Rosacea & Insects

Question 1

Driving Factors of Acne Vulgaris

Answer 1

Follicular hyperkeratinization (occurs when the cells of the follicle become cohesive and do not shed normally onto the skin’s surface)

Increased sebum production

Cutibacterium acne within the follicle

Inflammation

Question 2

Microcomedo

Answer 2

Considered the precursor for the clinical lesions of acne vulgaris (First stage of acne)

Increased sebum production
Follicular hyperkeratinization

Question 3

Closed Comedome - Whitehead

Answer 3

Accumulation of sebum and keratinous material converts a microcomedo into a closed comedo

Small or no opening of the follicle to the skin
Build-up of sebaceous material
Inflammation surrounding the follicle

Question 4

Open Comedome - Blackhead

Answer 4

The follicular orifice is opened with continued distension, forming an open comedo

Opening of pore dilates
Build-up of sebaceous material
Inflammation surrounding the follicle

Question 5

Inflammatory Papule (Pimple)

Answer 5

Follicular rupture and presence of bacteria contributes to the development of inflammatory lesions

Bacterial byproduct causes inflammation and infection in the surrounding skin

Question 6

Inflammatory Pustule

Answer 6

Immune system sends white blood cells to fight infection and creates pus in the pore

Question 7

Nodule or Cyst

Answer 7

Follicle wall bursts and a capsule is created via enzymes secreted by white blood cells to contain infection.

Marked inflammation is present in addition to erythema and tenderness.

Question 8

Contributing Factors to Acne Vulgaris

Answer 8

Androgens (sex hormones) stimulate the growth and secretory function of sebaceous glands

Mechanical trauma can rupture comedos, causing inflammatory lesions

Stress seams to have an effect on severity

Question 9

Topical Retinoids

Answer 9

Beneficial for both comedonal and inflammatory lesions

Question 10

Topical Antimicrobial Therapies

Answer 10

Beneficial for inflammatory lesions

Question 11

Oral Antibiotics

Answer 11

For severe inflammatory acne

Question 12

Benzoyl Peroxide

Answer 12

Decreases the emergence of antibiotic resistant bacteria

Often used in conjunction with other therapies (topical retinoids, antimicrobial therapies, oral antibiotics)

Question 13

Treatment of Comedonal (noninflammatory) Acne

Answer 13

Topical Retinoid - Tretinoin

Question 14

Treatment of Mild Papulopustular and Mixed Acne

Answer 14

Benzoyl peroxide +/- topical antibiotic (erythromycin, clindamycin) and topical retinoid

Question 15

Treatment of Moderate Papulopustular and Mixed Acne

Answer 15

Benzoyl peroxide + topical retinoid + oral antibiotic (tetracycline class)

Question 16

Treatment of Severe Acne

Answer 16

Retinoid + oral abx (tetracycline class) + benzoyl peroxide

OR

Oral isotretinoin monotherapy

Question 17

Treatment of Acne during Pregnancy

Answer 17

Some acne medications are teratogenic

Retinoids are super contraindicated in pregnancy

Safe regimen for pregnancy: oral erythromycin, topical clindamycin, topical azelaic acid

Question 18

Acne Rosacea

Answer 18

Chronic skin disorder of the central face

• Most prevalent in fair-skinned individuals
• Female > Males
• Usually emerges in 30s
• Estimated 1-10% in white population

Question 19

Pathogenesis of Acne Rosacea

Answer 19

Not well understood

• Abnormalities in immunity
• UV damage
• Vascular dysfunction
• Inflammatory reactions to cutaneous microorganisms

Question 20

Presentation of Acne Rosacea

Answer 20

Erythema of central face, persisting for months or more

Nose, cheeks, chin, and forehead are commonly affected

Four subtypes:

• Erythematotelangiectatic
• Papulopustular
• Phymatous
• Ocular

Question 21

Erythematotelangiectatic Rosacea

Answer 21

Chronic redness of central face

Flushing (wet or dry)

Skin sensitivity

Dry appearance

Telangiectasias

Question 22

Papulopustular Rosacea

Answer 22

Papules and pustules of central face

Inflammation can be confluent

NO comedones

Question 23

Phymatous Rosacea

Answer 23

Tissue hypertrophy causing irregular contours

Mostly nose but can involve cheeks, forehead and chin

Mostly affects men

Question 24

Ocular Rosacea

Answer 24

Often coincides with other types of rosaceas

> 50% of those with other types

Children and adults

May precede, coincide, or follow

Dry eyes, pain, itching, blurry vision, photosensitivity, blepharitis (An inflammation of the eyelid that affects the eyelashes or tear production), keratitis (Inflammation of the clear tissue on the front of the eye (cornea).), conjunctivitis, stye.

