General Practise/Primary Care

Question 1

What is Acne Vulgaris?

Answer 1

chronic inflammatory dermatosis notable for:
1. open/closed comedones (black/whiteheads) 2. inflammatory lesions(papules,pustules,nodules)

puberty and adolescence.

Question 2

Pathophysiology of Acne Vulgaris

Answer 2

caused by chronic inflammation in pockets of skin called: PILOSEBACEOUS UNIT.

they contain the hair follicles and sebaceous gland.

sebaceous gland makes natural skin oils and waxy substance known as sebum.

increased sebum production.
keratin trapping.
blockage of pilosebaceous unit.
swelling and inflammation.

Propionibacterium acnes colonises the skin. excessive growth.

Question 3

How do androgenic hormones have a role in acne?

Answer 3

increase in puberty.
improves with anti-androgenic hormonal contraception.

increase production of sebum.

Question 4

lesions in acne

Answer 4

Macules - flat skin mark

Papules - small skin lump

Pustules - small lump w/ yellow pus

Comedones - skin coloured papule - blocked pilosebaceous unit

Blackheads - open comedone with black pigmentation in centre

Ice Pick Scars - small indent in skin after acne lesion heal

Hypertrophic Scars - small skin lump after acne lesion heals

Rolling Scars - irregular wave like irregularity of skin after acne lesion heals

Question 5

Aetiology of Acne Vulgaris

Answer 5

Genetics : fhx higher risk

hormones: androgens eg testosterone and dehydroepiandrosterone sulfate

age: adolescence due to increased hormone production

environment: diet,stress,polllutants.

Question 6

Clinical Features of Acne

Answer 6

comedones - dilated sebaceous follicule.
- top closed: whitehead
- top open : blackhead

papules,pustules: when follicle bursts release irritant

excessive response inflammatory : nodules cysts

sequence of events cause scarring:
icepick and hypertrophic scars.

Question 7

how would you describe drug induced acne

Answer 7

monomorphic

pustules

Question 8

what is acne fulminans

Answer 8

very severe acne

systemic upset - fever.

hospital required.

responds to oral steroids

Question 9

Differentials of Acne Vulgaris

Answer 9

Rosacea
Folliculitis
Perioral Dermatitis

Question 10

How would Rosacea be diff to acne?

Answer 10

erthema,telangiectasia, papules/pustues in central face:
- forehead
- nose
-cheeks
-chin

differences:
- no comedones
- flushing and ocular involvement
- no scarring

Question 11

how would folliculitis be diff to acne?

Answer 11

caused by staph aurus. inflmmation of hair follicles.

uniform appearance
anywhere where there is hair.
itching more common

Question 12

how would perioral dermatitis be diff to acne?

Answer 12

small papules and pustules around mouth.

only perioral, periocular or nasolabial region.

no comedones.

scaly/dry

Question 13

Classifying Acne Vulgaris

Answer 13

mild : open/closed comedone with/without inflammatory lesions sparse.

moderate : widespread non-inflammatory lesions and numerous papules and pustules

severe: extensive inflammatory lesions including nodules, pitting and scarring

Question 14

How would you manage mild to moderate acne?

Answer 14

12 weeks topical combo therapy 1st line:
fixed combos of
topical adapalene + topical benzoyl peroxide

topical tretinoin + topical clindamycin

topical benzoyl peroxide + topical clindamycin

if options contraindicated: topical benzoyl peroxide monotherapy

Question 15

How would you manage moderate to severe acne?

Answer 15

12 weeks:
fixed combos of

topical adapalene + topical benzoyl peroxide

topical tretinoin + topical clindamycin

topical adapalene+ benzoyl peroxide + either oral lymecycline or oral doxycycline

topical azelaic acid + either oral lymcycline/doxycycline

Question 16

rules for administering tetracyclines in acne

Answer 16

avoid in pregnant, breastfeeding.

children under 12 avoid.

use erythromycin in pregnancy

Question 17

why is minocycline less appropriate in acne?

Answer 17

irreversible pigmentation

Question 18

why should a topical retinoid/benzoyl peroxide be prescribed with an abx?

Answer 18

reduce the risk of abx resistance developing.

dont use topical and oral abx at same time.

Question 19

give a complication of long term abx use

acne tx

Answer 19

gram-negative folliculitis

high dose oral trimethoprim effective if it happens

Question 20

give an alternative to oral abx in women for acne tx?

Answer 20

combined oral contraceptive

use with topical agent

dianette (co-cyprindiol) - anti-androgen properties

increased VTE risk.
use 2nd line.

3 months max

Question 21

if none of the above tx for acne works what to do ?

what is the contraindication for it?

Answer 21

oral isotretinoin

pregnancy contraindication to topical and oral retinoid tx

Question 22

to reduce risk of abx resistance in acne tx what should be avoided?

Answer 22

monotherapy with topical abx

monotherapy with oral abx

topical and oral abx together

Question 23

when to refer on for acne?

Answer 23

mild to moderate not responding to 2 tx courses

not responded to previous tx that includes oral abx

scarring
persistent pigment changes
persistent psychological distress

Question 24

side effects of isotretinoin

Answer 24

teratogenicity
hyperlipidaemia
hepatotoxicity

dry skin/lips
photosensitivity
depression,anxiety, suicidal ideation

Question 25

tetracycline side effect

Answer 25

permanent teeth discolouration in kids under 8 or pregnant women

Question 26

What is Acute Bronchitis?

Answer 26

chest infection.
self limiting

inflammation of trachea and major bronchi.

oedematous large airways and sputum production.

resolves before 3 weeks.

leading cause: viral infection

Question 27

clinical features of acute bronchitis

Answer 27

cough: can be productive or not
sore throat
rhinorrhoea
wheeze

most pts have normal chest exam some could have;
low grade fever
wheeze

Question 28

how would you investigate for acute bronchitis

Answer 28

clinical diagnosis

crp testing - tells you if abx in indicated

Question 29

how to differentiate acute bronchitis from pneumonia?

Answer 29

hx: sputum wheeze breathless - at least one in pneumonia

exam: no other focal chest signs.
no systemic features.
the above 2 only in pneumonia

Question 30

How would you manage pneumonia?

Answer 30

Analgesia

good fluid intake

consider abx if:
- systemically unwell
- pre-existing co-morbidities
- CRP of 20-100 mg/L