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Habif Clinical Dermatology > Chapter 7: Acne, Rosacea, and Related Disorders > Flashcards

Chapter 7: Acne, Rosacea, and Related Disorders Flashcards

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1
Q

What are the classifications of acne lesions

A

Acne lesions were divided into inflammatory and noninflammatory lesions

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2
Q

What are the types of noninflammatory acne lesions

A

Open comedones

closed condomes

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3
Q

What are the types of inflammatory acne lesions

A

Papules
Pustules
Nodules

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4
Q

For mild comedonal acne what should the treatment begin with?

A

Topical retinoid

adaption in 4 to 8 weeks consider adding topical antibacterial
-benzoyl peroxide

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5
Q

For mild papular pustular acne what should the treatment begin with?

A

Start with retinoid or topical antibacterials or both

- consider adding oral antibiotic for three month trial

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6
Q

What is the treatment for moderate papular pustular acne?

A

Start with topical antibacterials (drying therapy) maximum effect at eight weeks then add retinoid if acne not controlled

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7
Q

What is the treatment for severe papular pustular or nodular acne or long history of acne treatment or scarring?

A

Accutane

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8
Q

What is the first-line treatment for acne?

A

Retinoids

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9
Q

What is tazarotene?

A

Second line treatment for all types of acne because of greater expense, irritation.

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10
Q

What are the topical retinoids?

A

Tretinoin
Adapalene
Tazarotene
salicylic acid (has retinoid properties)

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11
Q

What are the topical antibacterials, antibiotics, and anti-inflammatory drugs Used for acne?

A 
Benzoyl peroxide
clindamycin phosphate
erythromycin
Dapsone
Sulfur-sulfacetamide sodium
Azelaic Acid
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12
Q

What are some oral antibiotics used for acne?

A 
Tetracycline
doxycycline
Minocycline
Erythromycin
Azithromycin
Ampicillin or Amoxicillin
sulfamethoxazole trimethoprim
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13
Q

What oral contraceptive drugs and hormonal therapy are beneficial in treatment of acne?

A

Norethindrone-Acetate ethyinyl estradiol
Norgestimate-ethinyl estradiol
Spriranolactone
Prednisone

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14
Q

What are the oral retinoids?

A

Isotretinoin

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15
Q

How does acne begin in predisposed individuals?

A

When sebum production increases. Propionibacterium acnes proliferates in sebum, and the follicular epithelial lining becomes altered and forms plugs called comedones.

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16
Q

How do antibiotics work in prevention of inflammation?

A

Prevent neutrophil chemotaxis

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17
Q

What are Fordyce spots

A

Cluster of sebaceous glands (tiny, white-yellow spots) normally present on the Vermillion border, Buccal mucosa, female areolae (Montgomery’s tubercles), the labia minora, the prepuce, and around the anus.

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18
Q

How does testosterone affect acne?

A

Testosterone is converted to dihydrotestosterone in the skin and acts directly on the sebaceous gland to increase in size and metabolic rate

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19
Q

What effect does estrogen have an acne?

A

Decrease sebaceous glands secretion.

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20
Q

Where are sebaceous glands located?

A

Located throughout the entire body except the palms, soles, dorsum of the foot, and lower lip.

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21
Q

What is retention keratosis?

A

Cornified cells remained adherent to the follicular canal directly above the opening of the sebaceous gland to form a plug (microcomedo)

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22
Q

Is P. Acnes normal skin flora?

A

Yup

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23
Q

How does P. Acnes affect inflammation?

A

Lipases, proteases, hyaluronidase, and chemotactic factors are produced by P. acnes.

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24
Q

What is the effect of chemotactic factors for inflammation with acne?

A

Chemotactic factors attract neutrophils to the follicular wall. Neutrophils elaborate hydrolases that weaken the wall. The wall thins, becomes inflamed (red papule), and ruptures, releasing part of the comedone into the dermis.

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25
Q

Is acne inherited disease?

A

Yes. Acne does not end at age 19 but can persist into a person’s 40s. Many women have their first episode after age 25.

Acne can be controlled, but not cured.

