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DERMATOLOGY 5 > Seborrhea Acne Rosacea > Flashcards

Seborrhea Acne Rosacea Flashcards

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1
Q

ACNE VULGARIS

A

INFLAMMATION OF PILOSEBACEOUS UNITS

FACE, TRUNK, BUTTOCKS
MC > adolescents

Manifestion:
> comedomes
> papulopustule
> nodules
> cysts

RESULTS IN > Pitted, depressed + hypertrophic scars

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2
Q

ACNE KEY POINTS

A

Very common > affecting 85% young people

Age onset > puberty 10-17 yrs Females
14-19 yrs Males

Late onset > first at 25 yrs
MALES > FEMALE

Lower in asians/ africans

Genetics aspects:

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2
Q

ACNE KEY POINTS

A

Very common > affecting 85% young people

Age onset > puberty 10-17 yrs Females
14-19 yrs Males

Late onset > first at 25 yrs
MALES > FEMALE

Lower in asians/ africans

Family history > parents with severe acne

Severe acne linked with XXY syndrome

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3
Q

PATHOGENISIS FOLLICULAR KERATINISATION

A

FOLLICULAR KERATINISATION
> change in keratinisation pattern in pilosebaceous unit
> keratinous material > becomes more dense + blocking secretion of sebum
> KERATIN PLUGS > COMEDOMES > “ time bombs of acne”
> LINOLEIC ACID > regulates keratinocyte proliferation > decreased in acne
> commedonal pluggings + complex interaction between androgens + bacteria (P.acne) in plugged sebaceous units > INFLAMMATION

ANDROGENS

Propionibacterium acnes

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4
Q

PATHOGENISIS - ANDROGENS

A

ANDROGENS > stimulate sebaceous glands to produce larger amount of sebum

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5
Q

PATHOGENSIS - BACTERIA

A

BACTERIA > contain lipase > converts lipids to fatty acids > produce pro inflammatory mediates > IL-1, TNFa

Fatty acids + pro inflammatory mediators cause > sterile inflammatory response to pilocebacous units

Distended follicle wall break > contents (sebum, lipids, fatty acids, keratin, bacteria) > enter dermis
> produce inflammatory + foreign body response
» papule
» pustule
» nodule

Rupture + intense inflammation > leads to scars

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6
Q

CONTRIBUTORY FACTORS TO ACNE

A

Acnegenic mineral oils
Rarely dioxin

DRUGS
> lithium
> hydantoin
> isoniazid
> glucocorticoids
> oral contraceptive
> iodides
> bromides
> androgens > testosterone
> danazole

OTHERS
> emotional stress > exacerbation
> occlusion + pressure on skin > hands on face
&raquo_space; ACNE MECHANICA

ACNE NOT CAUSED BY FOOD/ CHOCOALTE/ FATTY FOODS

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7
Q

ACNE - CLINICAL MANIFESTATION

A

Week - months
Worse in fall + winter

Pain in lesions > esp. nodulocystic type

SKIN LESIONS
> open comedomes > blackheads
> closed comedomes > whiteheads
> papules
> papulopustules > papules topped by pustule
> papulopustula acne

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8
Q

ACNE COMEDOMES

A

Keratin plugs formed within follicular ostia

> comedomes linked with small ostia > closed comedomes/ whiteheads

> comedomes linked with large ostia > open comedomes/ blackheads

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9
Q

ACNE PAPULOPUSTULA

A

Some inflammatory papules become nodular
> represent at early stages of nodulocystic acne

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10
Q

ACNE - NODULES/ CYST

A

> 1-4 cm diameter
soft nodules > result > repeated follicular ruptures + reencapsulation with inflammation, abscess formation + foreign body reaction

> cysts > pseudocysts > not lined by epithelium BUT represent with fluctuating abscess

Scars > atrophic depressed (often pitted) or hypertrophic (sometimes keloidal)

SEBORRHEA > on face + scalp + severe

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11
Q

NODULOCYSTIC ACNE

A

open + closed comedomes
papulopustular lesions
nodules + cysts

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12
Q

SPECIAL FORMS ACNE

A

ACNE CONGLOBATA
ACNE FULMINANS
ACNE IN ADULT WOMAN
TROPICAL ACNE
ACNE WITH FACIAL EDEMA
RECALCITRAN ACNE
ACNE EXCORIEE
NEONATAL ACNE
OCCUPATION ACNE
CHLORACNE
ACNE COSMETICA
POMADE ACNE
ACNE MECHANICA

