Chapter 7: Acne, Rosacea, and Related Disorders Flashcards
(128 cards)
1
Q
What are the classifications of acne lesions
A
Acne lesions were divided into inflammatory and noninflammatory lesions
2
Q
What are the types of noninflammatory acne lesions
A
Open comedones
closed condomes
3
Q
What are the types of inflammatory acne lesions
A
Papules
Pustules
Nodules
4
Q
For mild comedonal acne what should the treatment begin with?
A
Topical retinoid
adaption in 4 to 8 weeks consider adding topical antibacterial
-benzoyl peroxide
5
Q
For mild papular pustular acne what should the treatment begin with?
A
Start with retinoid or topical antibacterials or both
- consider adding oral antibiotic for three month trial
6
Q
What is the treatment for moderate papular pustular acne?
A
Start with topical antibacterials (drying therapy) maximum effect at eight weeks then add retinoid if acne not controlled
7
Q
What is the treatment for severe papular pustular or nodular acne or long history of acne treatment or scarring?
A
Accutane
8
Q
What is the first-line treatment for acne?
A
Retinoids
9
Q
What is tazarotene?
A
Second line treatment for all types of acne because of greater expense, irritation.
10
Q
What are the topical retinoids?
A
Tretinoin
Adapalene
Tazarotene
salicylic acid (has retinoid properties)
11
Q
What are the topical antibacterials, antibiotics, and anti-inflammatory drugs Used for acne?
A
Benzoyl peroxide clindamycin phosphate erythromycin Dapsone Sulfur-sulfacetamide sodium Azelaic Acid
12
Q
What are some oral antibiotics used for acne?
A
Tetracycline doxycycline Minocycline Erythromycin Azithromycin Ampicillin or Amoxicillin sulfamethoxazole trimethoprim
13
Q
What oral contraceptive drugs and hormonal therapy are beneficial in treatment of acne?
A
Norethindrone-Acetate ethyinyl estradiol
Norgestimate-ethinyl estradiol
Spriranolactone
Prednisone
14
Q
What are the oral retinoids?
A
Isotretinoin
15
Q
How does acne begin in predisposed individuals?
A
When sebum production increases. Propionibacterium acnes proliferates in sebum, and the follicular epithelial lining becomes altered and forms plugs called comedones.
16
Q
How do antibiotics work in prevention of inflammation?
A
Prevent neutrophil chemotaxis
17
Q
What are Fordyce spots
A
Cluster of sebaceous glands (tiny, white-yellow spots) normally present on the Vermillion border, Buccal mucosa, female areolae (Montgomery’s tubercles), the labia minora, the prepuce, and around the anus.
18
Q
How does testosterone affect acne?
A
Testosterone is converted to dihydrotestosterone in the skin and acts directly on the sebaceous gland to increase in size and metabolic rate
19
Q
What effect does estrogen have an acne?
A
Decrease sebaceous glands secretion.
20
Q
Where are sebaceous glands located?
A
Located throughout the entire body except the palms, soles, dorsum of the foot, and lower lip.
21
Q
What is retention keratosis?
A
Cornified cells remained adherent to the follicular canal directly above the opening of the sebaceous gland to form a plug (microcomedo)
22
Q
Is P. Acnes normal skin flora?
A
Yup
23
Q
How does P. Acnes affect inflammation?
A
Lipases, proteases, hyaluronidase, and chemotactic factors are produced by P. acnes.
24
Q
What is the effect of chemotactic factors for inflammation with acne?
A
Chemotactic factors attract neutrophils to the follicular wall. Neutrophils elaborate hydrolases that weaken the wall. The wall thins, becomes inflamed (red papule), and ruptures, releasing part of the comedone into the dermis.
25
Is acne inherited disease?
Yes. Acne does not end at age 19 but can persist into a person's 40s. Many women have their first episode after age 25.
Acne can be controlled, but not cured.
26
How does diet affect acne?
History suggests that high glycemic carbohydrates (bread, bagels, donuts, crackers, candy, cake, chips), those that substantially boost blood glucose levels, trigger a series of hormonal changes that cause acne
Milk has also been implicated as possibly increasing acne severity
27
What is the clinical presentation Comedonal acne?
The earliest type of acne is usually noninflammatory comedones. There are no inflammatory lesions because colonization with P. acne's has not yet occurred
28
What is the initial treatment for comedonal acne?
Retinoids are applied at bedtime
Tazorac may be most effective and most irritating. Start with a low concentration of the cream or gel and increase the concentration of irritation does not occur
29
What is mild inflammatory acne?
