SM_264a: Acne, Rosacea, and Related Disorders

Question 1

Acne pathogenesis involves ____, ____, ____, and ____

Answer 1

Acne pathogenesis involves follicular epidermal hyperproliferation, excess sebum production, inflammation (IL-1), and Cutibacterium acnes

(cells become abnormally adherent, excess sebum, increased pro-inflammatory cytokines, bacteria)

Question 2

Sebum production is regulated by ____ and involves ____

Answer 2

Sebum production is regulated by androgens and involves androgen receptors

(holocrine secretion as the sebaceous gland matures - contents go into sebaceous gland and then sebaceous duct)

Question 3

Describe Cutibacterium acnes

Answer 3

Cutibacterium acnes

• Gram +, anaerobic, microaerobic
• Resident flora of follice
• Acne patients have more than controls
• Promotes inflammation: antibodies to cell wall activate complement, produces lipases / proteases / hyaluronidases, binds TLR2 increasing proinflammatory cytokines

(feeds off sebum)

Question 4

This is a ____

Answer 4

This is a closed comedone

(non-inflammatory, palpable)

Question 5

This is an _____

Answer 5

This is an open comedone

(clinically inflammed lesions - raised, elevated, red)

Question 6

This is an ____

Answer 6

This is an acne papule

(dilation of follicle, extrustion of material in follice into dermis, nodules)

Question 7

This is an ____

Answer 7

This is an acne pustule

Question 8

This is an ____

Answer 8

This is an acne nodule (and cysts)

Question 9

These are ____

Answer 9

These are acne sinus tracts

Question 10

This is ____

Answer 10

This is post-inflammatory hyperpigmentation

Question 11

This is ____

Answer 11

This is acne scarring

(boxcar scars, rolling scars, no medication can reduce scarring)

Question 12

This is ____ acne

Answer 12

This is drug-induced acne

Question 13

This is acne related to ____

Answer 13

This is acne related to polycystic ovary syndrome

(hyperandrogenism due to increased levels or increased sensitivity to androgen)

Question 14

This is ___

Answer 14

This is acne fulminans

(sudden onset of very severe acne, can have systemic symptoms, acne + arthritic symptoms)

Question 15

Describe acne treatment

Answer 15

Acne treatment

• Early
• Adequately aggressive for severity
• Algorithmic approach
• Target pathogenic factors: often involves combined topicals and orals
• Patient education is critical

Question 16

___ are first line treatment for comedonal acne

Answer 16

Retinoids are first line treatment for comedonal acne

(tretinoin, adapalene, tazarotene)

Question 17

Inflammatory acne topic treatment involves ____ and ____

Answer 17

Inflammatory acne topic treatment involves retinoids and benzoyl peroxide

(no resistance to benzoyl peroxide, also antibiotics such as clindamycin, dapsone, and sodium sulfacetamide and sulfur)

Question 18

Describe systemic treatment of acne

Answer 18

Systemic treatment of acne

• Moderate to severe inflammatory
• Minocycline > doxycycline >> tetracycline
• Sarecycline: antimicrobial, anti-inflammatory, reduces free fatty acid levels
• Erythromycin (pregnancy, kids < 8 yo)
• TMP/SMX
• Isotretinoin: reduces sebum production, decreases androgen synthesis, induces cell cycle arrest and apoptosis in sebocytes

Question 19

____ is used with antibiotics to minimize resistance

Answer 19

Benzoyl peroxide is used with antibiotics to minimize resistance

Question 20

____ is first line treatment for acne fulminans

Answer 20

Isotretinoin is first line treatment for acne fulminans

Question 21

Hormonal therapy of acne involves ____ and ____

Answer 21

Hormonal therapy of acne involves combination birth control pills and spironolactone

• Combination birth controls: decrease LH and androgen production, increase hepatic sex-hormone binding globulin levels which decreases free testosterone levels
• Spironolactone: androgen receptor blocker, 5alpha-reductase inhibitor

Question 22

____ is the main indication for hormonal therapy of acne

Answer 22

Hyperandrogenemia is the main indication for hormonal therapy of acne

Question 23

___ is used to generate reactive oxygen species to destroy acne

Answer 23

Photodynamic therapy is used to generate reactive oxygen species to destroy acne

Question 24

Rosacea pathogenesis involves ____, ____, and ____

Answer 24

Rosacea pathogenesis involves neurovascular instability and increased reactivity, innate immunity abnormality, and inflammation of follicle and surrounding dermis

(inflammatory signaling, vascular signaling and response leading to hyperreactivity of vessels, sensory response, exogenous triggers, and endogenous risk factors)

Question 25

\_\_\_\_ are found on the skin in increased amounts in rosacea due to increased amounts of \_\_\_\_