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13
Q

ACNE CONGLOBATA

A

> severe nodulocystic acne
more on trunk than face
coalescing nodules, cysts, abscess + ulceration
on buttocks
spontaneous remission long delayed
in polycystic ovary syndrome
rare in XYY Genotype
> tall males
> slight mental retardation
> aggressive behavrious

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14
Q

ACNE FULMINANS

A

> rare
teenage boys 13-17 yrs
acute onset
severe cystic acne w/ suppuration + ulceration
malaise
fatigue
fever
generalised arthralgias
leukocytosis
elevated erythrocyte sedimentation rate

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15
Q

ACNE IN ADULT WOMAN

A

> persistent acne
hirsute female (often)
with/ without irregular cycles
hyper secretion of adrenal glands + ovarian androgens
dehydroepiandrosterone sulphate DHEAS
polycystic ovary syndrome
congenital adrenal hyperplasia

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16
Q

SAPHO SYNDROME

A

> RARE
SYNOVITIS
ACNE - ACNE FULMINANS
PALMOPLANTAR PUSTULOSIS
HIDRADENTITIS SUPPURATIVA
HYPEROSTOSIS
OSTEITIS

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17
Q

PAPA SYNDROME

A

Sterile PYOGENIC ARTHRITIS
PYODERMA GANGRENOUS ACNE

> inherited autoinflmmatory disorder
very rare

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18
Q

TROPICAL ACNE

A

> flare of acne
severe folliculitits
inflammatory noduels
draining cyst
trunk + buttocks
tropical climates
secondary infection to Staph. aureus

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19
Q

ACNE WITH FACIAL EDEMA

A

> linked with recalcitrant
disfiguring midline facial edema
woody induration w or w/o erythema

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20
Q

RECALCITRANT ACNE

A

> linked to congenital adrenal hyperplasia
11b or 21b hydroxyls deficiencies

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21
Q

ACNE EXCORIEE

A

> mild acne
young women
extensive excoriation + scarring
due > emotional + psychological problems
> obsessive compulsive disorder

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22
Q

NEONATAL ACNE

A

> nose + cheeks of newborns/ infants
related to glandular development
transient

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23
Q

OCCUPATION ACNE

A

> exposure tar derivatives
cutting oils
chlorinated hydrocarbons (CHLORACNE)
large comedomes
inflammatory papules + cyst
not restricted to predilection sites

