Chapter 13 (Acne/Rosacea) Flashcards
Histologic features of rosacea
Pilosebaceous gland hyperplasia with fibrosis, inflammation, and telangiectasia
Diagnosis?
Morbihan’s Dx
-Edema of forhead, eyelids, and cheeks associated with rosacea (MC in papulopustular and glandular type)
Diagnosis?
Pyoderma Faciale aka rosacea fulminans
Fulminant onset of superficial and deep abscesses, cystic lesions, and sometimes sinus tracts. With edema and intense reddish/cyanotic erythema
Treatment for rosacea fulminans
(similar to acne fulminans)
- Oral steroids x weeks followed by, (can d/c after weeks on isotretinoin)
- Isotretinoin 10-20mg increasing to 0.5-1mg/kg (only after acute inflammatory component is controlled); Full 120-150 dose
Treatment for pregnant patient with rosacea fulminans
Consider Category B Antibiotics
- Amoxicillin
- Erythromycin
- Azithromycin
- Clindamycin
What is the most common cause of the disorder pictured
MCC of Perioral Dermatitis
Use of fluorinated topical corticosteroids (classes 1-3) in form of creams, ointments, and inhalers
Treatment of Perioral Derm due to steroids
- D/C steroid use and protecting skin from inhaled steroids
- Doxycycline
- Tacrolimus ointment 0.1% or Pimecrolimus cream to prevent flaring after steroid d/c
Treatment of perioral derm WITHOUT steroid exposure
- Oral/Topical Abx
- Topical Adapalene
- Azelaic Acid
- Metronidazole
Diascopic and histologic appeareance of disorder in image
Lupus miliaris disseminatus faciei (A FIGURE dx)
**Eyelid involvment
Diascopy-discrete papules appear yellowish-brown
Histology-Caseating epithelioid cell granulomas
Treatment of LMDF
Self-involution is expected (eventually, can take years)
1. Isotretinoin
2. Minocycline
- Tranilast (Not FDA approved)
Describe morphology and location of LMDF
Firm, yellowish-brown or red, 1-3mm, monomorphous smooth-surfaced papules
Butterfly area, lateral face, below mandible, and periorificially (Eyelids characteristically involved)
Pt lacks hx of rosacea (flushing, persistent erythema, or telangiectasia)
What is the folicular occlusion triad
- Acne conglobata
- HS
- Dissecting cellulitis
Diagnosis and typical morphology
Neonatal Acne
-Transient facial papules or pustules that clear spontaneously (MC in males)
Acne with onset after first 6 weeks of life or persists beyond neonatal acne period is termed:
Infantile Acne
Txt for infantile acne that persists
Usually remits in 1 year
For prolonged cases:
- BPO
- Erythromycin
- Retinoinds
Txt for inflammatory infantile acne
Erythromycin 125 mg BID
Trimethoprim 100 MG BID
Acne that evolves from persistant infantile acne or begins >1 year is termed
Midchildhood acne
-uncommon, MC in males
Findings that merit pedi endo workup in pt with midchildhood acne/earlier onset
+PE findings suggestive of hormonal d/o
- Sexual precocity (Development of secondary sexual characteristics prior to puberty)
- Virilization
- Growth abnormality
Define preadolescent acne and typical workup
Acne with onset of 7-12
-This is time of adrenarce; unless signs of androgen excess–no workup needed
Pathogenesis of Acne
- Hyperproliferation and abnml differentiation of keratinocytes (unknown cause)
- Forms a keratinous plug in lower infundibulum that causes impaction and distention of follicle
- retained cells block follicular opening, lower protion of follicle is dilated by entraped sebum–follicular contents get d/c into dermis–combo of keratin, sebum, and p acnes leads to release of proinflammatory mediators & accumulation of lymphocytes, neutrophils, and FB giant cells - Androgen stimulation of sebaceous gland
- P acnes
Key feature of mechanical/frictional acne
Unusual distribution of acne lesions (MC distribution for typical acne is face, neck, chest)
-Factors causing this include: chin straps, violins, hats, collars, casts, chairs/seats–these factors irritate the follicular epithelium and exacerbate the changes that lead to comedogenesis and follicular rupture
Findings that increase likelihood of hyperandrogenism and thus warrant workup
- irregular menses
- hirsuitism
- seborrhea
- acanthosis nigricans
- androgenic alopecia
What to consider in female patient that has acne resistnat to conventional therapy, who relapses shortly after isotretinoin, or expierences sudden onset of severe acne?
Virilizing tumor
Test to r/o virilizing tumor
- DHEAS: >800 in adrenal tumor; 400-800 congenital adrenal hyperplasia
- Free/Total Testosterone: >200 suggests ovarian tumor;150-200 in PCOS
(both obtained 2 weeks prior to menses)
-LH/FSH (increased ration in PCOS)
Clinical diagnosis of PCOS
- Presence of anovulation (<9 pds per yr or pd>40 days apart)
- signs of hyperandrogenism (acne and hirsuitism)
Medications that can worsen acne
- Corticosteroids
- Anabolic steroids
- Neuroleptics/Antipsychotics (Aripipazole(abilify), clozapine, lurasidone (latuda), olanzapine (zyprexa), quetiapine (seroquel), risperidone (risperdal)
- Lithium
- Cyclosporine
Diagnosis
Osteoma cutis
-Small, firm papules resulting from long standing acne vulgaris
Complications of Acne
- Scarring/Keloids
- Residual hyperpigmentation
- PG (MC in acne fulminans and pt txt with high dose isotretinoin)
- Osteoma cutis
- Solid facial edema: persistent, firm facial swelling (uncommon)
Acne that is nodular, cystic, and pustular occurring mainly on back, buttocks, and thighs. Abscesses often occur but comedones are sparse
Tropical Acne
33 y/o femal presents with acne that starts in sprin and clears by fall. Lesions are dull-red, dome shaped, hard, small papules on cheeks, sides of neck, chest and shoulders, and upper arms. No comedones or pustules are noted. What is the diagnosis?
Acne estivalis (Mallorca Acne)
- Exclusive to 25-40 y/o females
- Starts in spring-progresses over summer-completely clear by fall
- comedones and pusutules absent
- characteristically on upper arms
Diagnosis and treatment
Acne estivalis/Mallorca Acne
Does NOT respond to abx
Will benefit from topical retinoids
Diagnosis and typical findings
Steroid acne
-Sudden outcropping of inflamed papules most numerous on trunk and arms (also face)
papules rather than comedones
-Can be cause with medium or high doses of steroids taken for as briefly as 3-5 days
Diagnosis?
Pt has pmhx of inflammatory acne x years. He has been treated with abx (does not recall name) for ‘a long time’. Presents with superficial pustules flaring out from the nares.
Gram Negative Folliculitis
- Occurs in patients who were treated for long periods of time with tetracylines
- Can present with superficial pustules or fluctuant, deep seated nodules
Bacteria cx from gram-negative folliculitis
- Klebsiella
- E. Coli
- Enterobacter
- Proteus (cx from deep seated nodules)
- Due to long term abx use allowing nares to become colonized
TOC for gram negative folliculitis
Isotretinoin (clears acne + eliminates colonization of nares)
If isotretinoin cannot be tolerated or is CI–Amoxicillin or Bactrim
