CHAPTER 17 skin

Question 1

Acne vulgaris has the highest incidence among individuals aged

Answer 1

12 to 25 years,
with incidence peaking at 15 years of age.

Question 2

percentage of all adults have active acne,
percentage of adult who will experience acne at some point in their lives.

Answer 2

-Twenty (20)percent of all adults have active acne
-85% will experience acne at some point in their lives.

Question 3

Acne means

Answer 3

Prime of life: disease of adolescent

Question 4

severity of acne gender

Answer 4

80% of cases occur in women
-acne is often more severe in males. —Fifty percent of adult women have premenstrual flares of acne, and many women have their first flare, or worsening of existing acne, during pregnancy.

Question 5

ethnicity with highest Incidence of acne

Answer 5

Hispanic teenagers have the highest incidence of acne and resultant scarring.

Question 6

etiology of acne

Answer 6

An increase in production of sex hormones (androgens) in puberty and adolescence
*An increase in sebum production resulting from activation of the sebaceous glands (during puberty and adolescence) and genetic factors
*A disorder of epithelial cell “stickiness” (keratinization) and sheddingedu (desquamation), leading to keratin plug formation
*Proliferation of Propionibacterium acnes bacteria inside the hair follicles
*The host inflammatory response

Question 7

inflammatory disorder of the sebaceous gland and accompanying hair follicle (known collectively as a pilosebaceous unit

Answer 7

Acne

Question 8

Most of them are located on the face, back, chest, and upper arms, the most common sites for acne

Answer 8

Approximately 5,000 pilosebaceous units are present in the human body.

Question 9

Acne lesions include:

Answer 9

comedones, papules, nodules, and cysts.
Painful nodules and cysts are found in severe forms of acne.

Question 10

primary lesions of acne and are caused by a defect in desquamation at the opening of the pilosebaceous follicle.

Answer 10

Comedones

Question 11

Instead of regular cellular shedding, desquamation is reduced, and shed epithelial cells become “sticky,” forming plugs that block follicular openings in a process known as

Answer 11

Retention hyperkeratosis.

Question 12

about 2 months for the accumulated shed epithelial cells, sebum, and keratin to produce a

Answer 12

Comedone

Question 13

-(“whiteheads”)
-(“blackheads”).

Answer 13

Closed comedones (“whiteheads”)
-closed comedones are small papules 1 to 3 mm in size that are the same color as the surrounding skin, sometimes with a visible white plug.

-open comedones: (“blackheads”).
Open comedones have a black-colored central plug. The hard plug on some comedones can be removed easily by putting firm pressure on the sides of the lesion.

Question 14

amino acid precursor of melanin.

Answer 14

Tyrosine

Question 15

is an anaerobic diphtheroid that is part of the normal skin flora in humans and is responsible in large part for the inflammatory response observed in acne vulgaris.

Answer 15

P. acnes

Question 16

common side effect of many topical acne medications

Answer 16

Dry irritated skin

Question 17

lesions are primarily noninflammatory comedones with occasional small papules.

Answer 17

mild acne

Question 18

lesions are mainly inflammatory lesions such as papules and pustules. The papules range in size from a few millimeters to one-half centimeter
-Pustules are easier to recognize; they appear like pointed papules, with yellow to green-colored tops.

Answer 18

moderate acne

Question 19

lesions are mainly nodules and cysts. This form of acne always results in scar formation.
-variable, from numerous atrophic pits (“pockmarks”) to large, depressed scars.
-Darker skin, keloids and hypertrophic scars can result.
- more common in males.
-fistula formation is seen in some patients.

Answer 19

severe acne, or nodulocystic acne

Question 20

inflammatory lesions that appear bright to dark red (or brown), depending on the patient’s shade of skin.
-are smaller and feel harder than acne cysts

Answer 20

Nodules

Question 21

-severe cystic acne in which nodules, cysts, and abscesses develop;
-lesions are predominantly located on the trunk area instead of the face. -Females should be evaluated for polycystic ovary syndrome (PCOS)

Answer 21

acne conglobata

Question 22

-characterized by acute onset of multiple painful, ulcerated acne lesions, along with systemic symptoms such as fever, chills, malaise, and generalized joint and muscle aches.
is rare and is seen in young adolescent males.

