What are the four main factors in the development of acne?
-Sebaceous gland hyperplasia (especially via androgen)
-Abnormal follicular desquamation
-Proprionobacterium acne colonization
What is a microcomedo?
Non-inflammatory comedones, which are small, below the surface clots below the surface of the skin which then progress into blackheads (open) or whiteheads (closed), which are non-inflammatory comedones
What happens to blackheads and whiteheads?
These trap debris and become inflammatory and turn into papules, nodules, cysts, etc.
What are some topical treatments of acne?
-OTC: Benzoyl peroxide or salicylic acid
Prescription: Antimicrobials, retinoids
Which is more effective, benzoyl peroxide or salicylic acid?
How does Benzoyl peroxide work?
Multiple MOA: killes P. acnes and mildly comedolytic and anti-inflammatory
Benzoyl peroxide is typically used in combination with ______.
T or F. Benzoyl peroxide limits development of P. acnes ABX resistance
What are the AEs of Benzoyl peroxide?
well-tolerated, but can get irritation, bleaching of fabric, and rarely allergic contact dermatitis
What are some topical ABX for acne?
Clindamycin and erythromycin (these have some anti-inflammatory effects- primary reason for use)
T or F. Topical ABX are not recommended for monotherapy for acne
T. This tends to increase ABX-resistance and these are not comedolytic so not that effective
How should topical ABX be used in acne?
Add topical BP or use a combo product
How do topical retinoids work?
The 1st line therapy for acne lately (and preferred for maintenance), and work by normalizing follicular desquamation (Comedolytic), anti-inflammatory, and enhance penetration of other compounds by getting rid of dead layers of skin
What are some topical retinoid options?
-Adapalene (milder and better tolerated)
-Tazarotene (more for severe, do not give in pregnancy)
What are systemic ABX given for acne?
These are more for cases of moderate to severe *inflammatory* acne (most are not FDA approved for acne except Solodyn (minocycline)
the goal is maintenance with a topical (want to work people off PO ABX in 3-6 months)
Preferred systemic ABX for acne? over 8 yo
Tetracycline, Doxy, Mino
What are some AEs of systemic tetracycline?
GI upset, tooth staining
What are some AEs of systemic Doxycycline?
What are some AEs of systemic Minocycline?
dyspigmentation, lupus-like rxns, SJS, pseudotumor cerebri, DHS
When are oral contraceptives used for acne?
consider for females with moderate to severe acne with flares around menstration cycles
How do OCs help in acne?
they have an anti-androgen effect to suppress sebum production
When are oral retinoids indicated (Isotretinoin)?
severe, scarring, and refractory acne
How does Isotretinoin work?
*affects all four main factors of acne production* (decreases size/activity of sebaceous glands, normalizies follicular keratinization, inhibits P. acnes, anti-inflammatory)
What are some common AEs of oral retinoids?
-dry lips, skin, eyes
What are some rarer, more severe AEs of oral retinoids?
-depression, suicidal ideation
-increased risk of fractures, epiphyseal closure
-IBD (UC over CD)
How should MILD comedonal acne be treated (typically pre-adolescent acne)?
How should mild inflammatory acne be treated?
topical retinoid+ topical ABX
How should moderate inflammatory acne be treated?
topical retinoid + topical ABX + oral ABX
How should SEVERE inflammatory acne be treated?
Minimal scarring: topical retinoid + topical ABX + oral ABX
Basic skin care during acne treatment
-Gentle cleansing 1-2x day
-Mild, fragrance-free cleanser
-oil-free moisturizer with SPF 30+ bid
-avoid OTC acne washes and topicals during treatment (too irritating)
Myths of acne
-Acne is NOT caused by poor hygiene or diet
-diet controversial (high glycemic index may lead to hyperinsulinemia and stimulate androgen synthesis
-milk may actually be problematic
When to refer to a dermatologist?
-severe acne (cysts, nodules)
-no response to treatment after 12 weeks
-if systemic ABX needed over 1yr
-acne assoicated with a systemic disease
What is the patient pop for rosacea?
This is a relapsing and remitting problem common in women over 30 with fair skin
What things contribute to rosacea?
What are some triggers of rosacea?
sunlight, exercise, hot/cold, stress, foods, alcohol
What are the four types of rosacea?
-Phymatous (swelling- can lead to a large nose)
What are some topical treatments for rosacea?
-metronidazole (more anti-inflammatory)
-sodium sulfacetamide with sulfur
Other treatments for rosacea?
-laser, surgery, IPL (intense pulse light)
What is perioral dermatits (aka periorificial)
Variant of rosacea that affects primarily women 20-45 yrs (and some prepubertal children)
Triggers for perioral dermatitis?
-Hx of topical steroid use in that area
-Candida, demodex mites
How does perioral dermatitis present?
rash or 'pimples' around mouth or nose, eyes, labia rarely
How is perioral dermatitis treated?
-dincontinue topical steroids
Mild: Topical ABX (Metrocream)
Severe: PO ABX
and may need topical non-steroidal anti-inflammatory
What is folloculitis?
Common sequlae of Staph aureus, Strep, or Pseudomonas infection
What is a fungal cause of folliculitis?
Other causes of folliculitis?
-Mechanical (areas of friction)
-eosinophilic folloculitis (common in HIV or transplant patients with immunosuppresstants)
How is folliculitis treated?
or topical ABX/antifungals
What is Hidradenitis suppurativa (HS)?
condiition affecting apocrine gland bearing areas (commonly in the axillary, inguinal, underneath the breasts, and other body folds) commonly affecting women more than men
What are some risk factors for HS?
How is mild HS treated?
topical and/or oral ABX to suppress inflammation
How is moderate to severe HS treated?
injected steroids, TNFa inhibitors, surgery