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26
Q

How does diet affect acne?

A

History suggests that high glycemic carbohydrates (bread, bagels, donuts, crackers, candy, cake, chips), those that substantially boost blood glucose levels, trigger a series of hormonal changes that cause acne

Milk has also been implicated as possibly increasing acne severity

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27
Q

What is the clinical presentation Comedonal acne?

A

The earliest type of acne is usually noninflammatory comedones. There are no inflammatory lesions because colonization with P. acne’s has not yet occurred

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28
Q

What is the initial treatment for comedonal acne?

A

Retinoids are applied at bedtime

Tazorac may be most effective and most irritating. Start with a low concentration of the cream or gel and increase the concentration of irritation does not occur

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29
Q

What is mild inflammatory acne?

A

Mild pustular and papular inflammatory acne is defined as fewer than 20 pustules.

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30
Q

What is the treatment for mild inflammatory acne?

A

Benzoyl peroxide, topical antibiotic, or combination medicine and the retinoid are initially applied on alternate evenings.

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31
Q

What is moderate to severe inflammatory acne?

A

More than 20 pustules

Temporarily disfiguring

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32
Q

What is the treatment for moderate to severe inflammatory acne

A

Topical retinoid and combined with a topical antibiotic.

– Patients using drying agents should adjust the frequency of application to induce a mild, continuous peel.

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33
Q

What a severe nodulocystic acne

A

Localized cystic acne (few cysts on face, chests, or back) diffuse cystic acne (wide areas of the face, chest, and back)

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34
Q

What is pyoderma faciale

A

Inflamed cysts localized on the face in females

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35
Q

What is acne conglobota?

A

Highly inflammatory, with cysts that communicate under the skin, abscesses, and burrowing sinus tracks

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36
Q

What is the treatment for cystic acne?

A

Oral antibiotics, conventional topical therapy, and periodic intralesional Kenalog injections may keep this problem under adequate control.

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37
Q

What are the three less common variants of cystic acne?

A

Pyoderma faciale
acne Fulminans
acne conglobota

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38
Q

Who is affected by pyoderma faciale?

A

Adult women ranging in age from the teens to the 40s.

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39
Q

What is the treatment for pyoderma faciale?

A

Treatment was begun with prednisone (1 mg/kg daily for one to two weeks)

Isotretinoin was then added (0.2 to 0.5 mg/kg/day)

Slow tapering of the corticosteroid of the following 2 to 3 weeks

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40
Q

What is acne fulminans?

A

Acne fulminans is a rare ulcerated form of acne of unknown etiology with an acute onset and systemic symptoms.

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41
Q

Who is most commonly affected by acne fulminans?

A

Adolescent white boys

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42
Q

What are the systemic symptoms associated with acne fulminans?

A 
Arthralgias 
severe muscle pain 
painful bone lesions  in 40% of patients
weight loss
fever
leukocytosis
elevated ESR
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43
Q

What is the treatment for acne fulminans

A

Antibiotic therapy is not effective.

Oral corticosteroids are the primary therapy.
Isotretinoin 0.5 mg/kg is started simultaneously and, as in the therapy of severe cystic acne, is continued for five months

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44
Q

What is the follicular occlusion triad syndrome?

A

Acne conglobota
hidradenitis supportiva
dissecting cellulitis of the scalp

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45
Q

What is acne conglobotta?

A

A chronic, highly inflammatory form of cystic acne in which involved areas contain a mixture of double comedones (two blackheads that communicate under the skin), papules, pustules, communicating cyst, abscesses, and draining sinus tracks.

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46
Q

What is a major difference between acne conglobota and acne fulminans?

A

There is no fever or weight loss as is seen in acne fulminans

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47
Q

What do most patients require for the treatment of nodulocystic acne?

A

Most patients will require the rapid introduction of isotretinoin

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48
Q

What are the four pathogenic factors responsible for the development of acne?

A
  1. Hyperkeratinization
  2. Increase testosterone levels
  3. Bacterial colonization with P. Acnes
  4. Inflammation
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49
Q

How do retinoids improve acne?