Answer 25

Cathelecidins are found on the skin in increased amounts in rosacea due to increased amounts of demadex mites (cathelecidins are antimicrobial peptides)

Question 27

This is ____ rosacea

Answer 27

This is erythematotelangiectatic rosacea

Question 28

This is ____ rosacea

Answer 28

This is papulopustular rosacea

Question 29

This is ____ rosacea

Answer 29

This is phymatous rosacea (on nose, brow, and cheek)

Question 30

This is ____ rosacea

Answer 30

This is ocular rosacea

Question 31

Describe ocular rosacea

Answer 31

Ocular rosacea * Most of all rosacea patients * 1/3 have sight-treatening corneal disease * Ocular disease may precede skin disease * Skin may be subtle in almost all ocular rosacea cases * No diagnostic test, nonspecific symptoms

Question 32

Eyelid findings in ocular rosacea include ____ and \_\_\_\_

Answer 32

Eyelid findings in ocular rosacea include blepharitis and conjunctival hyperemia

Question 33

Corneal findings in ocular rosacea include ____ and \_\_\_\_

Answer 33

Corneal findings in ocular rosacea include superficial punctate keratitis and epithelial erosions (1/3 of rosacea patients have corneal involvement)

Question 34

Describe treatment of erythematotelangiectatic rosacea

Answer 34

Erythematotelangiectatic rosacea treatment * Avoidance of sun and other triggers * Redness associated with papules / pustules: azelaic acid, metronidazole, sodium sulfacetamide and sulfur * Diffuse (background) redness: brimonide tartrate gel, oxymetazoline HCl cream, vascular lasers, and intensed pulsed light

Question 35

Brimonidine tatrate gel used to treat diffuse redness in erythematotelangiectatic rosacea is a \_\_\_\_

Answer 35

Brimonidine tatrate gel used to treat diffuse redness in erythematotelangiectatic rosacea is a selective alpha2-adrenergic receptor agonist

Question 36

Oxymetazoline cream used to treat diffuse redness in erythematotelangiectatic rosacea is a ____ and \_\_\_\_

Answer 36

Oxymetazoline cream used to treat diffuse redness in erythematotelangiectatic rosacea is a selective alpha-1A-adrenergic receptor agonist and vasoconstrictor

Question 37

Describe treatment of papulopustular rosacea

Answer 37

Papulopustular rosacea treatment * Topical medications: azelaic acid, metronidazole, ivermectin, sodium sulfacetamide and sulfur * Oral medications: doxycycline = minocycline \> tetracycline, metronidazole, isotretinoin * Avoidance of sun and other triggers

Question 38

Ivermectin is used in topical treatment of papulopustular rosacea because it \_\_\_\_

Answer 38

Ivermectin is used in topical treatment of papulopustular rosacea because it acts against the demadex mite

Question 39

Describe treatment of phymatous rosacea

Answer 39

Phymatous rosacea treatment * Isotretinoin: decreases tissue volume, decreases sebaceous gland size / number * Surgical excision, hot loop contouring * Ablative laser: carbon dioxide, erbium (YAG)

Question 40

This is \_\_\_\_

Answer 40

This is periorificial (perioral) dermatitis

Question 41

Describe periorificial (perioral) dermatitis

Answer 41

Periorificial (perioral) dermatitis * Spearing, vermillion border * Young women, children * Frequent history of potent topical steroid use with positive response but rebound flare * Etiology unknown

Question 42

Describe treatment of periorificial dermatitis

Answer 42

Periorificial dermatitis treatment * Avoid topical corticosteroids * Topical agents: metronidazole, erythromycin, clindamycin, sodium sulfacetamide / sulfur, azelaic acid, topical calcineurin inhibitors (tacrolimus) * Oral antibiotics: doxycycline / minocycline / tetracycline, erythromycin

Question 43

Avoid ____ in treatment of periorificial dermatitis

Answer 43

Avoid topical corticosteroids in treatment of periorificial dermatitis

Question 44

This is \_\_\_\_

Answer 44

This is hidradenitis suppurative

Question 45

Describe presentation of hidradenitis suppurativa

Answer 45

Hidradenitis suppurativa presentation * Axillae, breasts, inguinal creases, buttocks, perineum * Often bilateral * Tender, red, draining nodules ± abscesses * Open comedones -\> double comedones * Scarring

Question 46

Describe treatment of hidradenitis suppurative

Answer 46

Hidradenitis suppurative * Weight loss, smoking cessation * Topical agents * Systemic agents * Adalimumab * Intralesional injection of corticosteroids * Incision and drainage of acute abscesses * Surgical excision of diseased areas: primary closure, split-thickness skin grafting, and healing by secondary intent