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DERMATOLOGY 5 > Seborrhea Acne Rosacea > Flashcards

Seborrhea Acne Rosacea Flashcards

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1
Q

ACNE VULGARIS

A

INFLAMMATION OF PILOSEBACEOUS UNITS

FACE, TRUNK, BUTTOCKS
MC > adolescents

Manifestion:
> comedomes
> papulopustule
> nodules
> cysts

RESULTS IN > Pitted, depressed + hypertrophic scars

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2
Q

ACNE KEY POINTS

A

Very common > affecting 85% young people

Age onset > puberty 10-17 yrs Females
14-19 yrs Males

Late onset > first at 25 yrs
MALES > FEMALE

Lower in asians/ africans

Genetics aspects:

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2
Q

ACNE KEY POINTS

A

Very common > affecting 85% young people

Age onset > puberty 10-17 yrs Females
14-19 yrs Males

Late onset > first at 25 yrs
MALES > FEMALE

Lower in asians/ africans

Family history > parents with severe acne

Severe acne linked with XXY syndrome

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3
Q

PATHOGENISIS FOLLICULAR KERATINISATION

A

FOLLICULAR KERATINISATION
> change in keratinisation pattern in pilosebaceous unit
> keratinous material > becomes more dense + blocking secretion of sebum
> KERATIN PLUGS > COMEDOMES > “ time bombs of acne”
> LINOLEIC ACID > regulates keratinocyte proliferation > decreased in acne
> commedonal pluggings + complex interaction between androgens + bacteria (P.acne) in plugged sebaceous units > INFLAMMATION

ANDROGENS

Propionibacterium acnes

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4
Q

PATHOGENISIS - ANDROGENS

A

ANDROGENS > stimulate sebaceous glands to produce larger amount of sebum

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5
Q

PATHOGENSIS - BACTERIA

A

BACTERIA > contain lipase > converts lipids to fatty acids > produce pro inflammatory mediates > IL-1, TNFa

Fatty acids + pro inflammatory mediators cause > sterile inflammatory response to pilocebacous units

Distended follicle wall break > contents (sebum, lipids, fatty acids, keratin, bacteria) > enter dermis
> produce inflammatory + foreign body response
» papule
» pustule
» nodule

Rupture + intense inflammation > leads to scars

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6
Q

CONTRIBUTORY FACTORS TO ACNE

A

Acnegenic mineral oils
Rarely dioxin

DRUGS
> lithium
> hydantoin
> isoniazid
> glucocorticoids
> oral contraceptive
> iodides
> bromides
> androgens > testosterone
> danazole

OTHERS
> emotional stress > exacerbation
> occlusion + pressure on skin > hands on face
&raquo_space; ACNE MECHANICA

ACNE NOT CAUSED BY FOOD/ CHOCOALTE/ FATTY FOODS

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7
Q

ACNE - CLINICAL MANIFESTATION

A

Week - months
Worse in fall + winter

Pain in lesions > esp. nodulocystic type

SKIN LESIONS
> open comedomes > blackheads
> closed comedomes > whiteheads
> papules
> papulopustules > papules topped by pustule
> papulopustula acne

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8
Q

ACNE COMEDOMES

A

Keratin plugs formed within follicular ostia

> comedomes linked with small ostia > closed comedomes/ whiteheads

> comedomes linked with large ostia > open comedomes/ blackheads

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9
Q

ACNE PAPULOPUSTULA

A

Some inflammatory papules become nodular
> represent at early stages of nodulocystic acne

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10
Q

ACNE - NODULES/ CYST

A

> 1-4 cm diameter
soft nodules > result > repeated follicular ruptures + reencapsulation with inflammation, abscess formation + foreign body reaction

> cysts > pseudocysts > not lined by epithelium BUT represent with fluctuating abscess

Scars > atrophic depressed (often pitted) or hypertrophic (sometimes keloidal)

SEBORRHEA > on face + scalp + severe

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11
Q

NODULOCYSTIC ACNE

A

open + closed comedomes
papulopustular lesions
nodules + cysts

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12
Q

SPECIAL FORMS ACNE

A

ACNE CONGLOBATA
ACNE FULMINANS
ACNE IN ADULT WOMAN
TROPICAL ACNE
ACNE WITH FACIAL EDEMA
RECALCITRAN ACNE
ACNE EXCORIEE
NEONATAL ACNE
OCCUPATION ACNE
CHLORACNE
ACNE COSMETICA
POMADE ACNE
ACNE MECHANICA