A

Retinoids reverse the abnormal patterns of keratinization seen in acne vulgaris.

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50
Q

What is the mechanism of action for retinoids?

A

Retinoids initiate increased cell turnover in both normal follicles and comedones and reduce the cohesion between keratinized cells

New comedone formation is prevented by continued use.

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51
Q

Why do retinoids make the skin more susceptible to sunburn?

A

Continual topical application leads to thinning of the stratum corneum, making the skin more susceptible to sunburn, sun damage, and irritation from wind, cold, or dryness.

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52
Q

What areas of the skin should be avoided by retinoids?

A

The corners of the nose, the mouth, and the eyelid should be avoided; these areas are the most sensitive and the most easily irritated.

53
Q

What is the typical response to retinoid therapy?

A

3 to 6 weeks.

New papules and pustules may appear because comedones become irritated during the process of being dislodged.

54
Q

How long should retinoid treatment be continued before being considered a treatment failure.

A

An alternate treatment should be selected of adaption has not occurred after eight weeks

55
Q

What is differin?

A

Adapalene

Has tretinoin like activity in the terminal differentiation process of the hair follicle

Does not cause sun sensitivity

56
Q

What is azelaic acid?

A

And naturally occurring compound that has antikeratinizing, antibacterial, and anti-inflammatory properties.

Effective for noninflammatory and inflammatory acne.

Does not cause sun sensitivity or significant local irritation.

57
Q

What is the primary effects of benzoyl peroxide

A

Antibacterial And drying effect

Therefore it is most effective for inflammatory acne consisting of papules, pustules, and cysts

Drying varies from mild desquamation to scaliness, peeling, and cracking

Some comedones may respond

58
Q

What percentage of patients have an allergy to benzoyl peroxide

A

2%

59
Q

What is a major disadvantage of tetracycline?

A

The requirement the tetracycline must NOT be taken with food (in particular dairy products)

60
Q

What is the dosing for tetracycline in the treatment of acne

A

Started 500 mg twice daily for 3 to 6 weeks, after significant reduction in inflamed lesions decrease dosage to 250 mg twice each day

61
Q

What are some adverse effects of tetracycline

A

Photosensitivity
increased incidence of Candida albicans vaginitis
pseudotumor cerebri

Tooth staining produced by tetracycline occurs on the gingival third of the teeth in children treated before age 7

62
Q

What is the dosing of doxycycline for the treatment of acne?

A

100 mg QD or BID

Decrease the dosage once control is obtained

63
Q

Can doxycycline be taken with food?

A

Yes

64
Q

What is dosing for minocycline?

A

The usual initial dosages 50 to 100 mg b.i.d.

The dosage can be tapered when a significant decrease in the number of lesions is as observed usually 3 to 6 weeks

65
Q

Can minocycline be taken with food?

A

Inhibitory effect on gastrointestinal absorption with food and milk is significantly greater for tetracyclines than for minocycline.

27% inhibition for milk
13% inhibition for food

66
Q

What are some adverse effects for minocycline?

A

Minocycline is highly lipid soluble and readily penetrates the cerebrospinal fluid causing dose related ataxia, vertigo, nausea and vomiting in some patients

May cause pseudo-tumor cerebri

Headache (75%)
transient visual disturbances (41%)
diplopia (41%)
pulsatile tinnitus (17%)
nausea and vomiting (25%)

A bluegray pigmentation of the skin, oral mucosa, nails, sclera, bone, and thyroid gland has been found in some patients, usually those taking high dosages of minocycline for extended periods

67
Q

What can be used to treat gram-negative acne?

A

Ampicillin or amoxicillin

68
Q

When should you consider gram-negative acne?

A

Consider gram-negative acne after prolonged antibiotics usage

69
Q

Where’s DHEAS produced?

A

Dehydroepiandrosterone is produced in the adrenal glands and converted to testosterone

70
Q

How is DHT produced?

A

Testosterone is converted at target 5-alpha- reductase to dihydrotestosterone

71
Q

What are the most important hormones in the pathogenesis of acne?

A

Androgens:
free testosterone
dehydroepiandrosterone sulfate

72
Q

When should hormone test be ordered for evaluation of acne?