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24
CHLORACNE
> chlorinated aromatic hydrocarbons > in electrical conductors > insecticides + herbicides > severe in industrial accidents/ intended poisoning (DIOXIN)
25
ACNE COSMETICA
due to comedogenic cosmetics
26
POMADE ACNE
> forehead > africas > applying pomade to hair
27
ACNE MECHANICA
> flares of preexisting acne > hands on face > forehead > pressure of football helmet
28
ACNE LIKE CONDITIONS
STEROID ACNE DRUG INDUCED ACNE ACNE AESTIVALIS GRAM NEGATIVE FOLLICULITITS
29
STEROID ACNE
> systemic/ topical glucocorticoids > monomorphous folliculitis > small erythematous papules + pustules > without commodores
30
DRUG INDUCED ACNE
> monomorphous acne like eruption > due > phenytoin, lithium, isoniazid, > high dose vit.B complex > epidermal growth factor inhibitors > halogenated compounds > NO COMODOEMS
31
ACNE AESTIVALIS
> papular eruption after sun exposure > Mallorca acne > forehead, shoulders, arms, neck , chest NO COMEDOMES > PATHOGENSIS UNKNOWN
32
GRAM NEGATIVE FOLLICULTIIS
> multiple tiny yellow pustules > develop on top of acne vulgaris > due to long term ABX administration
33
DIAGNOSIS ACNE
COMODOMES > required to dx any type of acne COMODOMES > not a feature of acne like conditions
34
DIFFERENTIAL DIASGNOSIS ACNE
FACE: > s. aureus folliculitis > pseudofollicultiis barbae > rosacea > personal dermatitis TRUNK: > Malassezia folliculitis > hot tub pseudomonas folliculitis > s.aureus folliculitis > acne like conditions
35
ACNE - LAB EXAMS
> no labs required > if suspicious endocrine disorder > hormonal exam >> T hormone >> free testosterone >> follicle stimulating hormone >> leutonizing hormone >> DHEAS >>> exclude adrenal hyperandorgenism + polycystic ovary syndrome ** SEVERE ACNE PX > HORMONE LEVELS ARE NORMAL >> ALT, AST, TRIGLYCERIDE + CHOLESTEROL LEVELS >> required if systemic isotretinoin tx planned
36
ACNE COURSE
> most often clears spontaneouslyy by early 20s > can exist in 4th decade / older > flares in winter
37
MANAGEMENT ACNE
> assessed individually + therapy modified accordnly > goal > remove plugging of pilar drainage > reduce sebum production > tx bacterial colonisation
38
MILD ACNE
> topical Abx > clindamycin + erythromycin > benzoyl peroxidase gels > topical retinoids >> tretinoin >> adapalene > after improvement > meds reduces to lowest effective dose > improvement occurs over 2-5months > can be longer for non inflammatory comodomes > topical retinoids > apply evening > topical abx + benzoyle peroxidase applied during day > combination therapy best >> benzoyl peroxide + erythromycin gels plus topical retinoids >> tretinoin/ tazarotene gel, adapalene ACNE SURGERY > EXTRACTION OF COMODOMES >> only when done after pretreatment w/ topical retinoids
39
MODERATE ACNE
> oral abx added along to mild acne tx > most effective ABX: MINOCYCLINE 50-100mg x 2 daily > DOXYCYCLINE 50-100mg x2 daily FEMALES: > control with oral oestrogen w/ progesterone/ anti androgens > risk of reoccurrence after stopping tx FOR INFLAMMATORY CYST/NODULES: > intralesional triamcinolone
40
SEVERE ACNE MANAGEMENT
ADDITONAL TX ALONG WITH TX FOR MODERATE ACNE > systemic tx > isotretinoin for cyst/ conglobate acne > this retinoid >> inhibits sebaceous gland function + keratinisation >> very effective ORAL ISOTRETINOIN > leads to complete remission in all cases > lasting months - years
41
INDICATION FOR ORAL ISOTRETINOIN - ACNE
> moderate + severe > recalcitrant + nodular acne > px must have resistant to other acne tx including systemic abx
42
CONTRAINDICATION ISOTRETINOIN -ACNE
> Irotretinoin = teratogenic > pregnancy must be prevented + effective contraception is necessary when taking isotretinoin > tetracycline + isotretinoin > cause pseudotumor cerebri (bening intracranial swelling) > both should never be used together
43
DOSASE OF ISOTRETINOIN - ACNE
> 0.5 - 1mg/kg with food > improvement within 20wks with 1mg/kg > for severe > esp > trunk > 2mg/kg > 3 or more courses given in refractory cases
44
OTHER SYSTEMIC TX FOR SEVERE ACNE