Answer 22

-Acne fulminans
-patients should be referred as soon as possible to a dermatologist and treated with prednisone for its anti-inflammatory effects in combination with isotretinoin, which is the treatment regimen of choice for this condition,
–although other anti-inflammatory and immunosuppressant compounds (e.g., dapsone, cyclosporine A) have also been used.

Question 23

A. complete history is crucial to the diagnosis and supplants the importance of most diagnostic tests, which
-B. a complete blood count (CBC), blood chemistry panel, urinalysis, and erythrocyte sedimentation rate (ESR) can be helpful. Abnormal laboratory results seen in cases of acne fulminans include leukocytosis, an elevated ESR, anemia, and hematuria.
leukocytosis, an elevated ESR, anemia, and hematuria.

Answer 23

Acne diagnosis
B. For acne fulminans,

Question 24

What to do if an endocrine disorder such as PCOS is suspected

Answer 24

-an evaluation for excessive androgen production should be done.
-A complete physical examination, along with laboratory tests that include serum total and free testosterone and dehydroepiandrosterone sulfate, is recommended.
-A pelvic ultrasound should be ordered to assess for enlarged and polycystic ovaries.

Question 25

acne differential diagnosis

Answer 25

-Rosacea
-Telangiectasias
-hot tub folliculitis” (folliculitis lesions
-Perioral dermatitis

Question 26

caused by Staphylococci), which appears within 1 to 4 days after hot tub use, due to insufficient temperature and inadequate chlorination of the water.
Patients will complain of small red pustules that are occasionally pruritic.
it is located on the areas of the body that were immersed in the water, such as the lower torso, buttocks, and legs

Answer 26

hot tub folliculitis” (folliculitis lesions

Question 27

similar presentation as acne vulgaris that appears as small, erythematous papules occurring around the mouth area and nasolabial folds, which is the main diagnostic clue.
It is more common in adult women (usually 20 to 30 years old); treatment is similar to that for rosacea except that topical corticosteroids are not indicated.

Answer 27

Perioral dermatitis

Question 28

dilations of small groups of superficial blood vessels- may be present at the skin surface

Answer 28

Telangiectasias

Question 29

more common in adults and older patients and is located more centrally on the face, cheeks, chin, and nose

Answer 29

Rosacea

Question 30

acne mental health impact

Answer 30

more than 90% of persons with acne have felt depressed and
-14% have considered suicide.

Question 31

to prevent and/or minimize scarring and permanent pigmentation changes

Answer 31

primary goal of acne treatment

Question 32

acne treatment

Answer 32

-Mild acne is treated with topical medications only
- systemic antibiotics may be used in moderate cases that are unresponsive to topical agents and in severe case
-Acne treatment tends to be slow compared with most infections treated with antibiotics and can take up to 4 to 6 weeks before visible results are detected.

Question 33

topical Treatment of Comedonal Acne

Answer 33

-respond well to topical retinoids,
-Synthetic retinoids such as tretinoin (Retin-A) and adapalene gel (Differin) decrease comedone formation by increasing cell turnover and decreasing epithelial cell cohesiveness.

Question 34

tretinoin cream

Answer 34

Mild adverse effects of tretinoin include dryness, erythema, scaling, and burning.
-Adverse reactions include excessive skin irritation, an apparent exacerbation of symptoms, transient pigmentation changes, stinging on application to the skin, and dry skin
Adapalene gel seems better tolerated on sensitive skin than tretinoin, but patients with extremely sensitive skin can still develop skin irritation.
-To avoid excessive skin irritation, the patient should wait for at least 10 to 15 minutes after washing and should allow the skin time to dry before applying topical acne agents.
-can cause thinning of the top layer of epidermis during the first 4 weeks of treatment and can result in dryness and irritation.
-The thickness of the epidermis returns to normal after 4 to 6 weeks.
-Sunscreen or sunblock should be used during the entire treatment period, especially at this time.
–warn patients and parents that tretinoin and, to a lesser extent, adapalene gel will cause a worsening of acne lesions during the first 4 to 6 weeks of treatment, as preexisting comedones will continue to surface during this time.
-Improvement should become visible by 6 to 8 weeks
-a trial period of 2 months is generally recommended for topical retinoids, unless the patient develops contact dermatitis or other problems with the medicine.
–Patients with a history of eczema or with sunburned skin should not use this medicine.
–The patient should avoid the eyes, mouth, angles of the nose, and mucous membranes when applying this medicine.
-
-the effects of other topical acne agents, such as benzoyl peroxide, sulfur, resorcinol, and salicylic acid, should be allowed to subside before the application of topical retinoids
-The most potent and irritating dose of tretinoin is the 0.05% liquid formulation.
-acne breakouts may occur with up to 4 to 6 weeks of treatment, after which the skin will begin to clear.