A

Women presenting with rapid onset (1-4 months) of acne, hirsutism, androgenetic alopecia, or signs of virilization, such as low voice, increased muscle mass, increased libido, or clitoromegaly, require screening to rule out a tumor.

73
Q

What test should be ordered when evaluating hormonal induced acne?

A 
Total testosterone and free testosterone
DHEAS
ACTH stimulation
prolactin
luteinizing hormone
follicle stimulating hormone
lipid profiles
glucose tolerance test

Total testosterone and free testosterone or the most practical ways of evaluating hormonal influence in the female

74
Q

What is the treatment approach for hormonal acne?

A

Three options:

  1. Estrogens
  2. Anti-androgens
  3. Glucocorticoids
75
Q

What are the anti-androgen options for the treatment of acne?

A

Spironolactone

76
Q

How does progesterone only hormonal therapy affect acne?

A

Progesterone only makes acne worse.

77
Q

What are the side effects of oral contraceptive medications?

A

Increased risk of venous thromboembolism,
stroke
myocardial infarction

risks are increased in patients who smoke cigarettes or who have a history of hypertension, diabetes or migraine

Oral contraceptives may slightly increase the risk of developing breast cancer but have some protective effects against ovarian and endometrial cancer

78
Q

What is the mechanism of action for spironolactone?

A

Spironolactone acts as an anti-androgen peripherally by competitively blocking receptors for dihydrotestosterone in sebaceous glands.

79
Q

What is the dosage of spironolactone in the treatment of hormonally induced acne?

A

Spironolactone at a dosage of 200 mg per day suppresses Sebum production by 75% and can reduce lesion counts by up to 75% over a four-month period.

Typically should start with 25mg PO QD, and titration up.

80
Q

What are the side effects of spironolactone?

A

Side effects are dose-related.

Menstrual irregularities (80%)

Gynecomastia

Breast tenderness or enlargement
decreased libido

Confusion, dizziness, GI disturbance

Electrolyte imbalances

81
Q

How do corticosteroids help with acne?

A

Should be considered for patients with elevated DHEAS levels

Low-dose steroids administered at bedtime prevent the pituitary from producing extra ACTH and thereby reduce the production of adrenal androgens.

82
Q

How should isotretinoin be dosed?

A

Total cumulative dose determined for Remission.

Total cumulative dose 120-150 mg/kg.
some studies suggest 220 mg/kg.

Daily dose is typically started at 0.5 then increase to 1 mg/kg

83
Q

What are the indications for isotretinoin?

A

Severe, recalcitrant cystic or nodular inflammatory acne

Moderate acne unresponsive to conventional therapy

patients who scar

Excessive oiliness

Severely depressed or dysmorphobic patients

Sebaceous hyperplasia

84
Q

How should isotretinoin be dosed for excessive oily patients.

A

Some patients respond to a long-term low dose regimen such as 10 mg every other or every third day

85
Q

What is the typical duration of therapy for isotretinoin?

A

A standard course of isotretinoin therapy is 16 to 20 weeks

86
Q

How many patients relapse from isotretinoin?

A

40%

Relapse usually occurs within the first three years after isotretinoin the stopped, most often during the first 18 months after therapy.

87
Q

How is isotretinoin given?

A

Patients are seen every four weeks

Isotretinoin is given in two divided doses daily, preferably with meals.

Adverse reactions can be minimized by starting at 10 to 20 mg twice each day and gradually increasing the dosage during the first 4 to 6 weeks.

88
Q

What laboratory studies are required for isotretinoin?

A

Pregnancy test

Triglyceride test

Complete blood cell counts

Liver function test.

89
Q

What are the Most common side effects associated with isotretinoin?

A

Side effects are frequently dose-dependent and reversible after discontinuing.

Mucus/skin effects

Elevated triglyceride levels

Musculoskeletal effects

Headaches

Elevated liver enzyme levels

Amenorrhea

90
Q

Which patients are typically at risk for gram-negative acne?

A

Patients with a long history of treatment with oral antibiotics for acne have an increased carriage rate of gram-negative rods in the interior nares.