> systemic glucocorticoids > esp > acne conglobata, fulminans + SAPHO + PAPA syndromes > TNF-a INHIBITORS > INFLIXIMAB + ANAKINRA INFLAMMATORY CYST/ NODULES > intralesional triamcinolone >> 0.05ml of 3-5mg/mL solution
45
ROSACEA
> chronic inflammatory acne form disorder of facial pilosebaceous units > linked with increased reactivity of capillaries >> result > flushing + telangiectasia (dilated vessels) > rubbery thickening of nose >> cheeks >> forehead >> chin >>> due > sebaceous hyperplasia, edema + fibrosis
46
ROSACEA - EPIDEMIOLOGY
> affecting 10% fair skinned > 30-50 yrs > peak 40-50 yrs > FEMALES > rhinopehyma mc in males > celtic people > skin prototype I + II > southern mediterraneans > rare > pigmented people > skin prototype V + VI > brown/black
47
CLASSIFICATION ROSACEA - PLEWING + KLIGMAN CLASSIFICATION
EPISODIC ERYTHEMA > FLUSHING + BLUSHING STAGE 1 > persistent erythema w/ telangiectasis STAGE 2 > persistent erythema > telangiectasis > papules > tiny pustules STAGE 3 > persistent deep erythema > dense telangiectasis > papules > pustules > nodules > solid edema centra part of face PROGRESSION FROM ONE STAGE TO ANOTHER DOESNT ALWAYS OCCUR MAY START W/ STAGE 2 OR 3 stages may overlap
48
ROCASEA - CLINICAL MANIFESTATION
> hx of episodic reddening of face - flushing > w increased skin temp > due to heat stimuli in mouth > hot liquids, spicy foods + alcohol > exposure to sun > solar elastosis + heat >> cooks working with hot stove > can occur de novo w/o any hx of acne/ seborrhoea DURATION > days, weeks, months
49
SKIN LESIONS - ROSACEA
EARLY > pathognomic flushing - red face > tiny papules > papulopustules 2-3mm > pustules often small < 1mm > no comodones LATE > red facies > dusky red papules > nodules > scattered lesions > telangiectases > makes sebaceous hyperplasia > lymphedema in chronic subarea > disfigurement of nose, forehead, eyelids, ears, chin DISTRIBUTION > symmetric localisation on face > rare > neck, chest V shape, back + scalp
50
ERYTHEMATOUS ROSACEA - STAGE 1
> episodic erythema > flushing + blushing > due > mutlutple telangiectasis > red face
51
ROSACEA - SPECIAL LESIONS
> rhinopehyma - enlarged nose > metophyma > enlarged cushion like swelling of forehead > blepharophyma > swelling of eyelid > otophyma > cauliflower like swelling of earlobes > gnathophyma > swelling of chin DUE: sebaceous gland hyperplasia + fibrosis PALPATION > soft + rubber life
52
ROSACEA - EYE INVOLVEMENT
> red eyes > chronic blepharitis > conjunctivitis > episcelritis > rosacea keratitis > serious > corneal ulcer may form
53
ROSACEA - LAB EXAM
BACTERIAL CULTURE > rule out s.aureus infection > scraping DERMATOPAHTOLOGY EARLY > non specific perifolicular + pericapillary inflammation > occasional foci of tuberculoid + granulomatous areas > dilated capillaries > foci of neutrophils high + within follicle LATER STAGE > diffuse hypertrophy of connective tissue > sebaceous gland hyeprplasia > epithelia granuloma without cessation + foreign body giant cells RHINOPHYMA > very marked lobular sebaceous hyperplasia - glandular type > marked increase in connective tissue fibrous type > large ecstatic veins - fibroangiomatous type
54
DIFFERENTIAL DIAGNOSIS
FACIAL PAPULES/ PUSTULES > acne > no comedones in rosacea > peri oral dermatitis > s.aureus folliculitis > demodex follicular infestation FACIAL FLUSHING/ ERYTHEMA > seborrheic dermatitis > prolonged use of topical glucocortcoids > lupus > dermatomyositis COURSE > prolonges > reoccurrence common > after years disease disappears spontaneously > usually lifetime > men + rare women develop rhinophyma
55
PREVENTION ROSACEA
> reduction/ eliminate alcohol
56
TOPICAL TREATMENT - ROSACEA
> metronidazole gel/ cream 0.75% twice daily > metronidazole cream 1% once daily > sodium sulfacetamide, sulfure lotion 10% + 5% > topical antibiotics > erythromycin gel > less effective > topical ivermectin
57
SYSTEMIC TREATMENT - ROSACEA
> oral abx > more effective than topical abx > minocycline/ doxycycline 50-100mg twice daily > doxycycline > phototoxic drug > limited exposure to sun/ summer > tetracycline > 1-1.5g/d MOST EFFECTIVE > ORAL METRONIDAZOLE > 500mg BID
