Acne and Rosacea

Question 1

What are the four main factors in the development of acne?

Answer 1

• Sebaceous gland hyperplasia (especially via androgen)
• Abnormal follicular desquamation
• Proprionobacterium acne colonization
• Inflammation

Question 2

What is a microcomedo?

Answer 2

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

Question 3

What happens to blackheads and whiteheads?

Answer 3

These trap debris and become inflammatory and turn into papules, nodules, cysts, etc.

Question 4

Question 5

What are some topical treatments of acne?

Answer 5

-OTC: Benzoyl peroxide or salicylic acid

Prescription: Antimicrobials, retinoids

Question 6

Which is more effective, benzoyl peroxide or salicylic acid?

Answer 6

Benzoyl peroxide

Question 7

How does Benzoyl peroxide work?

Answer 7

Multiple MOA: killes P. acnes and mildly comedolytic and anti-inflammatory

Question 8

Benzoyl peroxide is typically used in combination with ______.

Answer 8

retinoids

Question 9

T or F. Benzoyl peroxide limits development of P. acnes ABX resistance

Answer 9

T.

Question 10

What are the AEs of Benzoyl peroxide?

Answer 10

well-tolerated, but can get irritation, bleaching of fabric, and rarely allergic contact dermatitis

Question 11

What are some topical ABX for acne?

Answer 11

Clindamycin and erythromycin (these have some anti-inflammatory effects- primary reason for use)

Question 12

T or F. Topical ABX are not recommended for monotherapy for acne

Answer 12

T. This tends to increase ABX-resistance and these are not comedolytic so not that effective

Question 13

How should topical ABX be used in acne?

Answer 13

Add topical BP or use a combo product

Question 14

How do topical retinoids work?

Answer 14

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

Question 15

What are some topical retinoid options?

Answer 15

• Adapalene (milder and better tolerated)
• Tretinoin
• Tazarotene (more for severe, do not give in pregnancy)

Question 16

What are systemic ABX given for acne?

Answer 16

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)

Question 17

Preferred systemic ABX for acne? over 8 yo

Answer 17

Tetracycline, Doxy, Mino

Question 18

What are some AEs of systemic tetracycline?

Answer 18

GI upset, tooth staining

Question 19

What are some AEs of systemic Doxycycline?

Answer 19

photosensitivity, esophagitis

Question 20

What are some AEs of systemic Minocycline?

Answer 20

dyspigmentation, lupus-like rxns, SJS, pseudotumor cerebri, DHS

Question 21

When are oral contraceptives used for acne?

Answer 21

consider for females with moderate to severe acne with flares around menstration cycles

Question 22

How do OCs help in acne?

Answer 22

they have an anti-androgen effect to suppress sebum production

Question 23

When are oral retinoids indicated (Isotretinoin)?

Answer 23

severe, scarring, and refractory acne

Question 24

How does Isotretinoin work?

Answer 24

*affects all four main factors of acne production* (decreases size/activity of sebaceous glands, normalizies follicular keratinization, inhibits P. acnes, anti-inflammatory)

Question 25

What are some common AEs of oral retinoids?

Answer 25

- dry lips, skin, eyes - nosebleeds, - muscles aches - mild HA

Question 26

What are some rarer, more severe AEs of oral retinoids?

Answer 26

- teratogenic - depression, suicidal ideation - increased risk of fractures, epiphyseal closure - IBD (UC over CD)

Question 27

How should MILD comedonal acne be treated (typically pre-adolescent acne)?

Answer 27

topical retinoid

Question 28

How should mild inflammatory acne be treated?

Answer 28

topical retinoid+ topical ABX

Question 29

How should moderate inflammatory acne be treated?

Answer 29

topical retinoid + topical ABX + oral ABX

Question 30

How should SEVERE inflammatory acne be treated?

Answer 30

Minimal scarring: topical retinoid + topical ABX + oral ABX Scarring: Isotretinoin

Question 31

Basic skin care during acne treatment

Answer 31

- 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)

Question 32

Myths of acne

Answer 32

- 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

Question 33

When to refer to a dermatologist?

Answer 33

- severe acne (cysts, nodules) - no response to treatment after 12 weeks - if systemic ABX needed over 1yr - acne assoicated with a systemic disease

Question 34

What is the patient pop for rosacea?

Answer 34

This is a relapsing and remitting problem common in women over 30 with fair skin

Question 35

What things contribute to rosacea?

Answer 35

- Inflammation - Demodex folliculorum - genetics - vascular abnormalities - triggers

Question 36

What are some triggers of rosacea?

Answer 36

sunlight, exercise, hot/cold, stress, foods, alcohol

Question 37

What are the four types of rosacea?

Answer 37

- Erythematotelangiectatic - Papulopustular - Phymatous (swelling- can lead to a large nose) - Ocular

Question 38

Rosacea

Question 39

What are some topical treatments for rosacea?

Answer 39

- metronidazole (more anti-inflammatory) - azelaic acid - sodium sulfacetamide with sulfur

Question 40

Other treatments for rosacea?

Answer 40

- PO tetracycline - laser, surgery, IPL (intense pulse light)

Question 41

What is perioral dermatits (aka periorificial)

Answer 41

Variant of rosacea that affects primarily women 20-45 yrs (and some prepubertal children)

Question 42

Triggers for perioral dermatitis?

Answer 42

- Hx of topical steroid use in that area - menstruation, pregnancy - stress - fluorinated toothpaste - Candida, demodex mites

Question 43

How does perioral dermatitis present?

Answer 43

rash or 'pimples' around mouth or nose, eyes, labia rarely

Question 44

How is perioral dermatitis treated?

Answer 44

-dincontinue topical steroids Mild: Topical ABX (Metrocream) Severe: PO ABX and may need topical non-steroidal anti-inflammatory

Question 45

What is folloculitis?

Answer 45

Common sequlae of Staph aureus, Strep, or Pseudomonas infection

Question 46

What is a fungal cause of folliculitis?

Answer 46

Pityrosporum orbiculare

Question 47

Other causes of folliculitis?

Answer 47

- Mites (demodex) - Mechanical (areas of friction) - eosinophilic folloculitis (common in HIV or transplant patients with immunosuppresstants)

Question 48

Question 49

How is folliculitis treated?

Answer 49

-antibacterial soaps/washes or topical ABX/antifungals

Question 50

What is Hidradenitis suppurativa (HS)?

Answer 50

condiition affecting apocrine gland bearing areas (commonly in the axillary, inguinal, underneath the breasts, and other body folds) commonly affecting women more than men

Question 51

What are some risk factors for HS?

Answer 51

Obesity Cigs Fam Hx

Question 52

HS

Question 53

How is mild HS treated?

Answer 53

topical and/or oral ABX to suppress inflammation

Question 54

How is moderate to severe HS treated?

Answer 54

injected steroids, TNFa inhibitors, surgery