Mild pustular and papular inflammatory acne is defined as fewer than 20 pustules.
30
What is the treatment for mild inflammatory acne?
Benzoyl peroxide, topical antibiotic, or combination medicine and the retinoid are initially applied on alternate evenings.
31
What is moderate to severe inflammatory acne?
More than 20 pustules
Temporarily disfiguring
32
What is the treatment for moderate to severe inflammatory acne
Topical retinoid and combined with a topical antibiotic.
| – Patients using drying agents should adjust the frequency of application to induce a mild, continuous peel.
33
What a severe nodulocystic acne
Localized cystic acne (few cysts on face, chests, or back) diffuse cystic acne (wide areas of the face, chest, and back)
34
What is pyoderma faciale
Inflamed cysts localized on the face in females
35
What is acne conglobota?
Highly inflammatory, with cysts that communicate under the skin, abscesses, and burrowing sinus tracks
36
What is the treatment for cystic acne?
Oral antibiotics, conventional topical therapy, and periodic intralesional Kenalog injections may keep this problem under adequate control.
37
What are the three less common variants of cystic acne?
Pyoderma faciale
acne Fulminans
acne conglobota
38
Who is affected by pyoderma faciale?
Adult women ranging in age from the teens to the 40s.
39
What is the treatment for pyoderma faciale?
Treatment was begun with prednisone (1 mg/kg daily for one to two weeks)
Isotretinoin was then added (0.2 to 0.5 mg/kg/day)
Slow tapering of the corticosteroid of the following 2 to 3 weeks
40
What is acne fulminans?
Acne fulminans is a rare ulcerated form of acne of unknown etiology with an acute onset and systemic symptoms.
41
Who is most commonly affected by acne fulminans?
Adolescent white boys
42
What are the systemic symptoms associated with acne fulminans?
```
Arthralgias
severe muscle pain
painful bone lesions in 40% of patients
weight loss
fever
leukocytosis
elevated ESR
```
43
What is the treatment for acne fulminans
Antibiotic therapy is not effective.
Oral corticosteroids are the primary therapy.
Isotretinoin 0.5 mg/kg is started simultaneously and, as in the therapy of severe cystic acne, is continued for five months
44
What is the follicular occlusion triad syndrome?
Acne conglobota
hidradenitis supportiva
dissecting cellulitis of the scalp
45
What is acne conglobotta?
A chronic, highly inflammatory form of cystic acne in which involved areas contain a mixture of double comedones (two blackheads that communicate under the skin), papules, pustules, communicating cyst, abscesses, and draining sinus tracks.
46
What is a major difference between acne conglobota and acne fulminans?
There is no fever or weight loss as is seen in acne fulminans
47
What do most patients require for the treatment of nodulocystic acne?
Most patients will require the rapid introduction of isotretinoin
48
What are the four pathogenic factors responsible for the development of acne?
1. Hyperkeratinization
2. Increase testosterone levels
3. Bacterial colonization with P. Acnes
4. Inflammation
49
How do retinoids improve acne?
Retinoids reverse the abnormal patterns of keratinization seen in acne vulgaris.
50
What is the mechanism of action for retinoids?
Retinoids initiate increased cell turnover in both normal follicles and comedones and reduce the cohesion between keratinized cells
New comedone formation is prevented by continued use.
51
Why do retinoids make the skin more susceptible to sunburn?
Continual topical application leads to thinning of the stratum corneum, making the skin more susceptible to sunburn, sun damage, and irritation from wind, cold, or dryness.
52
What areas of the skin should be avoided by retinoids?
The corners of the nose, the mouth, and the eyelid should be avoided; these areas are the most sensitive and the most easily irritated.
53
What is the typical response to retinoid therapy?
3 to 6 weeks.
New papules and pustules may appear because comedones become irritated during the process of being dislodged.
54
How long should retinoid treatment be continued before being considered a treatment failure.
An alternate treatment should be selected of adaption has not occurred after eight weeks
55
What is differin?
Adapalene
Has tretinoin like activity in the terminal differentiation process of the hair follicle
Does not cause sun sensitivity
56
What is azelaic acid?
And naturally occurring compound that has antikeratinizing, antibacterial, and anti-inflammatory properties.
Effective for noninflammatory and inflammatory acne.
Does not cause sun sensitivity or significant local irritation.
57
What is the primary effects of benzoyl peroxide
Antibacterial And drying effect
Therefore it is most effective for inflammatory acne consisting of papules, pustules, and cysts
Drying varies from mild desquamation to scaliness, peeling, and cracking
Some comedones may respond
58
What percentage of patients have an allergy to benzoyl peroxide
2%
59
What is a major disadvantage of tetracycline?
