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Dermatology > Disorders of Sebaceous and Apocrine Glands > Flashcards

Disorders of Sebaceous and Apocrine Glands Flashcards

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1
Q

What is acne vulgaris?

A

Self-limited chronic inflammation of pilosebaceous unit

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2
Q

Pathogenesis of acne vulgaris

A
  1. Increased sebum production
  2. Follicular hyperkeratinization
  3. Proliferation of Cutibacterium acnes
  4. Inflammation

Typically beginning at puberty due to androgen stimulation of pilosebaceous unit and changes in keratinization at follicular orifice

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3
Q

Components of acne

A
  • Follicular plugging = blocks sebum drainage
  • Stimulation of sebaceous glands
  • Overgrowth of c. acnes
  • Inflammatory response
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4
Q

Where is acne vulgaris most commonly found?

A
  • Skin with high density of sebaceous follicles
  • Face, back, upper chest, neck, arms
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5
Q

What sex has more acne? Race?

A
  • Women > men in adulthood
  • No racial predilection
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6
Q

What medications can cause acne?

A

Corticosteroids, systemic or topical
Anabolic steroids

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7
Q

What are characteristic acne lesions

A
  • Open comedones (blackheads)
  • Closed comedones (whiteheads, noninflammatory base)
  • Erythematous inflammatory papules
  • Pustules
  • Nodules and cysts –> scarring, pitted or hypertrophic
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8
Q

Where do adult women most commonly get acne?

A

Deep-seated, tender red papules along mandibular jaw

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9
Q

What is the appearance of drug-induced acneiform eruptions?

A
  • Monomorphic inflammatory papules and pustules rather than open and closed comedones
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10
Q

What are etiological factors of acne in women?

A
  • Touching
  • Rubbing
  • Over-cleansing face with numerous products
  • Wearing cosmetics
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11
Q

What are etiological factors of acne in men?

A
  • Tends to be more severe on trunk
  • Consider grease from working in fast food restaurants, occlusion from sports equipment or hats, and drugs
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12
Q

Diagnosis of acne

A
  • Clinical
  • Skin biopsy if doubt
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13
Q

Mild acne

A
  • <20 comedones
  • <15 papules/pustules (nodules/cysts?)
  • <30 total
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14
Q

Moderate acne

A
  • 20-100 comedones
  • 15-50 papules/pustules(nodules/cysts?)
  • 30-125 total
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15
Q

Severe acne

A
  • > 100 comedones
  • > 50 papules/pustules
  • > 5 nodules/cysts
  • > 125 total
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16
Q

VISIA IGA Acne severity scale clear skin with no inflammatory or noninflammatory lesions

A

0

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17
Q

VISIA IGA Acne Severity Scale: almost clear; rare noninflammatory lesions with no more than one small inflammatory lesion

A

1

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18
Q

VISIA IGA Acne Severity Scale: Mild severity; some noninflammatory lesions with no more than a few inflammatory lesions

A

2

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19
Q

VISIA IGA acne severity scale: moderate severity; up to many noninflammatory lesions and may have some inflammatory lesions, but no more than one small nodular lesion

A

3

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20
Q

VISIA IGA Acne Severity Scale: Severe; up to many noninflammatory and inflammatory lesions, but no more than a few nodular lesions

A

4

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21
Q

What should be done if acne is itchy or has pustules, particularly on upper back, shoulder, and scalp of adolescents and young adults?

A
  • Scrape a pustule for KOH testing to assess for pityrosporum folliculitis
  • Can be treated with antifungal shampoo such as ketoconazole
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22
Q

Management pearls for acne

A
  • Acne often resolves after teenage years
  • Severe nodulocystic acne needs aggressive treatment
  • Acne typically requires consistent regular care over months to see improvement
  • Apply topical medication to entire area of potential acne involvement not just individual lesions
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23
Q

Therapy for mild acne

A
  • Topical retinoids
  • Benzoyl peroxide
  • Topical antibiotics
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24
Q

