Disorders of Sebaceous and Apocrine Glands Flashcards
What is acne vulgaris?
Self-limited chronic inflammation of pilosebaceous unit
Pathogenesis of acne vulgaris
- Increased sebum production
- Follicular hyperkeratinization
- Proliferation of Cutibacterium acnes
- Inflammation
Typically beginning at puberty due to androgen stimulation of pilosebaceous unit and changes in keratinization at follicular orifice
Components of acne
- Follicular plugging = blocks sebum drainage
- Stimulation of sebaceous glands
- Overgrowth of c. acnes
- Inflammatory response
Where is acne vulgaris most commonly found?
- Skin with high density of sebaceous follicles
- Face, back, upper chest, neck, arms
What sex has more acne? Race?
- Women > men in adulthood
- No racial predilection
What medications can cause acne?
Corticosteroids, systemic or topical
Anabolic steroids
What are characteristic acne lesions
- Open comedones (blackheads)
- Closed comedones (whiteheads, noninflammatory base)
- Erythematous inflammatory papules
- Pustules
- Nodules and cysts –> scarring, pitted or hypertrophic
Where do adult women most commonly get acne?
Deep-seated, tender red papules along mandibular jaw
What is the appearance of drug-induced acneiform eruptions?
- Monomorphic inflammatory papules and pustules rather than open and closed comedones
What are etiological factors of acne in women?
- Touching
- Rubbing
- Over-cleansing face with numerous products
- Wearing cosmetics
What are etiological factors of acne in men?
- Tends to be more severe on trunk
- Consider grease from working in fast food restaurants, occlusion from sports equipment or hats, and drugs
Diagnosis of acne
- Clinical
- Skin biopsy if doubt
Mild acne
- <20 comedones
- <15 papules/pustules (nodules/cysts?)
- <30 total
Moderate acne
- 20-100 comedones
- 15-50 papules/pustules(nodules/cysts?)
- 30-125 total
Severe acne
- > 100 comedones
- > 50 papules/pustules
- > 5 nodules/cysts
- > 125 total
VISIA IGA Acne severity scale clear skin with no inflammatory or noninflammatory lesions
0
VISIA IGA Acne Severity Scale: almost clear; rare noninflammatory lesions with no more than one small inflammatory lesion
1
VISIA IGA Acne Severity Scale: Mild severity; some noninflammatory lesions with no more than a few inflammatory lesions
2
VISIA IGA acne severity scale: moderate severity; up to many noninflammatory lesions and may have some inflammatory lesions, but no more than one small nodular lesion
3
VISIA IGA Acne Severity Scale: Severe; up to many noninflammatory and inflammatory lesions, but no more than a few nodular lesions
4
What should be done if acne is itchy or has pustules, particularly on upper back, shoulder, and scalp of adolescents and young adults?
- Scrape a pustule for KOH testing to assess for pityrosporum folliculitis
- Can be treated with antifungal shampoo such as ketoconazole
Management pearls for acne
- Acne often resolves after teenage years
- Severe nodulocystic acne needs aggressive treatment
- Acne typically requires consistent regular care over months to see improvement
- Apply topical medication to entire area of potential acne involvement not just individual lesions
Therapy for mild acne
- Topical retinoids
- Benzoyl peroxide
- Topical antibiotics
Acne pharmacotherapies
- Benzoyl peroxide
- Topical retinoids
- Topical abx
- Oral abx
- Oral retinoid
- Azelaic acid
- Salicylic acid
- Hormonal therapy
Types of topical retinoids
- Tretinoin
- Tazarotene
- Adapelene gel
- Trifarotene
- Tretinoin combination (tretinoin and clindamycin)
- Adapalene combination (adapalene and benzoyl peroxide)
Clinical pear for topical retinoids
- Start using gradually, such as every third night, then slowly increase to nightly as tolerated to avoid excessive irritation and dryness
MOA of retinoids
Decreases cohesion and increases turnover of epidermal cells
MC side effect of retinoids
Dryness and photosensitivity
CI for retinoids
Pregnancy
Advantage of benzoyl peroxide
No bacterial resistance
How is benzoyl peroxide dosed?
- 2.5%, 4%, 8%, 10%
- Start with lowest concentration then increase as tolerable
- Comes in gel, lotion, cream, pads, masks, and cleanseers
Side effects of benzoyl peroxide
- Skin irritation (erythema, xerosis, scaling, stonging, tightening, burning sensation)
- Bleaching of hair/clothing
What would you use topical antibiotics to treat?