The requirement the tetracycline must NOT be taken with food (in particular dairy products)
60
What is the dosing for tetracycline in the treatment of acne
Started 500 mg twice daily for 3 to 6 weeks, after significant reduction in inflamed lesions decrease dosage to 250 mg twice each day
61
What are some adverse effects of tetracycline
Photosensitivity
increased incidence of Candida albicans vaginitis
pseudotumor cerebri
Tooth staining produced by tetracycline occurs on the gingival third of the teeth in children treated before age 7
62
What is the dosing of doxycycline for the treatment of acne?
100 mg QD or BID
Decrease the dosage once control is obtained
63
Can doxycycline be taken with food?
Yes
64
What is dosing for minocycline?
The usual initial dosages 50 to 100 mg b.i.d.
The dosage can be tapered when a significant decrease in the number of lesions is as observed usually 3 to 6 weeks
65
Can minocycline be taken with food?
Inhibitory effect on gastrointestinal absorption with food and milk is significantly greater for tetracyclines than for minocycline.
27% inhibition for milk
13% inhibition for food
66
What are some adverse effects for minocycline?
Minocycline is highly lipid soluble and readily penetrates the cerebrospinal fluid causing dose related ataxia, vertigo, nausea and vomiting in some patients
May cause pseudo-tumor cerebri
```
Headache (75%)
transient visual disturbances (41%)
diplopia (41%)
pulsatile tinnitus (17%)
nausea and vomiting (25%)
```
A bluegray pigmentation of the skin, oral mucosa, nails, sclera, bone, and thyroid gland has been found in some patients, usually those taking high dosages of minocycline for extended periods
67
What can be used to treat gram-negative acne?
Ampicillin or amoxicillin
68
When should you consider gram-negative acne?
Consider gram-negative acne after prolonged antibiotics usage
69
Where's DHEAS produced?
Dehydroepiandrosterone is produced in the adrenal glands and converted to testosterone
70
How is DHT produced?
Testosterone is converted at target 5-alpha- reductase to dihydrotestosterone
71
What are the most important hormones in the pathogenesis of acne?
Androgens:
free testosterone
dehydroepiandrosterone sulfate
72
When should hormone test be ordered for evaluation of acne?
Women presenting with rapid onset (1-4 months) of acne, hirsutism, androgenetic alopecia, or signs of virilization, such as low voice, increased muscle mass, increased libido, or clitoromegaly, require screening to rule out a tumor.
73
What test should be ordered when evaluating hormonal induced acne?
```
Total testosterone and free testosterone
DHEAS
ACTH stimulation
prolactin
luteinizing hormone
follicle stimulating hormone
lipid profiles
glucose tolerance test
```
Total testosterone and free testosterone or the most practical ways of evaluating hormonal influence in the female
74
What is the treatment approach for hormonal acne?
Three options:
1. Estrogens
2. Anti-androgens
3. Glucocorticoids
75
What are the anti-androgen options for the treatment of acne?
Spironolactone
76
How does progesterone only hormonal therapy affect acne?
Progesterone only makes acne worse.
77
What are the side effects of oral contraceptive medications?
Increased risk of venous thromboembolism,
stroke
myocardial infarction
risks are increased in patients who smoke cigarettes or who have a history of hypertension, diabetes or migraine
Oral contraceptives may slightly increase the risk of developing breast cancer but have some protective effects against ovarian and endometrial cancer
78
What is the mechanism of action for spironolactone?
Spironolactone acts as an anti-androgen peripherally by competitively blocking receptors for dihydrotestosterone in sebaceous glands.
79
What is the dosage of spironolactone in the treatment of hormonally induced acne?
Spironolactone at a dosage of 200 mg per day suppresses Sebum production by 75% and can reduce lesion counts by up to 75% over a four-month period.
Typically should start with 25mg PO QD, and titration up.
80
What are the side effects of spironolactone?
Side effects are dose-related.
Menstrual irregularities (80%)
Gynecomastia
Breast tenderness or enlargement
decreased libido
Confusion, dizziness, GI disturbance
Electrolyte imbalances
81
How do corticosteroids help with acne?
Should be considered for patients with elevated DHEAS levels
Low-dose steroids administered at bedtime prevent the pituitary from producing extra ACTH and thereby reduce the production of adrenal androgens.
82
How should isotretinoin be dosed?
Total cumulative dose determined for Remission.
Total cumulative dose 120-150 mg/kg.
some studies suggest 220 mg/kg.
