Week 2 - C- Acne vulgaris - (Occlusion/Sebum/P.acne/Inflammation, grading, treatment), Rosacea - features, triggers, treatment

Question 1

We will discuss acne and rosacea - two distinct conditions affecting different age groups and distinct pathogenic mechanisms and clinical features However treatment options are more or less similar What is acne defined as? What age group is affected?

Answer 1

Acne is defined as chronic inflammatory disease of the pilosebaceous unit It usually affects people in their mid to late teen years

Question 2

What are the 4 major steps in the pathogenis of acne vulgaris (remember from psoriasis vulgaris - vulgaris means common) What are the 4 major steps?

Answer 2

Acne vulgaris is chronic inflammation of the pilosebaceous unit the 4 major steps are * Poral occlusion * Increased sebum production * Bacterial colonisation of the duct * Dermal inflammation

Question 3

4 factors of acne vulgaris * Pilosebaceous duct occlusion * Increased sebum production * Bacterial colonisation of the duct * Dermal inflammation Why does the piloseabeous duct become occluded?

Answer 3

The pilosebaceous duct becomes occluded due to ductal hypercornification - this is due to hyperproliferation of ductal keratinocytes or reduced separation of ductal corneocytes - both lead to a clumping of cells in the follicle

Question 4

What is it that causes ductal occlusion again and what can this lead to?

Answer 4

Ductal occlusion - caused by the hyperproliferation of keratinocytes and the cohesive corneocytes lead to a clumping of cells in the pilosebacoeus unit With an increased sebum production also, this can lead to the production of non-inflammatory lesions known as microcomedomes

Question 5

What are the two different types of comedomes?

Answer 5

Whiteheads are known as closed comedomes Blackheads are formed when the sebum/keratinocytes plug is opened to the skin surface and oxidised - open comedome

Question 6

What causes an increased sebum production in acne?

Answer 6

Sebum production responds to androgen production Therefore an increase in the androgen production / availability / responsiveness in puberty will lead to an increase in sebum production

Question 7

What is the bacteria that colonise the pilosebaceous duct in acne? What encourages greater bacterial coloinsation?

Answer 7

The bacterium, propionobacterium acnes colonises the duct in acne vulgaris High sebum concentration (driven by androgen) encourgaes propionobacterium colonisation

Question 8

What cause the dermal inflammation in acne?

Answer 8

Propionobacterium acne produces specific enzymes known as proteases that can lead to ductal rupture The contents of the duct then enter into the dermis causing dermal inflammation

Question 9

Summarise the 4 main factors involved in the pathogenic mechanism of acne vulgaris

Answer 9

Duct occlusion (hyperproliferation + keratinocytes) + increased sebum production (androgens) causes microcomedome formation (closed-whitehead, open-blackhead) Increased sebum also increased bacterial colonisation of the duct - propiobacterium acne P. acne releases proteases that causes duct rupture leading to dermal inflammation

Question 10

What are the inflammatory lesions formed in acne vulgaris known as?

Answer 10

Inflammatory papules - small pink lump with no pus Pustules can form (lump with pus) Cysts and nodules can also form Image shows papulo-pusutular acne with atrophic scarring

Question 11

What are the different gradings of acne?

Answer 11

Mild acne - scattered papules and pustules - mainly facial comedomes

Moderate acne - numerous papules and pustules with mild atophic scarring

Severe acne - as above + cysts and nodules and significant scarring Image shows severe nodulo-cystic acne

Question 12

What are the two most important complications of acne?

Answer 12

Scarring usually following deep inflammatory lesions and Post-inflammatory hyperigmentation

Question 13

What are different aggravating factors of acne? What is acne excoriee?

Answer 13

Obesity - weight loss can decrease androgen and therefore decrease sebum production

Job - oily environment

Stress - acne excoriee - picker’s acne

Acne excoriée is a type of acne that is sometimes called picker’s acne because it occurs when the affected individual picks at the acne lesions.

This kind of acne is most often seen in teen girls. The picking exacerbates the acne and causes scars; the scarring leads to more acne and, ultimately, more picking.

Question 14

Acne of course produces a huge psychological impact What are some of the psychological impacts?

Answer 14

Shame

Embarrassment and anxiety

Lack of confidence

Impaired social contact

Employment difficulties

Question 15

What are the different management steps for acne? (not looking for specific names)

Answer 15

Mild acne - tropical treatment alone

Moderate acne - topical treatment and oral antibiotics or oral contraceptives

Severe acne - isotretinoin

Question 16

What are the topical treatments that can be offered as first line treatment of mild acne vulgaris? Why are topical antibiotics given in combination with another topical agenet?

