Seborrhea Acne Rosacea Flashcards
ACNE VULGARIS
INFLAMMATION OF PILOSEBACEOUS UNITS
FACE, TRUNK, BUTTOCKS
MC > adolescents
Manifestion:
> comedomes
> papulopustule
> nodules
> cysts
RESULTS IN > Pitted, depressed + hypertrophic scars
ACNE KEY POINTS
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:
ACNE KEY POINTS
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
PATHOGENISIS FOLLICULAR KERATINISATION
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
PATHOGENISIS - ANDROGENS
ANDROGENS > stimulate sebaceous glands to produce larger amount of sebum
PATHOGENSIS - BACTERIA
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
CONTRIBUTORY FACTORS TO ACNE
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
»_space; ACNE MECHANICA
ACNE NOT CAUSED BY FOOD/ CHOCOALTE/ FATTY FOODS
ACNE - CLINICAL MANIFESTATION
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
ACNE COMEDOMES
Keratin plugs formed within follicular ostia
> comedomes linked with small ostia > closed comedomes/ whiteheads
> comedomes linked with large ostia > open comedomes/ blackheads
ACNE PAPULOPUSTULA
Some inflammatory papules become nodular
> represent at early stages of nodulocystic acne
ACNE - NODULES/ CYST
> 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
NODULOCYSTIC ACNE
open + closed comedomes
papulopustular lesions
nodules + cysts
SPECIAL FORMS ACNE
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
ACNE CONGLOBATA
> 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
ACNE FULMINANS
> rare
teenage boys 13-17 yrs
acute onset
severe cystic acne w/ suppuration + ulceration
malaise
fatigue
fever
generalised arthralgias
leukocytosis
elevated erythrocyte sedimentation rate
ACNE IN ADULT WOMAN
> 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
SAPHO SYNDROME
> RARE
SYNOVITIS
ACNE - ACNE FULMINANS
PALMOPLANTAR PUSTULOSIS
HIDRADENTITIS SUPPURATIVA
HYPEROSTOSIS
OSTEITIS
PAPA SYNDROME
Sterile PYOGENIC ARTHRITIS
PYODERMA GANGRENOUS ACNE
> inherited autoinflmmatory disorder
very rare
TROPICAL ACNE
> flare of acne
severe folliculitits
inflammatory noduels
draining cyst
trunk + buttocks
tropical climates
secondary infection to Staph. aureus
ACNE WITH FACIAL EDEMA
> linked with recalcitrant
disfiguring midline facial edema
woody induration w or w/o erythema
RECALCITRANT ACNE
> linked to congenital adrenal hyperplasia
11b or 21b hydroxyls deficiencies
ACNE EXCORIEE
> mild acne
young women
extensive excoriation + scarring
due > emotional + psychological problems
> obsessive compulsive disorder
NEONATAL ACNE
> nose + cheeks of newborns/ infants
related to glandular development
transient
OCCUPATION ACNE
> exposure tar derivatives
cutting oils
chlorinated hydrocarbons (CHLORACNE)
large comedomes
inflammatory papules + cyst
not restricted to predilection sites
CHLORACNE
> chlorinated aromatic hydrocarbons
in electrical conductors
insecticides + herbicides
severe in industrial accidents/ intended poisoning (DIOXIN)
ACNE COSMETICA
due to comedogenic cosmetics
POMADE ACNE
> forehead
africas
applying pomade to hair
ACNE MECHANICA
> flares of preexisting acne
hands on face
forehead > pressure of football helmet
ACNE LIKE CONDITIONS
STEROID ACNE
DRUG INDUCED ACNE
ACNE AESTIVALIS
GRAM NEGATIVE FOLLICULITITS
STEROID ACNE
> systemic/ topical glucocorticoids
monomorphous folliculitis
small erythematous papules + pustules
without commodores
DRUG INDUCED ACNE
> monomorphous acne like eruption
due > phenytoin, lithium, isoniazid,
high dose vit.B complex
epidermal growth factor inhibitors
halogenated compounds
NO COMODOEMS
ACNE AESTIVALIS
> papular eruption after sun exposure > Mallorca acne
forehead, shoulders, arms, neck , chest
NO COMEDOMES
PATHOGENSIS UNKNOWN
GRAM NEGATIVE FOLLICULTIIS
> multiple tiny yellow pustules
develop on top of acne vulgaris
due to long term ABX administration
DIAGNOSIS ACNE
COMODOMES > required to dx any type of acne
COMODOMES > not a feature of acne like conditions
DIFFERENTIAL DIASGNOSIS ACNE