91
Q

What bacteria are associated with gram-negative acne?

A 
Escherichia aerogenes
Proteus mirabilis
Klebsiella pneumoniae
Escherichia coli
Serratia marcescens
92
Q

What is typically used to treat gram-negative acne?

A

Bactrim or Septra
-high relapse rate

Isotretinoin at 1 mg/kg/day for 20 weeks is successful for resistant cases of gram-negative acne.

93
Q

What is steroid acne?

A

In predisposed individuals, sudden onset of follicular pustules and papules may occur 2 to 5 weeks after starting oral corticosteroids.

Steroid -induced acne is rare before puberty and in the elderly

94
Q

What is neonatal acne?

A

Acneiform lesions confined to the nose and cheeks may present at birth or may develop an early infancy.

Lesions make clear without treatment as the large sebaceous gland stimulated by maternal androgens become smaller and less active.

95
Q

What is infantile acne?

A

Infantile acne is uncommon

Age of onset is 6 to 16 months.

Patients with mild acne respond to topical treatment (benzyl peroxide and retinoids). Most infants with moderate acne respond to oral erythromycin 125 mg twice daily and to topical therapy.

96
Q

What is occupational acne?

A

An extensive, diffuse irruption of large comedones and pustules may occur in some individuals who are exposed to certain industrial chemicals.

97
Q

What is acne mechanica?

A

Mechanical pressure may induce an acneiform eruption

98
Q

What is acne cosmetica?

A

Closed and open comedones, papules, and pustules may develop and post adolescent women who regularly apply layers of cosmetics.

99
Q

What is excoriated acne?

A

Most acne patients attempt to drain comedones and pustules with moderate finger pressure.

Broad red erosions with adherent crust or obvious signs of manipulation and can easily be differentiated from resolving papules and pustules.

100
Q

What are senile comedones?

A

Excessive exposure to sunlight and predisposed individuals calls large open and closed comedones around the eyes and on the temples.

After treatment with retinoids, lesions that recur can be effectively be treated with a 2 mm curette.

The skin is helped taught and the comedone is lifted out of a quick flick of the wrist. It Is important to go deep enough to remove the entire lesion. Bleeding is controlled with Monsel’s solution.

101
Q

What are milia?

A

Tiny whites pea shaped cysts that occur on the face particular around the eyes.

They are derived from the lowest portion of the infidibulum of velous hairs.

Secondary milia may occur secondary to injury to the skin.

Milia have no opening to the skin and can not be extracted like black heads. However, may be extracted with a number 11 blade tip

102
Q

What is acne surgery?

A

Acne surgery is the manual removal comedones and the drainage of pustules and cysts.

103
Q

What are the instruments used for acne surgery?

A

The round loop comedones extractor

The oval loop acne extractor (Schamberg extractor)

Number 11 pointed tip scalpel blade

104
Q

What are the types of acne scars?

A

Ice pick

Rolling

Boxcar

105
Q

When should scar revision therapy begin?

A

Generally, it is advisable to wait until disease activity has been low or absent for several months.

106
Q

What is perioral dermatitis?

A

Occurs in young women and resembles acne

Papules and pustules on erythematous and sometimes scaling base are confined to the chin and nasolabial folds while sparing a clear zone around the Vermillion border

Perioral dermatitis occurs in an area where drying agents are poorly tolerated; topical preparations such as benzyl peroxide, tretinoin, and alcohol-based antibiotic lotions aggravate the irruption

107
Q

What is the pathogenesis of perioral dermatitis?

A

Unknown

Precipitated by the habitual, regular, and abundant use of moisturizing creams. Results in persistent hydration of the horny layer, impairment of barrier function, and proliferation of the skin for a period

108
Q

What is the treatment for perioral dermatitis?

A

Perioral dermatitis uniformly responds in 2 to 4 weeks to 1 g per day of tetracycline or erythromycin.

Doxycycline 100 mg once or twice daily is also effective.

109
Q

What causes acne rosacea flares?

A

Sun exposure may exacerbate condition.

Alcohol may accentuate erythema, but not cause the disease.