Answer 16

Usually topical vitamin A derivatives (retinoids) eg adapalene or tretinoin or

Topical benzoyl peroxide

Topical antibiotic can also be co-prescribed - co-prescribe to prevent anti-bacterial resistance developing

Question 17

For people with moderate acne not responding to topical treatment, what can be considered to add?

Answer 17

Moderate acne - topical treatment should be continued and add *

Oral antibiotics or oral contraceptives

Question 18

What are the oral antibiotics that are considered? (which is preferred) How long must they be continued for? (if no side effects)

Answer 18

Oral tetracycline eg oxytetracycline or doxycline (ends in cycline) or

Macrolide eg erythromycin - give if contraindicated to tetracycline as have a higher incidence of P.acne bacterial resistance developing (use eg if pregnant or side effects from tetracycline)

Try the antibotics for roughly 4-6 months

Question 19

What are the different side effects of tetracyclines?

Answer 19

Tetracyclines side effects - photosensitivity, GI upset

Also can stain teeth so not given if <12 years

Question 20

Mild acne (mainly comedomes, some papules and pustules) - topical treatment with retinoid (adapelene or tretinoin) or benzoyl peroxide Moderate acne - add oral antibiotics (tetracyclines (macrolide - eryhtromycin if contraindicated) or oral contraceptives What is the type of oral contracetpive that may be given to woman? How does it help to treat acne?

Answer 20

Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women. - helpful in females who require contraception

Co-cyprindiol (eg Dianette) - increased oestrogen increased sex hormone binding globulin (SHBG) which decreases free androgen, also decreases anrogen production by adrenal glands - DECREASE SEBUM

Question 21

Mild acne (mainly comedomes, some papules and pustules) - topical treatment with retinoid (adapelene or tretinoin) or benzoyl peroxide Moderate acne - add oral antibiotics (tetracyclines (macrolide - eryhtromycin if contraindicated) or oral contraceptives (combined pill) What is the drug given for severe acne? What are the indications for its use?

Answer 21

Oral Isotretinoin Indications

* severe acne - nodulo-cystic scarring

* Inadequate response to conventional therpy

* Relapse after adequate antibitoics

* Significant scarring

* Severe psychological impairment eg body dysmmoprhia disorder

Question 22

What is the mechanism of action of isotretinoin (brand name - roaccutane)? What are the side effects? When should contraception be used?

Answer 22

Works by reducing sebaceous gland activity

Side effects

Dry skin, lips, eyes, nose Teratogenic - Hepatitis Hyperlipidaemia

Question 23

What are the contraceptive requirements for a female on isotretinoin?

Answer 23

use contraceptions for one month prior, during and for one month after treatment

Should use 2 contraceptives - eg combined pill and barrier protection

Question 24

ACNE ROSACEA - more commonly known as rosacea now What areas are typically affected? How is it distinct from acne? Who is affected and what age range?

Answer 24

Acne rosacea is a chronic, inflammatory skin condition that can affect the cheeks, nose, eyes, chin, and forehead.

It is distinct from acne as it is not a disease of the pilosebaceous unti - the patients have normal sebum excretion rates and no comedomes

Mainly affects adults, females and males (F>M)

Question 25

State again what areas are affected by rosacea? What are the clinical features of the disease?

Answer 25

Clinical features

Papules, pustules and erythema (telangiectasia and flushing) typically in the cheeks, nose, eyes, chin and forehead

Question 26

What is often seen in men where there is the swelling + soft tissue overgrowth of the nose in rosacea - skin disorder characterized by a large, red, bumpy or bulbous nose? What other complications may occur due to rosacea?

Answer 26

This would be rhinophyma

Permanent telangiectasia from repeated flushing and ocular inflammation

Question 27

What are the different triggers related to acne rosacea?

Answer 27

Prominent facial flushing exacerbated by sudden change in temperature - sunlight, stress, alcohol and spicy food

Question 28

The aetiology of acne rosacea is unknown but what is the type of parasite that it is thought to be potentially linked to?

Answer 28

Follicular demodex mite numbers are often noted to be increased - demodex folliculorum

Question 29

Rosacea management involves avoiding the different trigger factors What are the pharmacological treatment options? - for mild disease and if not responding eg in severe What may be given which can treat the demodex mites?

Answer 29

Treatment options usually begin with topical metronidazole

If not responding then try oral antibiotics usually a tetracycline (oxytetracecyline) (use erythromycin - macrolide- if pregnant) Isotretinoin can be given if severe

Demodex mites may respond to topical ivermectin

Question 30

What may be given to treat the telangiectasia or rhinophyma?

Answer 30

Laser treatment may be required - this is rare