Question 35

Topical Treatment of Inflammatory Acne

Answer 35

-Patients with predominantly inflammatory lesions may respond well to topical antibiotics such as erythromycin or clindamycin, benzoyl peroxide, or a combination of benzoyl peroxide and erythromycin.
-other good candidates for nonretinoid topical acne therapy include patients who cannot tolerate tretinoin or adapalene gel or patients who have concurrent eczema.
–most common side effects include mild erythema or burning. Because topical antibiotic solutions use an alcohol base, they can cause excessive skin dryness. To avoid this problem, the clinician should tell the patient to start use gradually on a once-daily basis for 2 weeks.
–monotherapy with topical antibiotics may lead to bacterial resistance with a resultant slower therapeutic effect. —Switching the patient to a combination of antibiotics and benzoyl peroxide has shown increased efficacy and a reduction of antibiotic resistance in P. acnes

Question 36

Systemic Antibiotic and Hormonal Treatment of Moderate to Severe Acne

Answer 36

-topical acne medicines are a safer alternative than oral antibiotics, as they have less potential for adverse effects. Topical therapy has its limitations,
-Oral antibiotic treatment should generally be continued for 4 to 6 months, and maximal clinical results may not be evident before 3 to 4 months.
–Good candidates for oral antibiotic treatment include patients who
*have not responded to topical medications after a trial of at least 2 to 3 months.
*are unable to tolerate topical acne treatment.
*have large numbers of inflammatory lesions after several months on topical treatment.
*have severe nodulocystic acne.
*have large numbers of inflammatory lesions located on the back or upper outer arms (hard-to-reach areas).
*want quick relief from inflammatory acne.
*are at increased risk of pigmentation changes or scarring.

Question 37

Oral management of moderate to severe acne and treatment

Answer 37

-Oral antibiotics are the standard of care in the management of moderate to severe acne and treatment-resistant forms of inflammatory acne.
-P. acnes is a biofilm-forming organism, and topical treatment is recommended along with oral antibiotics
-oral antibiotics used in the treatment of inflammatory acne include doxycycline and minocycline, which are more effective than tetracycline.
-Trimethoprim-sulfamethoxazole and trimethoprim alone are also effective in instances where other antibiotics cannot be used.

Question 38

Minocycline therapy for moderate to severer acne

Answer 38

minocycline is superior to doxycycline in exerting not only an antibacterial effect against P. acnes but a direct anti-inflammatory effect as well
–starting dose of minocycline (for tetracycline-resistant acne) is 50 mg at bedtime for 1 week;
-the dose is then gradually increased to 100 mg at bedtime. Once improvement is seen at 4 to 6 weeks, the dose can be decreased gradually every 6 to 8 weeks.
-The maintenance dose of minocycline is 50 mg once daily.
-The safety of minocycline has not been established for longer than 12 weeks.
-Adverse effects of minocycline include vertigo, dizziness, and ataxia (due to its effects on the vestibular apparatus of the inner ear)

Question 39

hormonal therapy for acne control

Answer 39

–In addition to antibiotic treatment, certain combination progestin plus estrogen hormonal therapies used for birth control are also approved for moderate acne in women aged 15 years or older and have acne that is unresponsive to topical medications. —The patient should have no known contraindications to hormonal therapy, such as a history of thrombophlebitis or thromboembolic disorders, cerebrovascular or cardiovascular disease, breast or other estrogen-dependent neoplasms, hepatic tumors, or undiagnosed genital bleeding
–birth control pills containing the synthetic progestin drospirenone may have an increased risk for thrombus formation compared with combination pills containing other types of progestins

Question 40

Severe Acne treatment

Answer 40

Individuals with severe acne should be referred to a dermatologist for aggressive treatment with isotretinoin, a vitamin A derivative indicated for severe recalcitrant nodular acne that has not responded to conventional therapy (including oral antibiotics).

