Acneiform Questions

Question 1

What does acne consist of, and where is it normally found?

Answer 1

Consists of comedones, papules, pustules and nodules

Commonly found on the face, chest & back (where pilosebaceous units are common)

Question 2

At what age does acne commonly present?

Answer 2

(commonly starts during puberty) due to an overactivity of oil glands

**concern for an androgenic tumor if severe acne is present at a young age (under 8 y/o, not including newborns)

Question 3

What is the pathophysiology of acne?

Answer 3

(Chronic inflammatory condition driven by a hormonal component)
A combination of overactive oil glands and disruption of skin shedding will clog pores/collect bacteria (C. acnes)
The bacteria will cause inflammation which results in acneiform lesions

Question 4

What is classified as mild acne?

Answer 4

Few papules, pustules, comedones
-limited (small in # and size)
-no nodules or scarring

Question 5

What is classified as moderate acne?

Answer 5

Many papules, pustules, comedones
-more spread, more of a combination of all 3
-occasionally mild cystic/scarring (but NO PITTED scarring)

Question 6

What is classified as severe acne?

Answer 6

Excessive papules, pustules, nodules
-deep pitted scarring
-many locations or just one severe location
(Genetics can also play a factor here)

Question 7

What is papulopustular acne?

Answer 7

(papulo-) Papules and/or (-pustular) pustules

Question 8

What is comedonal acne?

Answer 8

Open comedones (blackheads) and closed comedones (skincolored fine bumps, hard to pop unlike papules/pustules)

Question 9

What is nodulocystic acne?

Answer 9

deep inflammatory lesions throughout the face

Question 10

What does acne treatment depend on?

Answer 10

type and severity
also location, motivation of patient, cost/insurance

Question 11

What are the topical treatments for mild-moderate acne?

Answer 11

Benzoyl Peroxide: reduces C.acnes (may cause redness/dryness and may cause bleaching of fabrics)

Topical Antibiotics (clindamycin): prevent growth of bacteria/anti-inflammatory (redness and dryness/ resistance possible, can cause C-diff if ingested)

Aczone Gel (topical dapsone): 12 years and over (adult female acne)

Retnoids (differin): increased cell turnover good for comedonal acne (irritation/dryness, thinning of skin can cause greater chance of sun burn)

Question 12

What are the treatments for moderate-severe acne?

Answer 12

-topicals used for mild-moderate also used here
-antibiotics are temporary (should not be used long term)
Oral antibiotics: (decrease bacteria C. acnes/anti-inflammatory), commonly the tetracyclines
**avoid pregnancy
**side effects: vomiting/nausea/diarrhea/vertigo, rash
If cycline antibiotics: may cause grey staining of teeth/skin

Question 13

What are some hormonal treatments for acne?

Answer 13

Combination birth control pills (estrogen-progesterone): oil gland inhibition
**risks for stroke, heart attacks, blood clots (ask about smoking, etc.)

Spironolactone: blocks androgen receptors
**nausea, vomiting menstrual irregularities, breast tenderness
**BLACK BOX WARNING: NO PREGNANCY

Question 14

What are important patient education points for acne?

Answer 14

There is no cure, adherence is needed to see a difference (may take 6 weeks), limit picking, cleansing regimen, adjusting diet/skincare if necessary

Discoloration scarring will go away over time, pitted scarring will be permanent

Question 15

When would you consider isotretinoin (accutane) as a treatment for acne?

Answer 15

If patient has severe nodulocystic acne as a last resort treatment, it will dry up oil glands
Generally monotherapy over 6 months, not using any other forms of treatment
-causing dryness & many other risky side effects
-Testing requirements: Serum HCG, Urine HCG, LFT, Cholesterol, triglycerides
**CATEGORY X BLACK BOX WARNING: NO PREGNANCY, IPLEDGE/CONSENT FORMS REQUIRED

Question 16

What are other treatment options for acne?

Answer 16

Chemical peels, laser, microdermabrasion, light therapy, natural remedies, OTC, IL/oral steroids (few days of oral steroids for a brief clearing of acne for a wedding/prom)

Question 17

What is rosacea?

Answer 17

A chronic and inflammatory vascular condition, where exposure to triggers causes vasculature to flush&blush (usually centrofacial) , common in fair-skinned adults

Question 18

What are the signs/symptoms of rosacea?

Answer 18

Acneiform lesions, erythema (flushing or constant), telangiectasia (blood vessels), burning/fire sensation, tenderness

Can be occular: blepharitis/keratitis (feeling of sand/grittiness in eye)

**often confused with lupus clinically (lupus butterfly rash is more purple/raised)

Question 19

What are the topical treatments for rosacea?

Answer 19

*** AVOID TRIGGERS, care for skin gently with cleansers, sun care, moisturizer

Topical antibiotics (metronidazole, clindamycin, sodium sulfacetamide)

Avoiding benzoyl peroxide (irritating and drying)
Topical retnoid (azaleic acid), can burn but tolerance will build

Mirvaso/Rhofade: topical vasoconstrictor (cosmetic, short relief-12 hrs, be cautious when applying-blood flow in hands/fingers may be compromised, flares may be worse after these wear off)

Question 20

What are the oral/other treatments for rosacea?

Answer 20

Oral doxycycline - low/anti-inflammatory dose (occular rosacea responds well to oral antibiotics)

Laser treatment for telangiectasia
Makeup (green camouflages red)
isotretinoin (when unresponsive to other treatment)

Question 21

What is Rhinophyma?

Answer 21

A complication of rosacea usually from delay/non treatment that results in tissue thickening of the nose which can block breathing
Can be removed by Co2 laser/hot loop cautery, and management of rosacea to prevent reoccurrence

Question 22

What triggers rosacea?

Answer 22

Temperature extremes, stress, spicy foods, alcohol (red wine sulfites) sun exposure, *triggers can be individual to each patient

Question 23

What causes steroid induced acne/rosacea?

Answer 23

When the inappropriate strength of steroids are given and used on the face (class I-III)

Question 24

What is folliculitis?

Answer 24

Inflammation of the hair follicle (which can either be infectious or non-infectious)

Question 25

What causes folliculitis?

Answer 25

Occlusion, scratching, shaving (hair will get stuck when regrowing in follicle and become inflamed)

Question 26

What are the clinical features of folliculitis?

Answer 26

follicular pustules, follicular erythematous papules/nodules, occurs in hair bearing skin (not palms/soles), pain and pruritis possible

If bacterial: usually caused by staph aureus

Question 27

How is folliculitis diagnosed?

Answer 27

Bacterial culture to determine if infectious/non-infectious, this should be taken if there is an atypical presentation, severe case, or if not responding to treatment (resistant bacteria)

**consider a nasal swab for recurrent/resistant cases

Question 28

What is the treatment for folliculitis?

Answer 28

mild cases usually self-resolve

Topical antibiotics like Mupirocin/Clindamycin

Oral antibiotics for extensive involvement (cephalexin, TMP sulfs/clindamycin if MRSA)

Question 29

What are the subtypes of folliculitis?

Answer 29

Hot tub folliculitis: pseudomonas grows in hot tub water (distribution will be in body parts exposed to hot tub)
Folliculitis barbae: occurs in shaving distribution (ex. beard line in men)