Acne pharmacotherapies

A
  • Benzoyl peroxide
  • Topical retinoids
  • Topical abx
  • Oral abx
  • Oral retinoid
  • Azelaic acid
  • Salicylic acid
  • Hormonal therapy
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25
Types of topical retinoids
* Tretinoin * Tazarotene * Adapelene gel * Trifarotene * Tretinoin combination (tretinoin and clindamycin) * Adapalene combination (adapalene and benzoyl peroxide)
26
Clinical pear for topical retinoids
* Start using gradually, such as every third night, then slowly increase to nightly as tolerated to avoid excessive irritation and dryness
27
MOA of retinoids
Decreases cohesion and increases turnover of epidermal cells
28
MC side effect of retinoids
Dryness and photosensitivity
29
CI for retinoids
Pregnancy
30
Advantage of benzoyl peroxide
No bacterial resistance
31
How is benzoyl peroxide dosed?
* 2.5%, 4%, 8%, 10% * Start with lowest concentration then increase as tolerable * Comes in gel, lotion, cream, pads, masks, and cleanseers
32
Side effects of benzoyl peroxide
* Skin irritation (erythema, xerosis, scaling, stonging, tightening, burning sensation) * Bleaching of hair/clothing
33
What would you use topical antibiotics to treat?
* Mild-moderate inflammatory acne
34
MOA of topical antibiotics
Reduces number of c.acnes in pilosebaceous unit
35
1st line topical antibiotics for mild-moderate inflammatory acne
Clindamycin and erythromycin
36
Can you use clindamycin/erythromycin alone?
No! Not for monotherapy, need BPO to reduce bacterial resistance
37
Common side effect of topical antibiotics
skin irritation
38
Forms of Clindamycin
* Gel, solution, lotion, foam, pledgets * Combo with BPO * Combo with tretinoin ## Footnote BID or foam QD
39
Forms of erythromycin
* gel, solution * Combo with BPO (Benzamycin) ## Footnote Resistance is emerging
40
What type of acne are oral antibiotics used to treat?
* Moderate acne with inflammatory papules or deeper seated lesions
41
Oral antibiotics for moderate acne
Doxycycline or minocycline
42
Prescription for doxycycline or minocycline for acne
* 100 mg every 12 hours to topical regimen of retinoid and benzoyl peroxide * Typically for 3 months, after which dose tapedred to 100 mg once daily for a month or two before stopping
43
MOA for oral Abx in acne
Inhibits c. acnes quicker than topicals
44
MC SE of oral abx (minocycline or doxycycline)
Upset stomach and photosensitivity
45
First line oral antibiotics for acne
* Tetracyclines (tetracycline, doxycycline, minocycline) * Macrolides (erythromycin, azithromycin) but increased resistance
46
Second line oral antibiotics for acne
* Bactrim * Cephalexin
47
Benefit of tetracyclines in acne
Anti-inflammatory and antibiotic properties
48
What oral antibiotic for acne could be used in pregnancy
cephalexin or macrolides: 1st line (pregnancy category B) ## Footnote Macrolides - azithromycin, erythromycin
49
What are side effects of bactrim?
* SJS, TEN
50
What are the second-line oral antibiotics for acne? Why would you choose to use one vs the other?
* Bactrim: used for severe acne that doesn't respond to other abx but contraindicated in pregnancy * Cephalexin (Keflex): less effective but relatively safe in pregnancy (category B)
51
When would you use isotretinoin (oral retinoids) for acne?
* Severe resistant nodular/cystic acne * Usually patient has failed oral abx
52
What is the MOA of isotretinoin
Not well known * Inhibition of sebaceous glands * Decrease in C. acnes
53
How is isotretinoin prescribed?
* Monotherapy * If need second dose, typically need 2 month break before restarting * Take with high fat meal ## Footnote .5-1 mg/kg/day divided BID x 15-20 weeks (4-6 months) Therapeutic goal of 120-150 mg/kg
54
What are the MC SE/CI of oral retinoids
* Dryness of skin and mucous membranes * Headaches * Thoughts of suicide and depression * Possible increased LFTs and hypertriglyceridemia * Myalgia * Never prescribe with oral tetracycline (side effects increase drastically) --> pseudotumor cerebri * CI IN PREGNANCY!!! BIRTH DEFECTS!
55
What do patients need to complete prior to giving them oral retinoids?
* iPledge: instruction brochure and enrollment * Female patient: 2 forms of birth control with negative pregnancy test x 2 before initiation, no blood donation during treatment * Bseline CMP/lipid monthly and pregnancy test, lipids >700-800 consider stopping or starting lipid lowering drug
56
Recap of treatment of each type of acne
* Noninflammatory comedonal: topical retinoids * Mild papulopustular: topical antimicrobial (BPO +ABX) and retinoid * Moderate papulopustular: topical retinoid + oral abx + BPO; hormonal therapy * Severe nodular: topical retinoid + oral ABX + BPO; oral isotretinoin; hormonal therapy
57
Patient education for acne
* Can take 6-8 weeks before improvement and get worse before it gets better * Wash BID * No harsh detergents/fabric softeners/dryer sheets * Diet (linked with dairy) * Avoid hand contact * Avoid products full of perfumes/fragrances
58
What is rosacea?
* Common, chronic inflammatory condition with relapsing-remitting course * Presents with facial flushing * Localized erythema * Telangiectasia * Papules and pustules * Located on nose, cheeks, brow, and chin * Commonly develops between age 30 and 50
