DCNP - Adnexal Disorders

Question 1

acne: male/female differences

Answer 1

Males tend to develop acne later in adolescence but develop greater severity
Females tend to have a less severe, but a more chronic course

Question 2

acne: triggering/exacerbating factors & medications

Answer 2

stress, hormonal fluctuations, endocrine disorders, smoking, and ultraviolet radiation

medications include topical and systemic corticosteroids, progesterone, testosterone, antidepressants, anti-seizure medications, isoniazid, and epidermal growth factor receptor (EGFR) drugs

Question 3

acne: 4 key factors

Answer 3

follicular hyper-keratinization
microbial colonization with Propionibacterium/Cutibacterium acnes
sebum production
Inflammatory mechanisms

Question 4

acne: contributing factors

Answer 4

diet
genetics
neuroendocrine regulatory mechanisms
increased sebum production
altered follicular differentiation

Question 5

acne: subsets

Answer 5

Acne excoriee - Habitual picking, usually by young women
Acne mechanica - Caused by friction or chafing from chin straps, sports padding or equipment
Chloracne - Due to occupational exposure to toxins like chlorinated or halogenated chemicals. Large comedones and pustules on face, trunk, genitals and extremities.
Acne Cosmetica - Adolescent females who wear a lot makeup. Comedones, papules pustules
Acne associated w/endocrine abnormalities - Often accompanied by hirsutism, menstrual irregularities, and virilizing characteristics. Pustules and cysts.
Conglobata - Most severe form of acne, usu. young adult males, inflammatory, deep nodules & cysts developing sinus and abscesses. Severely disfiguring
Fulminans - Explosive onset, usu. young adult males, febrile, constitutional symptoms incl. polyarthralgia, leukocytosis, anemia & hepatomegaly

Question 6

acne: neonatal

Answer 6

< 6 weeks
AKA neonatal cephalic pustulosis
common inflammatory response to Malassezia yeast affects up to 20% of infants
consists of papules and pustules on forehead, cheeks, eyelids, and chin. Less common on neck and trunk. Spontaneous resolution typically occurs by four months of age

Question 7

acne: infantile

Answer 7

6 weeks – 1 year
Lesions include papules, pustules, comedones, nodules, and cysts primarily onthe face.
Be aware for additional signs of virilization as it can be linked to underlying endocrinopathies
It has been linked to increased incidence of severe adolescent acne
Can result in scarring, so treatment is encouraged with use of topical BPO and off-label use of adapalene.

Question 8

acne: mid-childhood

Answer 8

age 1 – 7 years
When observed in children aged 18 months to 7 years and is the MOST concerning age group. Acne in this age range is rare and implies more significant systemic problems such as Cushing syndrome, premature adrenarche, congenitaladrenal hyperplasia, gonadal/adrenal tumors, or true precocious puberty
It is often misidentified as keratosis pilaris, rosacea, perioral dermatitis, or Demodex
Patients in this age group who present with chronic, severe, or virilizing acnerequire further evaluation for systemic disease. An appropriate evaluation wouldinclude use of growth charts, bone scans, total/free testosterone, dehydroepiandrosterone (DHEAS), prolactin, LH/FSH, 17-OH progesterone levels,and androstenedione
Both topical and oral therapies are advised, with the exception of prescribed tetracycline products, which are not recommended to children age 8 years and younger.

Question 9

acne: pre-adolescent

Answer 9

encompasses ages 8 to 12 years
Typically, comedones are evident on the face and neck, but are less common on the torso
This may be an indicator of emerging puberty as it corresponds to additional sebum production and increase in the size of sebaceous follicles
There is some evidence to suggest that the severity and prevalence of acne in the preteen years is predictive of advanced prepubertal maturity
Treatment with traditional topical therapies is advised until the individual’s level of severity and potential for scarring can be assessed.

Question 10

acne: adolescent

Answer 10

lasts approximately 5 years

Question 11

acne: conglobata

Answer 11

most severe form of acne and typically arises in adolescent males, although it does not exclude females. It distinguishes itself with nodules, abscess formation, and scars. Comedones may have more than one opening, and cystic lesions often drain. Sinus tracking is not uncommon. Keloid scars, depressed, hypertrophic, boxcar, or ice pick scars may be evident.