58
ORAL ISOTRETINOIN - ROSACEA
> severe disease > stage III > not responding to ABX + topical treatment > low dose of 0.1-0.5mg/kg per day > sometimes 1mg/kg required IVERMECTIN > 12mg PO in case of massive demdex infestation
59
SURGERY/ LASER - ROSACEA
> rhinophyma + telangiectasia > treated with excellent cosmetic results
60
BEHCET DISEASE
> multisystem polysymptomatic disease > w/ unpredictable excarbation + remission > all organ of body can be affeced >
61
EPIDEMIOLOGY BEHCET DISEASE
> RARE >3rd /4th decade > MC MALES
62
PATHOGENISIES BEHCET DISEASE
> vascular injuies + autoimmune response > circulating immune complexes + neutrophils > cause mucocutanous lesions > histologically > neutrophilic vascular reaction/ leukocytoclastic vasculitis > neutrophils of behcet disease > produce increased amount of superoxides + lysosomal enzymes > tissue injury > high levels of TNFa, IL-1B, IL-8 > activates neutrophils + cellular reaction between neutrophils + endothelial cells
63
CLINICAL MANIFESTATION BEHCET
> MUCOUS MEMBRANES: Aphthea >> painful >> punched out erosions/ ulcers with necrotic base >> occurs on oral mucous membranes, pharynx, larynx, vulva, penis, scrotum >> aphthea > erupt in cyclic fashion in oral cavity/ genital mucous membrnaes >> aphthea > persist wks - mnths before other symptoms
64
CLINICAL MANIFESTATION - BEHCET
CUTANOUS FINDINGS > sterile papulopustules + palpable purpura to erythema nodosum like lesions ERYTHEMA NODOSUM LIKE LESIONS > painful nodules on arms + legs > papulopustular lesions > acneiform papules + pustules > plaques like in sweet syndrome (acute febrile neutrophilic dermatosis) > pyoderma gangrenosum like lesions > palpable purpuric lesions of necrotizing vascultisis > thrombophlebitis
65
ORAL APHTHAE - BEHCET DISEASE
> punched out ulcers w/ necrotic base on buccal mucosa > punched out ulcer on tounge
66
GENITAL ULCERS - BEHCET DISEASE
> multiple large aphthous type ulcers on labial + perineal skin > large punched out ulcer on scrotum
67
SYSTEMIC FINDINGS - BEHCET DISEASE
EYE > posterior uveitis > anterior uveitis > retinal vasculitis > vitreitis > hypopyon > secondar cataracts > glaucoma > neovascular lesion MUSCULOSKELETAL > non erosive > asymmetric oligoarthritis NEUROLOGIC > onset delayed > occurs in 1/4 of px > meningioencephalitis > bening intracranial hypertension > cranial nerve palsies > brainstem lesions > pyramidal/ extrapyramidal lesions > psychosis VASCULAR/ CARDIAC > aneurysm > arterial occlusions > venous thrombosis > varices > hemoptysis > coronary vascultiis > myocarditis > coronary arteritis > endocarditis > valcular disease GI TRACT > aphthae throughout - mucous membranes
68
LAB EXAM - BEHCET DISEASE
DERMATOPATHOLOGY > non specific > leukocytoclastic vascultisi w/ fibrinoid necrosis of blood vessel wall in acute early lesions > lymphocytic vasculitis in late lesion PATHERGY TEST > positive pathergy test at 24/ 48h after skin puncture w/ sterile needle > leads to inflammatory pustule HLA TYPING > significant association > HLAB5 > HLA-B51
69
DIAGNOSIS BEHCET DISEASE
> made based on REVISED INTERNATIONAL CRITERIA FOR BEHCET DISEASE
70
DDX BEHCET DISEASE
> oral/ genital uclers > viral infection > herpes simplex virus > varicella zoster virus > hand food + mouth disease > herpangina > chancre > histoplasmosis > squamous cell carcinoma
71
PROGNOSIS BEHCET DISEASE
> highly variable course w/ recurrences + remission > mouth lesions always present > remission > weeks -months - years > one of leading causes for BLINDNESS > w/ CNS involvement > higher mortality rate
72
MANAGEMENT - BEHCET DISEASE - APHTHAE
> potent topical glucocorticoids > intralesional triamcinolone 3-10mg/mL injected into ulcer base > thalidomide 50-100mg PO in evening > colchicine > dapsone SYSTEMIC INVOLVEMENT > corticosteroids > azathioprine > cyclophophamide > azathioprine > chlorambucil > cyclosporine

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