Flashcards in Acneiform Eruptions Deck (36)
Describe the epidemiology of acne vulgaris
• Experienced by 90% of teenagers
• 3.5million annual visits to GPs
• Caucasian males
What are the risk factors for acne vulgaris?
• XYY genotype
• Polycystic ovarian syndrome
What are the four stages in formation of acne vulgaris?
1. Early comedone
2. Later comedone
3. Inflammatory papule/pustule
What occurs in 1. early comedone in formation of acne vulgaris?
• Infundibulum hyperkeratosis
• Androgen stimulation of sebum secretion
What occurs in 2. later comedone in formation of acne vulgaris?
Accumulation of shed keratin and sebum (seborrhoea) as corneocyte which are usually expelled to the epidermis begin block the exit route, so sebum cannot exit
What occurs in 3. Inflammatory papule/pustule in formation of acne vulgaris?
• Propionibacterium acnes proliferation due to blockage
• Mild inflammation as surrounding tissue attracts inflammatory cells
What occurs in 4. Nodule/cyst in formation of acne vulgaris?
Marked inflammation and scarring (depends on how deep inflammation is)
Describe the presentation of mild acne vulgaris
• Open and closed comedones
• < 20 comedones
• < 15 inflammatory lesions
• Or, total lesion count < 30
What is a comedone?
Skin-coloured, small bumps (papules) frequently found on the forehead and chin of those with acne.
• Open -> blackheads
• Closed -> white heads
What are closed comedones (whiteheads)?
Small, skin coloured popular with no apparent follicular opening or associated erythema.
What are open comedones (blackheads)?
Dilated follicular outlet, black coloration due to melanin deposition and lipid oxidation within the debris
Describe the presentation of moderate acne vulgaris
• Inflammatory lesions: papules, pustules, nodules and cysts.
• 20–100 comedones
• 15–50 inflammatory lesions
• Or, total lesion count 30–125
Describe the comodones and lesions of moderate acne vulgaris
• Papules range from 1 to 5 mm in diameter
• Pustules tend to have the same size but are filled with sterile white pus.
• Nodules can be inflamed, indurated and tender.
• Cysts are deeper and filled with a combination of pus and serosanguineous fluid.
Early treatment to prevent scarring
Describe the presentation of severe acne vulgaris
• > 5 pseudocysts
• Total comedo count > 100
• Total inflammatory count > 50
• Or total lesion count > 125
• Permanent scar and post inflammatory pigmentation
Cysts - liquid and pus inside dermis --> not always visible but are palpable
What is fulminans?
Most severe form of cystic acne and is characterized by the abrupt onset of nodular and suppurative acne with systemic manifestations (fever, artralgias, myalgias, hepatosplenomegaly)
Name a causative bacteria of acne vulgaris
Propionibacterium acnes (gram pos. human skin commensal)
What is drug induced acnes?
Acneiform eruption due to a side effect of numerous medications (anabolic steroids, corticosteroids, phenytoin, lithium, isoniazid)
What is acne excoriee?
Papules and comedones are neurotically excoriated (damaging skin due to picking spots) leaving crusted lesions that may scar. Treat the head.
Acne itself not that bad, but excoriation causes post-inflammatory pigmentation
What is important in the history of acne?
• Sex and age
• Prev treatment
• Cosmetic usage
• Menstrual history
What is important in the examination of acne vulgaris?
• Skin type and colour
• Lesion morphology (comodones, papules, cysts)
• Post-inflammatory pigmentation
Give seven treatments used for acne vulgaris
• Topical retinoids (reduce amount of corneocytes produced)
• Benzoyl Peroxide (anti-inflam. and antiseptic) - first line
• Topical antibiotics (Clindamycin/Erythromycin)
• Azelaic acid (anti-inflam)
• Antibiotic tablets (Lymecycline, Tetracyclin) - first line oral treatment
• In women, the combined oral contraceptive pill
• Isotretinoin tablets (reduces production of sebum) - last resort as teratogenic so can't get pregnant
What is rosacea?
Rosacea tends to affect the cheeks, forehead, chin and nose, and is characterised by persistent redness caused by dilated blood vessels, small bumps and pus-filled spots similar to acne
Describe the epidemiology of rosacea
• Most common in fair-skinned individuals
• Third and fourth decades of life (40 + 60yrs)
What is the pathogenesis of rosacea?
• Cause uncertain
• No seborrhoea
• Damage to dermal connective tissue
• Sensitivity to noxious stimuli increased
• Increased number of demodex folliculorum
What is demodex folliculorum?
Microscopic mite that can only survive on the skin of humans
What are the clinical features of rosacea?
• Affects central convey areas (nose, forehead, cheeks, chin)
• Vascular changes - episodic flushing, no sweat
• Erythema with burning sensation (triggered by stress, hot drinks, alcohol, spice)
• Papules and pustules, NO COMEDONES
• Persistent tissue thickening due to oedema, fibrosis and glandular hyperplasia
What are the features of vascular rosacea?
• Recurrent blush
• Telangiectasia (initially in nasal area)
What are the features of inflammatory rosacea?
• Small papules and pustules to occasional deep cystic nodules
• Absence of comedones
• Deeper red colour when compared to acne
• Soft or solid facial oedema
What are the features of phymatous rosacea?
• Overgrowth of sebaceous glands
• Skins becomes swollen and smoother - pore more apparent
• Lumpy surface
What are the features of ocular rosacea?
Symptoms range from a sensation of dryness or tired eyes to edema, tearing, pain, chalazia and corneal damage.
• Common; 50% of rosacea
What is the treatment of rosacea?
• Avoidance of obvious vasodilators and irritants
• Metronidazole cream or gel (topical)
• Tetracyclines (oral med)
• Surgery for rhinophymas (large, red, bumpy or bulbous nose)
• Azelaic acid cream or gel
• Ivermectin cream
Why can rosacea be difficult to treat?
As vasodilation unresponsive to topical or systemic therapy
How does acne vulgaris typically present in teenagers?
Lesions on forehead, nose and cheek
How does acne vulgaris typically present in adults?
Lesions of chin, neck and some on chest
• Usually irregular menstrual cycle
How does acne vulgaris typically present in infants?
Lesions on cheek but asymptomatic
• Reaction to hormones during pregnancy, presents 2-4weeks old but are different to teenagers as they will clear up themselves