Question 12

acne: fulminans

Answer 12

occurs uncommonly, but with an explosive onset in the teenage male population. It is accompanied by bone pain at the clavicle and sternum. Patients may experience fever and leukocytosis as well as joint pain, anemia, and liver enlargement. Other acne variants develop as a result of secondary changes imposed by external factors

Question 13

acne: diagnostics

Answer 13

bacterial culturesof a pustular lesion if gram negative folliculitis is suspected
Testing is indicated for those with clinical features of hyperandrogenism and include DHEAS and free testosterone as initial screening laboratory studies to evaluate hormonal influences

Question 14

acne: differentials

Answer 14

Milia – appear similar to closed comedo, but there is an absence of open comedo, papules, pustules, cysts and erythema
Sebaceous hyperplasia – these bumps are often indented in the center
Perioral dermatitis – location is primarily around the mouth with an absence ofcomedo
Rosacea – has an absence of comedo
Folliculitis (gram positive and gram negative; Pityrosporum) – gram negative -monomorphic eruptive papules and pustules; gram positive appears similarly toacne, but should be considered if eruptions are acute
Pseudofolliculitis barbae – has an absence of comedo and primary affects onlyhair bearing areas.
Angiofibromas – have violaceous hue
Keratosis pilaris – absence of comedo

Question 15

acne: benzoyl peroxide

Answer 15

antibacterial agent that kills C. acnes
mildly comedolytic
no resistance reported
not only enhances antibiotic therapy, it may reduce bacterial resistance.

Question 16

acne: retinoids

Answer 16

Ideal to treat comedonal acne and often combined for the additional acnevariants due to the fact that they are both comedolytic and antinflammatory.* Most common side effects include erythema, irritation, and dryness. There ishigher risk of photosensitivity with retinoids, so daily sunscreen should beencouraged.* A discussion regarding pregnancy risk is important for women of child bearingage.* Tretinoin and adapelene are pregnancy category C, but tazarotene is pregnancycategory X

Question 17

acne: topical antibiotics

Answer 17

Postulated to be effective through anti-inflammatory mechanisms in addition totheir antibacterial effects.

Question 18

acne: azelaic acid

Answer 18

comedolytic, anti-inflammatory, and antibacterial agent.* It is has also been shown to be effective in treatment ofhyperinflammatory pigmentation especially in dark skintypes* Azelaic acid is pregnancy category B.

Question 19

acne: dapsone

Answer 19

Anti-inflammatory in nature and it encouraged to beused in combination with topical retinoids if comedones are present.* It is oxidized with the co-application of benzoyl peroxide and topical dapsone cancause an organge-brown discoloration when applied together.* Dapsone is pregnancy category C

Question 20

acne: salicylic acid

Answer 20

Slightly comeodolytic and are often well tolerated

Question 21

acne: oral antibiotics

Answer 21

Oral tetracyclines (tetracycline, doxycycline, and minocycline) are the preferredoral antibiotics, however erythromycin, azithromycin,trimethoprim/sulfamethoxazole (TMP/SMX), and cephalexin allhave varying degrees of data supporting their use. Also have an anti-inflammatory effect. at least a 3-month trial must begiven before improvement will be seen. Concomitant use of maintenance topical regimens in addition to oral antibioticscannot be overemphasized to help reduce the likelihood of bacterial resistance

Question 22

acne: OCPs

Answer 22

decrease androgen production, increase sex hormone-binding globulin, and the binding of free testosterone.

Question 23

acne: spironolactone

Answer 23

inhibitsbinding of androgen receptors
25-100 mg twice daily
breakthrough bleedingor spotting, menstrual irregularities, headaches, diuresis,dizziness, fatigue, potential hyperkalemia, and breast tenderness
Lab Monitoring should be considered in those with a history of renaldisease, cardiovascular disease, or who are taking anangiotension-converting enzyme inhibitor or an angiotensinreceptor blocker.

Question 24

acne: prednisone

Answer 24

doses ranging from 5-15mg have shown someefficacy in the treatment of acne and can be used for the treatment ofacne fulminans or isotretinoin-induced acne fulminans-like eruptions.

Question 25

acne: isotretinoin

Answer 25

reduction in sebum leads to inhibition of p. acnes which is known tobe a promoter of inflammation. In addition, it also inhibits comedogenesis.
Can cause both spontaneous abortion and life-threateningcongential defects including craniofacial, cardiac, thymic, andCNS malformation
Bone marrow suppression
Primary birth control methods: Hormonal implant▪ IUD▪ Tubal sterilization▪ Male vasectomy▪ Hormonal shot▪ Vaginal ring▪ Hormonal patch▪ Oral contraceptiveo
Secondary birth control methods: Condoms▪ Cervical cap/diaphragm▪ Vaginal sponge
Triglyceride levels exceeding 800 mg/dL may warrant cessation oftherapy to prevent increased risk of acute pancreatitis
Systemic glucocorticosteroids can be given concurrently for 1-4 weeks in thepresence of acne conglobate or acne fulminans