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13
Q

ACNE CONGLOBATA

A

> severe nodulocystic acne
more on trunk than face
coalescing nodules, cysts, abscess + ulceration
on buttocks
spontaneous remission long delayed
in polycystic ovary syndrome
rare in XYY Genotype
> tall males
> slight mental retardation
> aggressive behavrious

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14
Q

ACNE FULMINANS

A

> rare
teenage boys 13-17 yrs
acute onset
severe cystic acne w/ suppuration + ulceration
malaise
fatigue
fever
generalised arthralgias
leukocytosis
elevated erythrocyte sedimentation rate

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15
Q

ACNE IN ADULT WOMAN

A

> persistent acne
hirsute female (often)
with/ without irregular cycles
hyper secretion of adrenal glands + ovarian androgens
dehydroepiandrosterone sulphate DHEAS
polycystic ovary syndrome
congenital adrenal hyperplasia

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16
Q

SAPHO SYNDROME

A

> RARE
SYNOVITIS
ACNE - ACNE FULMINANS
PALMOPLANTAR PUSTULOSIS
HIDRADENTITIS SUPPURATIVA
HYPEROSTOSIS
OSTEITIS

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17
Q

PAPA SYNDROME

A

Sterile PYOGENIC ARTHRITIS
PYODERMA GANGRENOUS ACNE

> inherited autoinflmmatory disorder
very rare

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18
Q

TROPICAL ACNE

A

> flare of acne
severe folliculitits
inflammatory noduels
draining cyst
trunk + buttocks
tropical climates
secondary infection to Staph. aureus

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19
Q

ACNE WITH FACIAL EDEMA

A

> linked with recalcitrant
disfiguring midline facial edema
woody induration w or w/o erythema

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20
Q

RECALCITRANT ACNE

A

> linked to congenital adrenal hyperplasia
11b or 21b hydroxyls deficiencies

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21
Q

ACNE EXCORIEE

A

> mild acne
young women
extensive excoriation + scarring
due > emotional + psychological problems
> obsessive compulsive disorder

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22
Q

NEONATAL ACNE

A

> nose + cheeks of newborns/ infants
related to glandular development
transient

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23
Q

OCCUPATION ACNE

A

> exposure tar derivatives
cutting oils
chlorinated hydrocarbons (CHLORACNE)
large comedomes
inflammatory papules + cyst
not restricted to predilection sites

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24
Q

CHLORACNE

A

> chlorinated aromatic hydrocarbons
in electrical conductors
insecticides + herbicides
severe in industrial accidents/ intended poisoning (DIOXIN)

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25
Q

ACNE COSMETICA

A

due to comedogenic cosmetics

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26
Q

POMADE ACNE

A

> forehead
africas
applying pomade to hair

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27
Q

ACNE MECHANICA

A

> flares of preexisting acne
hands on face
forehead > pressure of football helmet

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28
Q

ACNE LIKE CONDITIONS

A

STEROID ACNE

DRUG INDUCED ACNE

ACNE AESTIVALIS

GRAM NEGATIVE FOLLICULITITS

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29
Q

STEROID ACNE

A

> systemic/ topical glucocorticoids
monomorphous folliculitis
small erythematous papules + pustules
without commodores

30
Q

DRUG INDUCED ACNE

A

> monomorphous acne like eruption
due > phenytoin, lithium, isoniazid,
high dose vit.B complex
epidermal growth factor inhibitors
halogenated compounds
NO COMODOEMS

31
Q

ACNE AESTIVALIS

A

> papular eruption after sun exposure > Mallorca acne
forehead, shoulders, arms, neck , chest
NO COMEDOMES
PATHOGENSIS UNKNOWN

32
Q

GRAM NEGATIVE FOLLICULTIIS

A

> multiple tiny yellow pustules
develop on top of acne vulgaris
due to long term ABX administration

33
Q

DIAGNOSIS ACNE

A

COMODOMES > required to dx any type of acne

COMODOMES > not a feature of acne like conditions

34
Q

DIFFERENTIAL DIASGNOSIS ACNE

A

FACE:
> s. aureus folliculitis
> pseudofollicultiis barbae
> rosacea
> personal dermatitis

TRUNK:
> Malassezia folliculitis
> hot tub pseudomonas folliculitis
> s.aureus folliculitis
> acne like conditions