- Mild-moderate inflammatory acne
MOA of topical antibiotics
Reduces number of c.acnes in pilosebaceous unit
1st line topical antibiotics for mild-moderate inflammatory acne
Clindamycin and erythromycin
Can you use clindamycin/erythromycin alone?
No! Not for monotherapy, need BPO to reduce bacterial resistance
Common side effect of topical antibiotics
skin irritation
Forms of Clindamycin
- Gel, solution, lotion, foam, pledgets
- Combo with BPO
- Combo with tretinoin
BID or foam QD
Forms of erythromycin
- gel, solution
- Combo with BPO (Benzamycin)
Resistance is emerging
What type of acne are oral antibiotics used to treat?
- Moderate acne with inflammatory papules or deeper seated lesions
Oral antibiotics for moderate acne
Doxycycline or minocycline
Prescription for doxycycline or minocycline for acne
- 100 mg every 12 hours to topical regimen of retinoid and benzoyl peroxide
- Typically for 3 months, after which dose tapedred to 100 mg once daily for a month or two before stopping
MOA for oral Abx in acne
Inhibits c. acnes quicker than topicals
MC SE of oral abx (minocycline or doxycycline)
Upset stomach and photosensitivity
First line oral antibiotics for acne
- Tetracyclines (tetracycline, doxycycline, minocycline)
- Macrolides (erythromycin, azithromycin) but increased resistance
Second line oral antibiotics for acne
- Bactrim
- Cephalexin
Benefit of tetracyclines in acne
Anti-inflammatory and antibiotic properties
What oral antibiotic for acne could be used in pregnancy
cephalexin or macrolides: 1st line (pregnancy category B)
Macrolides - azithromycin, erythromycin
What are side effects of bactrim?
- SJS, TEN
What are the second-line oral antibiotics for acne? Why would you choose to use one vs the other?
- Bactrim: used for severe acne that doesn’t respond to other abx but contraindicated in pregnancy
- Cephalexin (Keflex): less effective but relatively safe in pregnancy (category B)
When would you use isotretinoin (oral retinoids) for acne?
- Severe resistant nodular/cystic acne
- Usually patient has failed oral abx
What is the MOA of isotretinoin
Not well known
* Inhibition of sebaceous glands
* Decrease in C. acnes
How is isotretinoin prescribed?
- Monotherapy
- If need second dose, typically need 2 month break before restarting
- Take with high fat meal
.5-1 mg/kg/day divided BID x 15-20 weeks (4-6 months)
Therapeutic goal of 120-150 mg/kg
What are the MC SE/CI of oral retinoids
- Dryness of skin and mucous membranes
- Headaches
- Thoughts of suicide and depression
- Possible increased LFTs and hypertriglyceridemia
- Myalgia
- Never prescribe with oral tetracycline (side effects increase drastically) –> pseudotumor cerebri
- CI IN PREGNANCY!!! BIRTH DEFECTS!
What do patients need to complete prior to giving them oral retinoids?
- iPledge: instruction brochure and enrollment
- Female patient: 2 forms of birth control with negative pregnancy test x 2 before initiation, no blood donation during treatment
- Bseline CMP/lipid monthly and pregnancy test, lipids >700-800 consider stopping or starting lipid lowering drug
Recap of treatment of each type of acne
- Noninflammatory comedonal: topical retinoids
- Mild papulopustular: topical antimicrobial (BPO +ABX) and retinoid
- Moderate papulopustular: topical retinoid + oral abx + BPO; hormonal therapy
- Severe nodular: topical retinoid + oral ABX + BPO; oral isotretinoin; hormonal therapy
Patient education for acne
- Can take 6-8 weeks before improvement and get worse before it gets better
- Wash BID
- No harsh detergents/fabric softeners/dryer sheets
- Diet (linked with dairy)
- Avoid hand contact
- Avoid products full of perfumes/fragrances
What is rosacea?
- Common, chronic inflammatory condition with relapsing-remitting course
- Presents with facial flushing
- Localized erythema
- Telangiectasia
- Papules and pustules
- Located on nose, cheeks, brow, and chin
- Commonly develops between age 30 and 50
What is the etiology of rosacea?
- Poorly understood
- Demodex mites may play role
Who more commonly gets rosacea?