Daily dose is typically started at 0.5 then increase to 1 mg/kg
83
What are the indications for isotretinoin?
Severe, recalcitrant cystic or nodular inflammatory acne
Moderate acne unresponsive to conventional therapy
patients who scar
Excessive oiliness
Severely depressed or dysmorphobic patients
Sebaceous hyperplasia
84
How should isotretinoin be dosed for excessive oily patients.
Some patients respond to a long-term low dose regimen such as 10 mg every other or every third day
85
What is the typical duration of therapy for isotretinoin?
A standard course of isotretinoin therapy is 16 to 20 weeks
86
How many patients relapse from isotretinoin?
40%
Relapse usually occurs within the first three years after isotretinoin the stopped, most often during the first 18 months after therapy.
87
How is isotretinoin given?
Patients are seen every four weeks
Isotretinoin is given in two divided doses daily, preferably with meals.
Adverse reactions can be minimized by starting at 10 to 20 mg twice each day and gradually increasing the dosage during the first 4 to 6 weeks.
88
What laboratory studies are required for isotretinoin?
Pregnancy test
Triglyceride test
Complete blood cell counts
Liver function test.
89
What are the Most common side effects associated with isotretinoin?
Side effects are frequently dose-dependent and reversible after discontinuing.
Mucus/skin effects
Elevated triglyceride levels
Musculoskeletal effects
Headaches
Elevated liver enzyme levels
Amenorrhea
90
Which patients are typically at risk for gram-negative acne?
Patients with a long history of treatment with oral antibiotics for acne have an increased carriage rate of gram-negative rods in the interior nares.
91
What bacteria are associated with gram-negative acne?
```
Escherichia aerogenes
Proteus mirabilis
Klebsiella pneumoniae
Escherichia coli
Serratia marcescens
```
92
What is typically used to treat gram-negative acne?
Bactrim or Septra
-high relapse rate
Isotretinoin at 1 mg/kg/day for 20 weeks is successful for resistant cases of gram-negative acne.
93
What is steroid acne?
In predisposed individuals, sudden onset of follicular pustules and papules may occur 2 to 5 weeks after starting oral corticosteroids.
Steroid -induced acne is rare before puberty and in the elderly
94
What is neonatal acne?
Acneiform lesions confined to the nose and cheeks may present at birth or may develop an early infancy.
Lesions make clear without treatment as the large sebaceous gland stimulated by maternal androgens become smaller and less active.
95
What is infantile acne?
Infantile acne is uncommon
Age of onset is 6 to 16 months.
Patients with mild acne respond to topical treatment (benzyl peroxide and retinoids). Most infants with moderate acne respond to oral erythromycin 125 mg twice daily and to topical therapy.
96
What is occupational acne?
An extensive, diffuse irruption of large comedones and pustules may occur in some individuals who are exposed to certain industrial chemicals.
97
What is acne mechanica?
Mechanical pressure may induce an acneiform eruption
98
What is acne cosmetica?
Closed and open comedones, papules, and pustules may develop and post adolescent women who regularly apply layers of cosmetics.
99
What is excoriated acne?
Most acne patients attempt to drain comedones and pustules with moderate finger pressure.
Broad red erosions with adherent crust or obvious signs of manipulation and can easily be differentiated from resolving papules and pustules.
100
What are senile comedones?
Excessive exposure to sunlight and predisposed individuals calls large open and closed comedones around the eyes and on the temples.
After treatment with retinoids, lesions that recur can be effectively be treated with a 2 mm curette.
The skin is helped taught and the comedone is lifted out of a quick flick of the wrist. It Is important to go deep enough to remove the entire lesion. Bleeding is controlled with Monsel's solution.
101
What are milia?
Tiny whites pea shaped cysts that occur on the face particular around the eyes.
They are derived from the lowest portion of the infidibulum of velous hairs.
Secondary milia may occur secondary to injury to the skin.
Milia have no opening to the skin and can not be extracted like black heads. However, may be extracted with a number 11 blade tip
102
What is acne surgery?
Acne surgery is the manual removal comedones and the drainage of pustules and cysts.
103
What are the instruments used for acne surgery?
The round loop comedones extractor
The oval loop acne extractor (Schamberg extractor)
Number 11 pointed tip scalpel blade
104
What are the types of acne scars?
Ice pick
Rolling
Boxcar
105
When should scar revision therapy begin?
Generally, it is advisable to wait until disease activity has been low or absent for several months.
106
What is perioral dermatitis?