35
Q

ACNE - LAB EXAMS

A

> no labs required
if suspicious endocrine disorder > hormonal exam
> T hormone
> free testosterone
> follicle stimulating hormone
> leutonizing hormone
> DHEAS
» exclude adrenal hyperandorgenism + polycystic ovary syndrome

** SEVERE ACNE PX > HORMONE LEVELS ARE NORMAL

> > ALT, AST, TRIGLYCERIDE + CHOLESTEROL LEVELS
required if systemic isotretinoin tx planned

36
Q

ACNE COURSE

A

> most often clears spontaneouslyy by early 20s
can exist in 4th decade / older
flares in winter

37
Q

MANAGEMENT ACNE

A

> assessed individually + therapy modified accordnly
goal > remove plugging of pilar drainage
reduce sebum production
tx bacterial colonisation

38
Q

MILD ACNE

A

> topical Abx > clindamycin + erythromycin
benzoyl peroxidase gels
topical retinoids
> tretinoin
> adapalene

> after improvement > meds reduces to lowest effective dose
improvement occurs over 2-5months
can be longer for non inflammatory comodomes
topical retinoids > apply evening
topical abx + benzoyle peroxidase applied during day
combination therapy best
> benzoyl peroxide + erythromycin gels plus topical retinoids&raquo_space; tretinoin/ tazarotene gel, adapalene

ACNE SURGERY > EXTRACTION OF COMODOMES
» only when done after pretreatment w/ topical retinoids

39
Q

MODERATE ACNE

A

> oral abx added along to mild acne tx

> most effective ABX: MINOCYCLINE 50-100mg x 2 daily
DOXYCYCLINE 50-100mg x2 daily

FEMALES:
> control with oral oestrogen w/ progesterone/ anti androgens
> risk of reoccurrence after stopping tx

FOR INFLAMMATORY CYST/NODULES:
> intralesional triamcinolone

40
Q

SEVERE ACNE MANAGEMENT

A

ADDITONAL TX ALONG WITH TX FOR MODERATE ACNE

> systemic tx > isotretinoin for cyst/ conglobate acne
this retinoid
> inhibits sebaceous gland function + keratinisation
> very effective

ORAL ISOTRETINOIN > leads to complete remission in all cases > lasting months - years

41
Q

INDICATION FOR ORAL ISOTRETINOIN - ACNE

A

> moderate + severe
recalcitrant + nodular acne
px must have resistant to other acne tx including systemic abx

42
Q

CONTRAINDICATION ISOTRETINOIN -ACNE

A

> Irotretinoin = teratogenic
pregnancy must be prevented + effective contraception is necessary when taking isotretinoin

> tetracycline + isotretinoin > cause pseudotumor cerebri (bening intracranial swelling)
both should never be used together

43
Q

DOSASE OF ISOTRETINOIN - ACNE

A

> 0.5 - 1mg/kg with food
improvement within 20wks with 1mg/kg
for severe > esp > trunk > 2mg/kg
3 or more courses given in refractory cases

44
Q

OTHER SYSTEMIC TX FOR SEVERE ACNE

A

> systemic glucocorticoids > esp > acne conglobata, fulminans + SAPHO + PAPA syndromes
TNF-a INHIBITORS > INFLIXIMAB + ANAKINRA

INFLAMMATORY CYST/ NODULES
> intralesional triamcinolone
» 0.05ml of 3-5mg/mL solution

45
Q

ROSACEA

A

> chronic inflammatory acne form disorder of facial pilosebaceous units
linked with increased reactivity of capillaries
> result > flushing + telangiectasia (dilated vessels)

> rubbery thickening of nose
> cheeks
> forehead
> chin
» due > sebaceous hyperplasia, edema + fibrosis

46
Q

ROSACEA - EPIDEMIOLOGY

A

> affecting 10% fair skinned
30-50 yrs
peak 40-50 yrs
FEMALES
rhinopehyma mc in males
celtic people > skin prototype I + II
southern mediterraneans
rare > pigmented people > skin prototype V + VI > brown/black

47
Q

CLASSIFICATION ROSACEA - PLEWING + KLIGMAN CLASSIFICATION

A

EPISODIC ERYTHEMA > FLUSHING + BLUSHING

STAGE 1
> persistent erythema w/ telangiectasis

STAGE 2
> persistent erythema
> telangiectasis
> papules
> tiny pustules

STAGE 3
> persistent deep erythema
> dense telangiectasis
> papules
> pustules
> nodules
> solid edema centra part of face