Question 26

acne: ILK

Answer 26

often will achieve resolution of thelesion within 48 hours of injection.
risks of atrophy and depigmentation

Question 27

acne keloidalis

Answer 27

mostly african, some asian & hispanic, rarely caucasian
chronic rubbing from shirt collars, hats, helmets,and close shaving haircuts all make acne keloidis worse
scarring alopecia
ther inciting factors have been proposed andinclude an innocuous chronic bacterial infection, frequent haircuts, curvature of the hair follicles, altered immune process, increased mast cells inlocalized areas of the scalp, and androgens
Contact bleeding maybe present and a burning sensation is sometimes described
If lesions are weeping or crusted, samples should be taken for culture andsensitivities to rule out a rare occurrence of bacterial or fungal etiology
High potency topical steroids applied twice daily alternating every two weeks* Topical retinoid like tretinoin 0.025% can be added* Topical clindamycin 1% can be used twice daily if pustular lesions are present* Intralesional injections of triamcinolone acetonate at a dose of 5-40mg/ml canbe injected every 4 weeks. Patients should be made aware that the potentialside effects include hypopigmentation and skin atrophy to injected sites.* Cryotherapy can be useful in early lesions, oral antibiotics, oral retinoids, surgery, laser

Question 28

dissecting cellulitis

Answer 28

neutrophilic cicatricial alopecia
Linked to follicular occlusion and a dramatic secondary inflammatory response tostimuli (i.e. staphylococcal antigens)
most commonly occurs in males of Africandescent between the ages of 20-40
rupture of follicle results in inflammatory cascade
Lesions can expand circumferentially into abbesses and sinus tracts allowing forinterconnection between nodules
can lead to keoids
exudate typically sterile
tetracyclines, oral retinoids, chlorhexadine/bpo
early tx can reverse hair loss but in persistent cases it can be permanent

Question 29

HS

Answer 29

delay in diagnosis average 7 yrs
economic impact of those diagnosed with HS is significant largely due to missed days of work, medical bills, or depression from the disease
assoc w/ obesity, smoking, metabolic dysfunction
apocrine gland dysfunction, poss genetic predisposition, hormonal involvement, clothing friction & nicotine
hallmark double comedone
dx: has occurred more than twice in a 6 month period or has persisted for more than 3 months
tx: Resorcinol 15% cream BID (antiseptic and a keratolytic) between flares inHurley stage I and II. It may cause some irritation.
progesterone only can exacerbate
zinc gluconate 90 mg daily

Question 30

perioral dermatitis

Answer 30

causes inc occlusive moisturizers/cosmetics, candida, Demodex mites, topical or inhaled fluorinated corticosteroids, toothpaste, and lip licking
TCS cause local immune suppression which leads to an overgrowth of bacteria, yeast, and demodex mites within the hairfollicle.* When the steroid is withdrawn, the local immunity is reconstituted resulting ininflammation of the hair follicles
15-35 y.o. women most common but poss in men & peds
Localized monomorphic erythematous papules and pustules, and sometimes finescale, involving the nasolabial folds, upper and lower lips, and the chin
can be unilateral
granulomatous changes can be seen
spares vermillion border
no comedones
Oral tetracyclines are considered first line therapy in patients older than 8 yearsold with a substantial amount of data on efficacy and reliability, however sideeffects can be problematic.* Topical antimicrobials metronidazole, erythromycin, clindamycin* Tacrolimus, and pimecrolimus are also appropriate as either monotherapy orcombination with oral antibiotics* Treatment typically takes 6-8 weeks

Question 31

rosacea

Answer 31

chronic, relapsing inflammatory disease of the skin that causespersistent erythema, papules, pustules, telangiectasia, and flushing that affectsthe nose, cheeks, chin, and forehead
most common onset 30-50, rhinophyma almost exclusive to men
Suspected contributing factors include genetic factors, repeated vasodilation,changes in the pilosebaceous structure, and colonization of microorganisms likeDemodex folliculorum.* Chronic sun exposure can prompt edema, impair lymphatic drainage, andproduce the characteristic telangiectasia and skin thickening.* There is an association with impairment of the skin barrier function resulting intransepidermal water loss making the skin prone to sensitivity, dryness, scaling,and peeling
Calcium channel blockers, sildenafil, nitrates, nicotinic acid, and niacin have all been associated
Rosacea has been observed in the pediatric population, but is not common