FACE:
> s. aureus folliculitis
> pseudofollicultiis barbae
> rosacea
> personal dermatitis
TRUNK:
> Malassezia folliculitis
> hot tub pseudomonas folliculitis
> s.aureus folliculitis
> acne like conditions
ACNE - LAB EXAMS
> 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
ACNE COURSE
> most often clears spontaneouslyy by early 20s
can exist in 4th decade / older
flares in winter
MANAGEMENT ACNE
> assessed individually + therapy modified accordnly
goal > remove plugging of pilar drainage
reduce sebum production
tx bacterial colonisation
MILD ACNE
> 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»_space; tretinoin/ tazarotene gel, adapalene
ACNE SURGERY > EXTRACTION OF COMODOMES
» only when done after pretreatment w/ topical retinoids
MODERATE ACNE
> 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
SEVERE ACNE MANAGEMENT
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
INDICATION FOR ORAL ISOTRETINOIN - ACNE
> moderate + severe
recalcitrant + nodular acne
px must have resistant to other acne tx including systemic abx
CONTRAINDICATION ISOTRETINOIN -ACNE
> 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
DOSASE OF ISOTRETINOIN - ACNE
> 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
OTHER SYSTEMIC TX FOR SEVERE ACNE
> 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
ROSACEA
> 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
ROSACEA - EPIDEMIOLOGY
> 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
CLASSIFICATION ROSACEA - PLEWING + KLIGMAN CLASSIFICATION
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
ROCASEA - CLINICAL MANIFESTATION
> 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
SKIN LESIONS - ROSACEA
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
ERYTHEMATOUS ROSACEA - STAGE 1
> episodic erythema
flushing + blushing
due > mutlutple telangiectasis > red face
ROSACEA - SPECIAL LESIONS
> 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
ROSACEA - EYE INVOLVEMENT
> red eyes > chronic blepharitis
conjunctivitis
episcelritis
rosacea keratitis > serious > corneal ulcer may form
ROSACEA - LAB EXAM
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
DIFFERENTIAL DIAGNOSIS
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
PREVENTION ROSACEA
> reduction/ eliminate alcohol
TOPICAL TREATMENT - ROSACEA
> 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
SYSTEMIC TREATMENT - ROSACEA
> 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
ORAL ISOTRETINOIN - ROSACEA
> 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
SURGERY/ LASER - ROSACEA
> rhinophyma + telangiectasia
treated with excellent cosmetic results
BEHCET DISEASE
> multisystem polysymptomatic disease
w/ unpredictable excarbation + remission
all organ of body can be affeced
EPIDEMIOLOGY BEHCET DISEASE
> RARE
3rd /4th decade
MC MALES
PATHOGENISIES BEHCET DISEASE
> 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
CLINICAL MANIFESTATION BEHCET
> 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
CLINICAL MANIFESTATION - BEHCET
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
ORAL APHTHAE - BEHCET DISEASE
> punched out ulcers w/ necrotic base on buccal mucosa
punched out ulcer on tounge
GENITAL ULCERS - BEHCET DISEASE
> multiple large aphthous type ulcers on labial + perineal skin
large punched out ulcer on scrotum
SYSTEMIC FINDINGS - BEHCET DISEASE
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
LAB EXAM - BEHCET DISEASE
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
DIAGNOSIS BEHCET DISEASE
> made based on REVISED INTERNATIONAL CRITERIA FOR BEHCET DISEASE
DDX BEHCET DISEASE
> oral/ genital uclers
viral infection > herpes simplex virus
varicella zoster virus
hand food + mouth disease
herpangina
chancre
histoplasmosis
squamous cell carcinoma
PROGNOSIS BEHCET DISEASE
> 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
MANAGEMENT - BEHCET DISEASE - APHTHAE
> 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