PROGRESSION FROM ONE STAGE TO ANOTHER DOESNT ALWAYS OCCUR

MAY START W/ STAGE 2 OR 3
stages may overlap

48
Q

ROCASEA - CLINICAL MANIFESTATION

A

> hx of episodic reddening of face - flushing
w increased skin temp
due to heat stimuli in mouth > hot liquids, spicy foods + alcohol
exposure to sun > solar elastosis + heat
> cooks working with hot stove
can occur de novo w/o any hx of acne/ seborrhoea

DURATION
> days, weeks, months

49
Q

SKIN LESIONS - ROSACEA

A

EARLY
> pathognomic flushing - red face
> tiny papules
> papulopustules 2-3mm
> pustules often small < 1mm
> no comodones

LATE
> red facies
> dusky red papules
> nodules
> scattered lesions
> telangiectases
> makes sebaceous hyperplasia
> lymphedema in chronic subarea > disfigurement of nose, forehead, eyelids, ears, chin

DISTRIBUTION
> symmetric localisation on face
> rare > neck, chest V shape, back + scalp

50
Q

ERYTHEMATOUS ROSACEA - STAGE 1

A

> episodic erythema
flushing + blushing
due > mutlutple telangiectasis > red face

51
Q

ROSACEA - SPECIAL LESIONS

A

> rhinopehyma - enlarged nose
metophyma > enlarged cushion like swelling of forehead
blepharophyma > swelling of eyelid
otophyma > cauliflower like swelling of earlobes
gnathophyma > swelling of chin

DUE: sebaceous gland hyperplasia + fibrosis

PALPATION > soft + rubber life

52
Q

ROSACEA - EYE INVOLVEMENT

A

> red eyes > chronic blepharitis
conjunctivitis
episcelritis
rosacea keratitis > serious > corneal ulcer may form

53
Q

ROSACEA - LAB EXAM

A

BACTERIAL CULTURE
> rule out s.aureus infection
> scraping

DERMATOPAHTOLOGY
EARLY
> non specific perifolicular + pericapillary inflammation
> occasional foci of tuberculoid + granulomatous areas
> dilated capillaries
> foci of neutrophils high + within follicle

LATER STAGE
> diffuse hypertrophy of connective tissue
> sebaceous gland hyeprplasia
> epithelia granuloma without cessation + foreign body giant cells

RHINOPHYMA
> very marked lobular sebaceous hyperplasia - glandular type
> marked increase in connective tissue fibrous type
> large ecstatic veins - fibroangiomatous type

54
Q

DIFFERENTIAL DIAGNOSIS

A

FACIAL PAPULES/ PUSTULES
> acne > no comedones in rosacea
> peri oral dermatitis
> s.aureus folliculitis
> demodex follicular infestation

FACIAL FLUSHING/ ERYTHEMA
> seborrheic dermatitis
> prolonged use of topical glucocortcoids
> lupus
> dermatomyositis

COURSE
> prolonges
> reoccurrence common
> after years disease disappears spontaneously
> usually lifetime
> men + rare women develop rhinophyma

55
Q

PREVENTION ROSACEA

A

> reduction/ eliminate alcohol

56
Q

TOPICAL TREATMENT - ROSACEA

A

> metronidazole gel/ cream 0.75% twice daily
metronidazole cream 1% once daily
sodium sulfacetamide, sulfure lotion 10% + 5%

> topical antibiotics > erythromycin gel > less effective
topical ivermectin

57
Q

SYSTEMIC TREATMENT - ROSACEA

A

> oral abx > more effective than topical abx
minocycline/ doxycycline 50-100mg twice daily
doxycycline > phototoxic drug > limited exposure to sun/ summer
tetracycline > 1-1.5g/d

MOST EFFECTIVE > ORAL METRONIDAZOLE
> 500mg BID

58
Q

ORAL ISOTRETINOIN - ROSACEA

A

> severe disease > stage III
not responding to ABX + topical treatment

> low dose of 0.1-0.5mg/kg per day
sometimes 1mg/kg required

IVERMECTIN
> 12mg PO in case of massive demdex infestation

59
Q

SURGERY/ LASER - ROSACEA

A

> rhinophyma + telangiectasia
treated with excellent cosmetic results

60
Q

BEHCET DISEASE

A

> multisystem polysymptomatic disease
w/ unpredictable excarbation + remission
all organ of body can be affeced