59
What is the etiology of rosacea?
* Poorly understood * Demodex mites may play role
60
Who more commonly gets rosacea?
* Lighter skin types * Females at younger age than males * Less common skin types IV-VI, perhaps because darker skin types less prone to photodamage and flushing/telangiectasia difficult to visualize
61
Subtypes of rosacea
* Erythematotelangiectatic * Papulopustular * Phymatous * Ocular rosacea
61
Description of erythematotelangiectatic rosacea
* Persistent erythema of central portion of face with intermittent flushing * Telangiectasias * Stinging or burning sensations on skin * MC subtype
61
Description of papulopustular rosacea
* Acneiform papules and pustules * Erythema and edema of central face with relative sparing of periocular areas * Lacks open comedones (differentiates between acne)
61
Description of phymatous rosacea
* Chronic inflammation and edema marked thickening of skin * Sebaceous hyperplasia * Cobblestoned appearance of affected skin * Most common on nose * Men more offten affected
62
Description of ocular rosacea
* Conjunctivitis * Blepharitis * Hyperemia * Dry, irritated, itchy eyes * Keratitis, scleritis, iritis potential but infrequent complications * Ocular rosacea in patients with or without cutaneous findings
62
Rosacea features
* Flushing * Telangiectasia of cheeks/forehead * Papules/pustules/nodules of nose/cheeks/forehead * Hyperplasia and fibrosis of sebaceous glands: -phyma
62
Rosacea symptoms
* Burning * Stinging * Edema * Plaques * Flushing
63
Rosacea triggers
* Weather (extremes of temperature) * Food and drink (hot beverages) * Exercise * Emotions * Topical products * Hormonal imbalances * Medications (niacin) * Sun exposure
64
Conservative treatment for rosacea
* Counseling on avoiding known triggers * Use of broad-spectrum sunscreens and sun avoidance * Camoglage makeups with green or yellow tint helpful in masking redness
65
Topical therapies for rosacea
* Metronidazole * Ivermectin cream * Sodium sulfacetamide with 5% sulfur * 15% azelaic acid gel * Brimonidine gel and oxymetazoline topical ## Footnote MISAB rosacea
66
Rosacea treatment
* Metronidazole .75% gel twice daily if oily skin types * Metronidazole .75% cream or lotion twice daily if normal to dry skin types * Azelaic acid 15% gel effective alternative * Sodium sulfacetamide with 5% sulfur lotion, cream, suspension, or cleanser * Erythromycin or clindamycin lotion, solution * Ivermectin 1% cream * Permethrin 5% cream * Once daily brimonidine .33% topical gel to reduce facial erythema * Once daily oxymetazoline topical for erythema
67
Systemic therapies for rosacea
* Tetracycline antibiotics: doxy 40 mg daily or minocycline 50 mg twice daily for 12 weeks * Oral metronidazole 200 mg twice daily * Azithromycin 250-500 mg daily 3 x/week * Isotretinoin in severe papulopustular rosacea
68
Therapies for telangiectasias/erythematotelangectatic rosacea
* Camoflauge cosmetics * Brimoinidine .33% topical gel * Vascular lasers * Intense pulsed light therapy
69
Therapies for flushing in rosacea
* Clonidine .05 mg twice daily * Intense pulsed light * Pulsed dye laser * Beta blockers
70
Therapies for rhinophyma in rosacea
* Surgical paring/sculpting * Electrosurgery * Laser
71
Therapies for rosacea fulminans
* Prednisolone 1 mg/kg daily while isotretinoin initiated then tapered over several weeks * Isotretinoin continued for several months
72
Description of perioral dermatitis
* Discrete erythematous micropapules and microvesicles * Confluent in perioral and periorbital skin
73
Factors that impact perioral dermatitis
* Mainly in females * Topical fluorinated glucocorticoids, fluorinated toothpaste, and OCP can be factors
74
Tx of periorbital dermatitis
* D/C steroid use * Topical and oral antibiotics
75
In the stages of acne, a ruptured follicular wall represents what?
Nodule
76
Microcomedone
* Hyperkeratotic infundibulum * Cohesive corneocytes * Sebum secretion
77
Comedone
* Accumulation of shed corneocytes and sebum * Dilation of follicular ostium
78
Inflammatory papule/pustule
* Further expansion of follicular unit * Proliferation of proprionibacterium acnes * Periorbital inflammation
79
Nodule
* Rupture of follicular wall * Marked perifollicular infalmmation * Scarring
80
In the stages of acne, a dilated follicular ostium represents what
Comedone
81
T/F: Acne cannot last from teenage years into adulthood
False
82
T/F: Acne is more common in men than women
False
83
What retinoid cream is now OTC?
Adapalene .1%
84
Retinoid creams should be used every _____ night starting out
3rd
85
MC side effect of topical retinoids is
Dryness
86
Rosacea develops between the ages of ...
30-50
87
Which form of rosacea can cause an enlargednose?
Phymatous
88
# Which is not a trigger of rosacea -weather -drink -niacin -emotions -all of the above
All of the above
89
A 23-year old female is beginning treatment with isotretinoin for her cystic acne. What is recommended frequency of serum pregnancy testing during treatment?
Two tests prior to starting and one test monthly

Dermatology (12 decks)

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