Question 32

rosace sxs

Answer 32

papules and pustules, mildedema, telangiectasias, and occasionally adisseminated violaceous hue.* Flushing associated with triggers*
triggers include skin care & cosmetic products
Avoid waterproof make-up, exfoliating scrubs, astringents, toners or productsthat contain alcohol, witch hazel, fragrance, menthol, camphor, peppermint, andeucalyptus oil
Secondary features including burning, stinging, dryness, and phymatous changes
Rosacea often affects the convex surfaces of the face, including the nose, centrofacial area, andforehead.* The nasolabial folds are generally spared.* Less common involvement of the chin or brow
ocular - conjunctivitis, blepharitis, and hyperemia. Patients often complain of dry, itchy, burning, stinging, irritated eyes. Can occur in conjunction with or without cutaneous findings
If symptoms of light-headedness, sweating, or palpitations accompany thesymptoms flushing attributed to rosacea, then further evaluation for possibleunderlying systemic disease should be prompted. Systemic causes may include:polycythemia vera, connective tissue disorders (i.e. lupus or dermatomyositis),carcinoid syndrome, mastocytosis.

Question 33

rosace tx

Answer 33

alpha2 agonist brimonidine 0.33% gel (Mirvaso) qam
alpha1A adrenoceptor agonist oxymetazoline hydrochloride, 1% cream (Rhofade) q am
Systemic adrenergic antagonists mirtazapine (alpha blocker), propranolol (beta blocker) and carvedilol(both alpha and beta blocker)
low dosedoxycycline (40mg) showed similar efficacy with less adverse effects than higherdosing. Photosensitivity is the main adverse effect. Minocycline carries anincreased risk of pigmentation, liver disorders, and lupus-like syndrome
low dosedoxycycline (40mg) showed similar efficacy with less adverse effects than higherdosing. Photosensitivity is the main adverse effect. Minocycline carries anincreased risk of pigmentation, liver disorders, and lupus-like syndrome
Eyelid hygiene with use of warm water and artificial tears twice daily

Question 34

Muir-Torre syndrome (MTS)

Answer 34

Autosomal dominant genetic syndrome with gene mutation of hMSH2and fewer with hMSH1o 50% patients report a family history of MTS.o Family history often reveals history of colon CA especially under 50 yrsoldo MTS associated with visceral malignancyo Patients with sebaceous adenomas should be referred for screeningevaluation for MTSo Can present with fairly benign appearing yellow papules on face, eyelids,head, neck or trunk. Sebaceous adenomas located BELOW the neck havea high association with MTS

Question 35

sebaceous hyperplasia

Answer 35

can leave scars or divots after destruction
Shave excision
Electrodessication (with or without curettage)
Bichloracetic or trichloracetic acid
Isotretinoin
Cryosurgery
Laser therapy/ablation (pulse dye wavelength 1720nm)
Topical retinoids (off-label)

Question 36

primary hyperhidrosis

Answer 36

craniofacial region, palms, soles, axilla, groin, orunder breasts
More than 90% of cases are primary (rather than secondary) with approximately50% affecting the axillae.* 2/3 of patients report a family history,

Question 37

secondary hyperhidrosis

Answer 37

Substance abuse (alcohol use or narcotic withdrawal, COPD, CHF,endocrine/metabolic Disorders( DM/hypoglycemia, thyroid disease, hypopituitarism), febrile Illness, infections like TB, ingestion of spicy foods, malignancies (carcinoid and pheochromocytoma), medications(antidepressants, cholinergic agonists, hypoglycemia agents, selectiveestrogen receptor modulators, neurological (Parkinson disease, spinalcord injury, Arnold-Chiari malformation), menopause, psychiatric(generalized or social anxiety disorders)

Question 38

hyperhidrosis tx

Answer 38

Aluminum chloride 20% 2-3 x per week
glycopyrronium - 9+, HA, wash hands after use to avoid mydriasis
glycopyrrolate and oxybutynin - bind at muscarinic receptors so acetylcholine is unable, Side effects:▪ Dry mouth▪ Abdominal symptoms▪ Constipation▪ Urinary retention▪ Tachycardia▪ Drowsiness▪ Blurred visiono Contraindicated in myasthenia gravis, pyloric stenosis, and paralytic ileus
iontophoresis - palms/soles, 3 days a week, erythema, vesiculation, and tingling
botox - decreased grip strength in palms
surgery - radical excision, limited excision,liposuction, curettage, or liposuctioncurettage.o Reoccurrence rates are high
Sympathectomy - Nerve conduction is surgically interrupted or redirected by cutting orclipping sympathetic nerves.o Can be helpful in treatment area, but compensatory sweating in otherareas (abdomen, back, legs, and gluteal region) are common
Microwave Thermolysis destroys eccrine glands