Question 25

Treatment of Erythematotelangiectatic Rosacea

Answer 25

First line: behavior changes - avoid trigger - sun protection - gentle skin care Second line - laser and pulsed light therapy - topical brimonodine

Question 26

Treatment of Papulopustular Rosacea

Answer 26

Mild-Moderate 1st Line topicals: (Metronidazole, Azelaic acid) 2nd Line topicals: ivermectin and sulfacetamide-sulfur Moderate-Severe or failed topical tx Oral abx: - Tetracyclines: doxycycline, minocycline, tetracycline - Macrolides: clarithromycin, azithromycin, erythromycin

Question 27

Treatment of Phymatous Rosacea

Answer 27

Early Disease: Isotretinoin Advanced Disease: surgical debulking and/or laser ablation

Question 28

Treatment of Ocular Rosacea

Answer 28

Refer to Ophthalmologist Topical abx, cyclosporin (immunosuppressive drug), oral abx

Question 29

Degree of Envenomation

Answer 29

Grade 1: Local pain and paresthesias at the sting Grade 2: Local symptoms as well as remote pain and paresthesias Grade 3: EITHER cranial nerve OR somatic skeletal neuromuscular dysfunction Grade 4: Both cranial nerve dysfunction AND somatic skeletal neuromuscular dysfunction

Question 30

Characteristic Signs of Envenomation

Answer 30

Local pain exacerbated by tapping near the sting site (tap sign) ``` Cranial nerve dysfunction •Hypersalivation •Abnormal eye movements •Blurred vision •Slurred speach •Tongue fasciculations ``` Somatic skeletal neuromuscular dysfunction –Fasciculations –Shaking and jerking of the extremities –Opisthotonos (arching of the back) –Emprosthotonos (tetanic forward flexion of the body) –Fever up to 104°F from excess motor activity

Question 31

Severe envenomations require monitoring for...

Answer 31

``` •Respiratory compromise –Suctioning of oral secretions –Endotracheal intubation •Myocardial infarction •Hyperthermia •Rhabdomyolysis ```

Question 32

Common Clinical Presentation of Bee Stings

Answer 32

Commonly result in a local reaction Swelling, erythema lasting a few hours to 1-2 days Treat with cold compress

Question 33

Large Local Reaction (LLR)

Answer 33

Bee Stings will cause a different response about 10% of the time –Exaggerated erythema and swelling –Gradually enlarges over 1-2 days –Resolves in 5-10 days –Cold compress, prednisone, antihistamines, NSAIDs

Question 34

Widow Bites

Answer 34

Cause a small local reaction * Often cause few symptoms because no venom injected * Blanched circular patch, surrounding red perimeter and a central punctum •Venom causes catecholamine release –Intermittant radiating pain –Abdominal/chest/back pain and muscle spasm –Local/regional diaphoresis, HA, N/V

Question 35

Common Recluse Bites

Answer 35

Often painless initially •Progress to severe pain in 2-8 hours •Usually a red plaque or papule with central pallor •May see two small puncture marks within the erythema •Vesiculation can occur •Resolves in a week

Question 36

Rare Recluse Bites

Answer 36

severe ulcerative necrosis can occur •Dark, depressed center develops after 1-2 days - Systemic symptoms •N/V, h/a, fever, chills •Rarely, renal failure, hemolytic anemia, hypotension, DIC, rhabdomyolysis can occur

Question 37

Vitiligo

Answer 37

an acquired skin depigmentation via an autoimmune process directed against melanocytes

Question 38

Epidemiology of Vitiligo

Answer 38

``` –1% of worldwide population –Affects males and females equally –Onset peaks in 2nd/3rd decades –Subtype (generalized vitiligo) can be associated with other autoimmune disease in 20-30% of patients –Family history in 20-30% of patients ```

Question 39

Clinical Presentation of Vitiligo

Answer 39

presents as milk-white macules with homogenous depigmentation and well-defined borders * Slowly progressive * Spontaneous repigmentationin 10-20%

Question 40

Diagnosis of VItiligo

Answer 40

* Consider screening for other autoimmune diseases | * Skin biopsy will show epidermis devoid of melanocytes

Question 41

Treatment of Vitiligo

Answer 41

Treatment focuses on prevention and repigmentation therapy * Treatment * Topical and systemic corticosteroids (first line) * Calcineurin inhibitors * Narrowband ultraviolet B phototherapy (extensive disease) * Skin grafts * Sunscreen * Makeup (Covermark, Dermablend) * Ask about psychological distress

Question 42

Hidradenitis Suppurativa (Acne Inversa)

Answer 42

Chronic inflammatory skin disorder involving the hair follicle Results from the cycle of follicular occlusion, rupture, and the associated immune response * Occurs in the axillary, inguinal and anogenital regions * 1-4% prevalence * Female > male; no racial predilection * Avg age of onset = 23 –Rarely before puberty or after menopause Other factors: genetics, mechanical stress, obesity, smoking, diet

Question 43

Progression of Hidradenitis Suppurativa

Answer 43

Begins with a single, deep-seated, inflammatory nodule - More nodules form as disease progresses - May form an abscess that opens to the skin - Purulent drainage occurs if ruptured As the disease progresses: - Sinus tracts - Comedones - Scarring

Question 44

Diagnosis of Hidradenitis Suppurativa

Answer 44

Based on lesion, location, chronicity, and relapse

Question 45

Treatment of Hidradenitis Suppurativa

Answer 45

``` •Local tx: –topical clindamycin –Intralesionalcorticosteroids •Systemic antibiotics –Doxycycline or minocycline •Anti-androgenic agents •Surgery –Punch debridement (nodules) or wide excision (scarring) •Severe, refractory cases –TNF inhibitors –Oral retinoids ``` Used in conjunction with lifestyle modifications

Question 46

Complications of Hidradenitis Suppurativa

Answer 46

* Fistulae * Strictures and contractures * Lymphatic obstruction * Infectious complications * Squamous cell cancer * Malaise, depression, suicide