61
Q

EPIDEMIOLOGY BEHCET DISEASE

A

> RARE
3rd /4th decade
MC MALES

62
Q

PATHOGENISIES BEHCET DISEASE

A

> vascular injuies + autoimmune response
circulating immune complexes + neutrophils > cause mucocutanous lesions
histologically > neutrophilic vascular reaction/ leukocytoclastic vasculitis
neutrophils of behcet disease > produce increased amount of superoxides + lysosomal enzymes > tissue injury
high levels of TNFa, IL-1B, IL-8 > activates neutrophils + cellular reaction between neutrophils + endothelial cells

63
Q

CLINICAL MANIFESTATION BEHCET

A

> MUCOUS MEMBRANES: Aphthea
> painful

> > punched out erosions/ ulcers with necrotic base

> > occurs on oral mucous membranes, pharynx, larynx, vulva, penis, scrotum

> > aphthea > erupt in cyclic fashion in oral cavity/ genital mucous membrnaes

> > aphthea > persist wks - mnths before other symptoms

64
Q

CLINICAL MANIFESTATION - BEHCET

A

CUTANOUS FINDINGS
> sterile papulopustules + palpable purpura to erythema nodosum like lesions

ERYTHEMA NODOSUM LIKE LESIONS
> painful nodules on arms + legs
> papulopustular lesions
> acneiform papules + pustules
> plaques like in sweet syndrome (acute febrile neutrophilic dermatosis)
> pyoderma gangrenosum like lesions
> palpable purpuric lesions of necrotizing vascultisis
> thrombophlebitis

65
Q

ORAL APHTHAE - BEHCET DISEASE

A

> punched out ulcers w/ necrotic base on buccal mucosa
punched out ulcer on tounge

66
Q

GENITAL ULCERS - BEHCET DISEASE

A

> multiple large aphthous type ulcers on labial + perineal skin
large punched out ulcer on scrotum

67
Q

SYSTEMIC FINDINGS - BEHCET DISEASE

A

EYE
> posterior uveitis
> anterior uveitis
> retinal vasculitis
> vitreitis
> hypopyon
> secondar cataracts
> glaucoma
> neovascular lesion

MUSCULOSKELETAL
> non erosive
> asymmetric oligoarthritis

NEUROLOGIC
> onset delayed
> occurs in 1/4 of px
> meningioencephalitis
> bening intracranial hypertension
> cranial nerve palsies
> brainstem lesions
> pyramidal/ extrapyramidal lesions
> psychosis

VASCULAR/ CARDIAC
> aneurysm
> arterial occlusions
> venous thrombosis
> varices
> hemoptysis
> coronary vascultiis
> myocarditis
> coronary arteritis
> endocarditis
> valcular disease

GI TRACT
> aphthae throughout - mucous membranes

68
Q

LAB EXAM - BEHCET DISEASE

A

DERMATOPATHOLOGY
> non specific
> leukocytoclastic vascultisi w/ fibrinoid necrosis of blood vessel wall in acute early lesions
> lymphocytic vasculitis in late lesion

PATHERGY TEST
> positive pathergy test at 24/ 48h after skin puncture w/ sterile needle
> leads to inflammatory pustule

HLA TYPING
> significant association
> HLAB5
> HLA-B51

69
Q

DIAGNOSIS BEHCET DISEASE

A

> made based on REVISED INTERNATIONAL CRITERIA FOR BEHCET DISEASE

70
Q

DDX BEHCET DISEASE

A

> oral/ genital uclers
viral infection > herpes simplex virus
varicella zoster virus
hand food + mouth disease
herpangina
chancre
histoplasmosis
squamous cell carcinoma

71
Q

PROGNOSIS BEHCET DISEASE

A

> highly variable course w/ recurrences + remission
mouth lesions always present
remission > weeks -months - years
one of leading causes for BLINDNESS
w/ CNS involvement > higher mortality rate

72
Q

MANAGEMENT - BEHCET DISEASE - APHTHAE

A

> potent topical glucocorticoids
intralesional triamcinolone 3-10mg/mL injected into ulcer base
thalidomide 50-100mg PO in evening
colchicine
dapsone

SYSTEMIC INVOLVEMENT
> corticosteroids
> azathioprine
> cyclophophamide
> azathioprine
> chlorambucil
> cyclosporine

DERMATOLOGY 5 (3 decks)

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