Hot drinks of any type should be avoided

110
Q

What are the cardinal features of acne rosacea?

A

Erythema and edema, papules and pustules, and telangectasias

111
Q

What is the treatment for rosacea?

A

Oral antibiotics and isotretinoin

– Both the skin and eye manifestations of rosacea respond to doxycycline (100 to 200 mg/day)

– Isotretinoin and 0.5 mg/kg/day for 20 weeks was effective in treating severe, refractive rosacea

112
Q

What is the treatment for mild rosacea?

A

Topical therapy

Patients with mild, moderate, or severe rosacea may respond to 0.75% metronidazole (MetroGel) applied twice each day or 1% metronidazole applied once each day.

113
Q

What over-the-counter therapy can be used for acute flushing or persistent erythema?

A

Oxymetazoline (Afrin nasal spray)

114
Q

What is the prevalence of ocular rosacea?

A

The prevalence in patients with rosacea is as high as 50%, with approximately 20% of his patients developing ocular symptoms before the skin lesions.

115
Q

What problems are associated with ocular rosacea?

A

Patients with ocular rosacea have been reported to have sub normal tear production (dry eyes), and they frequently have complaints of burning that are out of proportion to the clinical signs of disease.

116
Q

What is the treatment for ocular rosacea?

A

Doxycycline, 100 mg daily, will improve ocular disease and increased the tear breakup time.

117
Q

What is the hallmark of hidradenitis Supportiva?

A

The double comedone

-A black head with two or sometimes several service openings that communicate under the skin.

118
Q

Is HS curative?

A

Unlike acne, once the disease begins it becomes progressive and self-perpetuating.

The healing process permit alters the dermis

119
Q

What is the pathogenesis of hidradenitis supportiva

A

Lesions begin with follicular hyper keratosis and comedone formation and progress to rupture of the follicular infidibulum, with inflammation of the surrounding dermis.

120
Q

What is the follicular occlusion triad?

A
  1. Acne conglobotta
  2. Hidradenitis supportiva
  3. Dissecting cellulitis of the scalp.
121
Q

What is the management of hidradenitis supportiva

A

Antibiotics are the mainstay of treatment, especially for the early stages of the diseaseSuch as doxycycline 10 mg twice daily.

retinoin cream 0.5% may prevent duct occlusion, but it is irritating and must be used only as tolerated.

Isotretinoin may be effective in selected cases

Large cysts should be incised injury and, whereas smaller cells respond to intralesional injections of triamcinolone (Kenalog .5-10 mg/ml)

Weight loss helps to reduce activity.

Cigarette smoking has been identified as a major triggering factor.

122
Q

What surgical options are available for hidradenitis supportiva?

A

Electro surgery: a loop electrode in the cut and coagulation mode is used to excise all the elevated skin and subcutaneous tissue to the level of subcutaneous fat tissue. The defect is left for secondary healing; suturing is not performed.

Surgical excision is at times the only solution. Primary closure results in a recurrence rate and up to 70% of patients

123
Q

What is miliaria?

A

Heat rash

Eccrine sweat duct occlusion is the initial event. The duct ruptures, leaks sweat into the surrounding tissues, and induces an inflammatory response.

124
Q

What causes the different types of miliaria?

A

Occlusion occurs at three different levels to produce three distinct forms of miliaria

125
Q

What are the different types of miliaria?

A
  1. Miliaria crystallina
  2. Miliaria rubra
  3. Miliaria profunda
126
Q

What is miliaria crystallina?

A

Occlusion of the eccrine duct at the skin surface results in accumulation of sweat under the stratum corneum.

There is little or no erythema and the lesions are asymptomatic

127
Q

What is miliaria rubra?

A

The most common of the sweat-retention diseases, results from the occlusion of the intra-epidermal section of the eccrine sweat duct.

Instead of itching, the irruption is accompanied by stinging or “prickling” sensation

The palms and soles are spared.

128
Q

What is miliaria profunda?

A

Observed in the tropics in patients who have had several bouts of miliaria rubra.

Habif Clinical Dermatology (8 decks)

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