy and Nd:YAG laser
- Severe recalcitrant hidradenitis suppura- tiva responded to the approach reported by van Rappard: combination clindamycin and rifampin, each 300 mg twice daily for 2 to 4 months.
- wide surgical excision once inflammation is controlled
NOTE: INCISION AND DRAINAGE IS STRONGLY DISCOURAGED
Follicular inflammatory nodules in the scalp that progress to abscess
Scarring and alopecia
DISSECTING CELLULITIS OF THE SCALP
Most favored sites in dissecting cellulitis of the scalp
vertex and occiput
Treatment of dissecting cellulitis of the scalp
- oral antibiotics: tetracyclines, TMP-SMX, quinolones
- if S. aureus is cultured: oral rifampin and clindamycin
- intralesional steroids + isotretenoin 0.5-1 mkd for 6-12 mos.
- anti- TNF: infliximab and adalimumab
- retinoid alitretinoin
- marsupialization
- Nd:YAG laser
Persistent erythema of the convex surfaces of the face (cheeks and nose most common)
rosacea
Rhinophyma occurs in what subtype of rosacea
glandular subtype of rosacea
Topical and oral therapy for rosacea
Treatment is dis- continuance of the corticosteroid and institution of topical tacrolimus in combination with short-term minocycline.
Dramatically fulminant onset of superficial and deep abscess, cystic lesions, sinus tracts with purulent material
Pyoderma faciale
Pyoderma faciale is differentated from acne by
It is distinguished from acne by the absence of comedones, rapid onset, fulminating course, and absence of acne on the back and chest
Treatment of pyoderma faciale
- oral steroids , ffd by addition of isotretinoin 10-20 mg, increasing to 0.5–1 mg/kg only after the acute inflammatory component is well under control.
- for pregnant: amoxicillin, eryth- romycin, azithromycin, or clindamycin
the most frequently identified cause of perioral dermatitis
use of fluorinated topical corticosteroids
Treatment of perioral dermatitis
- discontinuing topical corticosteroids or protecting the skin from the inhaled product.
- doxycycline will lead to control.
- Tacro- limus ointment 0.1% or pimecrolimus cream will prevent flaring after stopping steroid use.
- In patients without steroid exposure, oral or topical antibiotics and topical adapalene, azelaic acid, and metronidazole