- Lighter skin types
- Females at younger age than males
- Less common skin types IV-VI, perhaps because darker skin types less prone to photodamage and flushing/telangiectasia difficult to visualize
Subtypes of rosacea
- Erythematotelangiectatic
- Papulopustular
- Phymatous
- Ocular rosacea
Description of erythematotelangiectatic rosacea
- Persistent erythema of central portion of face with intermittent flushing
- Telangiectasias
- Stinging or burning sensations on skin
- MC subtype
Description of papulopustular rosacea
- Acneiform papules and pustules
- Erythema and edema of central face with relative sparing of periocular areas
- Lacks open comedones (differentiates between acne)
Description of phymatous rosacea
- Chronic inflammation and edema marked thickening of skin
- Sebaceous hyperplasia
- Cobblestoned appearance of affected skin
- Most common on nose
- Men more offten affected
Description of ocular rosacea
- Conjunctivitis
- Blepharitis
- Hyperemia
- Dry, irritated, itchy eyes
- Keratitis, scleritis, iritis potential but infrequent complications
- Ocular rosacea in patients with or without cutaneous findings
Rosacea features
- Flushing
- Telangiectasia of cheeks/forehead
- Papules/pustules/nodules of nose/cheeks/forehead
- Hyperplasia and fibrosis of sebaceous glands: -phyma
Rosacea symptoms
- Burning
- Stinging
- Edema
- Plaques
- Flushing
Rosacea triggers
- Weather (extremes of temperature)
- Food and drink (hot beverages)
- Exercise
- Emotions
- Topical products
- Hormonal imbalances
- Medications (niacin)
- Sun exposure
Conservative treatment for rosacea
- Counseling on avoiding known triggers
- Use of broad-spectrum sunscreens and sun avoidance
- Camoglage makeups with green or yellow tint helpful in masking redness
Topical therapies for rosacea
- Metronidazole
- Ivermectin cream
- Sodium sulfacetamide with 5% sulfur
- 15% azelaic acid gel
- Brimonidine gel and oxymetazoline topical
MISAB rosacea
Rosacea treatment
- Metronidazole .75% gel twice daily if oily skin types
- Metronidazole .75% cream or lotion twice daily if normal to dry skin types
- Azelaic acid 15% gel effective alternative
- Sodium sulfacetamide with 5% sulfur lotion, cream, suspension, or cleanser
- Erythromycin or clindamycin lotion, solution
- Ivermectin 1% cream
- Permethrin 5% cream
- Once daily brimonidine .33% topical gel to reduce facial erythema
- Once daily oxymetazoline topical for erythema
Systemic therapies for rosacea
- Tetracycline antibiotics: doxy 40 mg daily or minocycline 50 mg twice daily for 12 weeks
- Oral metronidazole 200 mg twice daily
- Azithromycin 250-500 mg daily 3 x/week
- Isotretinoin in severe papulopustular rosacea
Therapies for telangiectasias/erythematotelangectatic rosacea
- Camoflauge cosmetics
- Brimoinidine .33% topical gel
- Vascular lasers
- Intense pulsed light therapy
Therapies for flushing in rosacea
- Clonidine .05 mg twice daily
- Intense pulsed light
- Pulsed dye laser
- Beta blockers
Therapies for rhinophyma in rosacea
- Surgical paring/sculpting
- Electrosurgery
- Laser
Therapies for rosacea fulminans
- Prednisolone 1 mg/kg daily while isotretinoin initiated then tapered over several weeks
- Isotretinoin continued for several months
Description of perioral dermatitis
- Discrete erythematous micropapules and microvesicles
- Confluent in perioral and periorbital skin
Factors that impact perioral dermatitis
- Mainly in females
- Topical fluorinated glucocorticoids, fluorinated toothpaste, and OCP can be factors
Tx of periorbital dermatitis
- D/C steroid use
- Topical and oral antibiotics
In the stages of acne, a ruptured follicular wall represents what?
Nodule
Microcomedone
- Hyperkeratotic infundibulum
- Cohesive corneocytes
- Sebum secretion
Comedone
- Accumulation of shed corneocytes and sebum
- Dilation of follicular ostium
Inflammatory papule/pustule
- Further expansion of follicular unit
- Proliferation of proprionibacterium acnes
- Periorbital inflammation
Nodule
- Rupture of follicular wall
- Marked perifollicular infalmmation
- Scarring
In the stages of acne, a dilated follicular ostium represents what
Comedone
T/F: Acne cannot last from teenage years into adulthood
False
T/F: Acne is more common in men than women
False
What retinoid cream is now OTC?
Adapalene .1%
Retinoid creams should be used every _____ night starting out
3rd
MC side effect of topical retinoids is
Dryness
Rosacea develops between the ages of …
30-50
Which form of rosacea can cause an enlargednose?
Phymatous
Which is not a trigger of rosacea
-weather
-drink
-niacin
-emotions
-all of the above
All of the above
A 23-year old female is beginning treatment with isotretinoin for her cystic acne. What is recommended frequency of serum pregnancy testing during treatment?
Two tests prior to starting and one test monthly