Occurs in young women and resembles acne
Papules and pustules on erythematous and sometimes scaling base are confined to the chin and nasolabial folds while sparing a clear zone around the Vermillion border
Perioral dermatitis occurs in an area where drying agents are poorly tolerated; topical preparations such as benzyl peroxide, tretinoin, and alcohol-based antibiotic lotions aggravate the irruption
107
What is the pathogenesis of perioral dermatitis?
Unknown
Precipitated by the habitual, regular, and abundant use of moisturizing creams. Results in persistent hydration of the horny layer, impairment of barrier function, and proliferation of the skin for a period
108
What is the treatment for perioral dermatitis?
Perioral dermatitis uniformly responds in 2 to 4 weeks to 1 g per day of tetracycline or erythromycin.
Doxycycline 100 mg once or twice daily is also effective.
109
What causes acne rosacea flares?
Sun exposure may exacerbate condition.
Alcohol may accentuate erythema, but not cause the disease.
Hot drinks of any type should be avoided
110
What are the cardinal features of acne rosacea?
Erythema and edema, papules and pustules, and telangectasias
111
What is the treatment for rosacea?
Oral antibiotics and isotretinoin
– Both the skin and eye manifestations of rosacea respond to doxycycline (100 to 200 mg/day)
– Isotretinoin and 0.5 mg/kg/day for 20 weeks was effective in treating severe, refractive rosacea
112
What is the treatment for mild rosacea?
Topical therapy
Patients with mild, moderate, or severe rosacea may respond to 0.75% metronidazole (MetroGel) applied twice each day or 1% metronidazole applied once each day.
113
What over-the-counter therapy can be used for acute flushing or persistent erythema?
Oxymetazoline (Afrin nasal spray)
114
What is the prevalence of ocular rosacea?
The prevalence in patients with rosacea is as high as 50%, with approximately 20% of his patients developing ocular symptoms before the skin lesions.
115
What problems are associated with ocular rosacea?
Patients with ocular rosacea have been reported to have sub normal tear production (dry eyes), and they frequently have complaints of burning that are out of proportion to the clinical signs of disease.
116
What is the treatment for ocular rosacea?
Doxycycline, 100 mg daily, will improve ocular disease and increased the tear breakup time.
117
What is the hallmark of hidradenitis Supportiva?
The double comedone
-A black head with two or sometimes several service openings that communicate under the skin.
118
Is HS curative?
Unlike acne, once the disease begins it becomes progressive and self-perpetuating.
The healing process permit alters the dermis
119
What is the pathogenesis of hidradenitis supportiva
Lesions begin with follicular hyper keratosis and comedone formation and progress to rupture of the follicular infidibulum, with inflammation of the surrounding dermis.
120
What is the follicular occlusion triad?
1. Acne conglobotta
2. Hidradenitis supportiva
3. Dissecting cellulitis of the scalp.
121
What is the management of hidradenitis supportiva
Antibiotics are the mainstay of treatment, especially for the early stages of the diseaseSuch as doxycycline 10 mg twice daily.
retinoin cream 0.5% may prevent duct occlusion, but it is irritating and must be used only as tolerated.
Isotretinoin may be effective in selected cases
Large cysts should be incised injury and, whereas smaller cells respond to intralesional injections of triamcinolone (Kenalog .5-10 mg/ml)
Weight loss helps to reduce activity.
Cigarette smoking has been identified as a major triggering factor.
122
What surgical options are available for hidradenitis supportiva?
Electro surgery: a loop electrode in the cut and coagulation mode is used to excise all the elevated skin and subcutaneous tissue to the level of subcutaneous fat tissue. The defect is left for secondary healing; suturing is not performed.
Surgical excision is at times the only solution. Primary closure results in a recurrence rate and up to 70% of patients
123
What is miliaria?
Heat rash
Eccrine sweat duct occlusion is the initial event. The duct ruptures, leaks sweat into the surrounding tissues, and induces an inflammatory response.
124
What causes the different types of miliaria?
Occlusion occurs at three different levels to produce three distinct forms of miliaria
125
What are the different types of miliaria?
1. Miliaria crystallina
2. Miliaria rubra
3. Miliaria profunda
126
What is miliaria crystallina?
Occlusion of the eccrine duct at the skin surface results in accumulation of sweat under the stratum corneum.
There is little or no erythema and the lesions are asymptomatic
127
What is miliaria rubra?
The most common of the sweat-retention diseases, results from the occlusion of the intra-epidermal section of the eccrine sweat duct.
Instead of itching, the irruption is accompanied by stinging or "prickling" sensation
The palms and soles are spared.
128
What is miliaria profunda?
Observed in the tropics in patients who have had several bouts of miliaria rubra.