Tretinoin and isotretinoin are confused by some patients as the same medication. Tretinoin is the active ingredient in Retin-A and is a topical medication.

Isotretinoin is an oral acne medication that is the only treatment that works on all causes and types of acne. The most familiar brand name of this drug was Accutane

Question 41

Accutane (Sotret, Amnesteem, Claravis, and Roaccutane.)

Answer 41

–It is a highly potent teratogen and carries significant medicolegal implications for the clinician when prescribed to female patients of reproductive age.
–he manufacturers of isotretinoin require all prescribers to join the iPLEDGE program to minimize fetal exposure to the drug.
–Two negative pregnancy tests must be obtained within 1 week of prescribing the isotretinoin,
– two reliable forms of contraception must be used (unless abstinence is the chosen method). Monthly pregnancy tests must be ordered thereafter. The patient must have maintained effective contraception for at least 1 month before, during, and after therapy.
– Only a 1-month supply of the drug should be prescribed at each visit, and it can be discontinued early if the patient’s acne nodule count decreases by 70% or more
–isotretinoin will induce long-term remissions of acne in up to 40% of patients. After a period of 2 months or more off therapy, if persistent or recurrent severe nodular acne recurs, referral to a dermatologist is recommended.

Question 42

Side effects of isotretinoin

Answer 42

–The most frequent adverse effect of isotretinoin is cheilitis, which occurs in up to 90% of patients.
– Other common adverse effects include dry skin, dry nose, dry mouth, pruritus, epistaxis, and an increase in skin fragility.
–Patients who complain of headache should be evaluated for pseudotumor cerebri or benign intracranial hypertension.
– If the patient complains of moderate to severe myalgia, the medication should be discontinued immediately and a creatine phosphokinase should be done
–Corneal opacities and decreased night vision have also been reported in patients taking isotretinoin.
–The link between isotretinoin and depression, psychosis, and suicide remains controversial, and some clinicians prefer not to prescribe this medication in patients with this type of psychiatric history.
–The incidence of hypertriglyceridemia is high (25%), and some patients develop elevated liver transaminases.
–Elevated blood sugar levels have also been seen in patients, as well as new-onset diabetes, although a causal association is unclear.
–Baseline laboratory testing, such as a fasting lipid panel and liver function tests, should therefore be done before starting treatment and weekly or biweekly thereafter until the patient’s response to therapy is determined, after which laboratory monitoring can be done monthly.

Question 43

Follow up and referral for acne

Answer 43

atients should be reevaluated in 4 to 6 weeks to monitor for response and any potential adverse effects of acne medication.

In particular, female patients on oral antibiotics or isotretinoin should be monitored for their continued use of reliable methods of birth control.

By the third month of treatment, clinical improvement of acne lesions should be visible. If no improvement is seen or if the acne worsens, topical treatment with two agents or systemic therapy should be considered.

Systemic oral antibiotic treatment should generally be continued for a period of 4 to 6 months.

Referral to dermatology: Moderate to severe acne that is unresponsive to conventional treatment should be referred to a dermatologist for more aggressive treatment to minimize scarring

Question 44

chronic and progressive skin disorder in middle-aged and older adults that resembles acne.

Answer 44

Rosacea

Question 45

who is more likely to get rosacea?

Answer 45

Rosacea is most common in persons aged 30 to 60 years who are of Irish, English, Scottish, Welsh, or eastern European ancestry.

Women are 3x more likely to develop rosacea than men

Question 46

causes of rosacea

Answer 46

Rosacea is idiopathic with no recognizable causes, other than certain exacerbating triggers.

Rosacea is a lifelong condition that is usually worsened by sun exposure.
–Other environmental triggers include: hot or cold weather, wind, overheating during exercise, excessive alcohol ingestion, hot beverages, spicy or aged food products such as cheese, emotional stress, irritating cosmetics, hot baths, saunas, hot tubs, smoking, caffeine, and excessive washing of the face

Question 47

characterized by flare-ups that include three cutaneous components:

Answer 47

1. The first component is vascular in nature, with persistent erythema that primarily involves the central face.
   –may be followed after a period of time by the development of telangiectasias or clusters of small, superficial blood vessels. flushing episodes may occur
   2.The second component is cutaneous and involves the development of recurrent acneiform, erythematous papules and pustules around the central face.
2. The third component consists of connective tissue hyperplasia around the central face with discrete sebaceous gland hyperplasia, consisting of persistent yellow papules particularly around the nose.

Question 48

nose may become swollen and bumpy from excess tissue in a condition called

Answer 48

rhinophyma

This condition is what gave the late comedian W.C. Fields his trademark bulbous nose
–Surgical reduction may be used to reduce the bulbous appearance of the nose.

Question 49

Subjective presentation of rosacea

Answer 49

Patients with rosacea usually do not seek out care because they mistakenly think they have acne, a sunburn, or a temporary rash.

They usually present because they become intolerant of the persistent burning, itching, or stinging sensations on the face, in particular.

Patients with ocular rosacea complain of watery, irritated, or bloodshot eyes (Blepharoconjunctivitis ).

Question 50

Objective presentation of rosacea

Answer 50

nitially the patient’s forehead, cheek, nose, or chin may have a rosy hue without comedones. This is the central third of the face and is referred to as the “flush/blush” area.

There may be inflammatory papules, pustules, and telangiectasias. Scarring is usually unapparent unless the patient also has concomitant acne.

Question 51

erythematotelangiectatic rosacea—flushing and persistent redness, which may include visible blood vessels

Answer 51

subtype I

Question 52

papulopustular rosacea—persistent redness with transient bumps and pimples

Answer 52

subtype 2

Question 53

phymatous rosacea—skin thickening usually with hyperplasia of the nose, resulting in a large, bumpy, and bulbous appearance

Answer 53

subtype 3

Question 54

ocular rosacea—ocular manifestations with dry eye, tearing and burning, erythematous eyelids, recurrent styes, and possible vision loss from corneal damage

Answer 54

subtype 4

Question 55

Differential diagnoses of rosacea include

Answer 55

adult acne, perioral dermatitis, seborrheic dermatitis, the “butterfly” rash of systemic lupus erythematosus, and corticosteroid-dependent facial dermatoses.

Question 56

Management of rosacea

Answer 56

The key to management is early diagnosis and avoidance of triggers because rosacea is a chronic condition with no known cure.

Topical treatments should be the mainstay of therapy, with oral antibiotics used only for breakthrough flare-ups.

Potent topical corticosteroids should be avoided because they may worsen the condition.

Question 57

topical tx of rosacea

Answer 57

Metronidazole cream is the mainstay of therapy but it may take up to 6 to 8 weeks for a therapeutic response to be seen.

If metronidazole (0.75% or 1%) is not effective, other topical antibiotics may be tried.
Topical ointments such as tretinoin and azelaic acid are also recommended.

Question 58

systemic tx of rosacea

Answer 58

Antibiotics should be reserved for flare-ups or when initiating therapy with topical medications, e dosage at home.
–Treatment with tetracycline, minocycline, or doxycycline typically delivers a rapid therapeutic response. -Antibiotic therapy is usually effective in reducing acneiform lesions, and this helps confirm the diagnosis of rosacea.
–These antibiotics typically work more as anti-inflammatory agents rather than as anti-infectives.
–The flushing and flat telangiectasias of rosacea tend to persist and do not respond well to antibiotic therapy.
–In refractory cases, isotretinoin may succeed when other measures have failed.

Question 59

electrocautery

Answer 59

a small needle may be used to destroy small telangiectasias.
Larger telangiectatic vessels may require laser treatment –(intense pulsed light therapy)

Question 60

one of the most common noncancerous skin growths seen in older adults.
–It is characterized by benign, warty-appearing growths that are usually found on the trunk, but they may also be seen on the hands and face. –They develop in both sun-exposed and sun-protected areas

Answer 60

Seborrheic keratosis

Question 61

Which age group is seborrheic keratosis more prevalent in?

Answer 61

Seborrheic keratosis is extremely common. It has been found in 88% of persons older than 65 years.

Question 62

-sudden development of multiple seborrheic keratotic lesions, along with skin tags, and acanthosis nigricans (a darkening and mild thickening of the skin in characteristic intertriginous areas)

Answer 62

Leser-Trélat sign

-is associated with various types of cancer, including lung and gastrointestinal cancers, and is thus considered a neoplastic syndrome.