Acne Vulgaris

adolescent acne

12-19 years or after menarche in girls common

acne vulgaris -- pathogenesis -**four factors are involved in the formation of acne lesions**:

increase in sebum production (influenced by androgens) keratin and sebum plug the hair follicle and accumulate leading to hyperkeratosis (comedone formation) P. acnes proliferates in the sebaceous follicle (releases enzymes and stimulates release of proinflammatory cytokines) inflammatory response

acne vulgaris -- distribution

mainly affects the face, neck, upper trunk, and upper arms

Ms. Garcia is a 22-year-old woman who was referred to the derm. clinic for new onset acne. Allergic to PCN. Gained 40 pounds over the past 4 years despite healthy diet and exercise habits. New upper lib and chin hair growth, irregular menstrual cycles since menarche, last period was 4 months ago. How would you describe her skin?

moderate *comedonal* and *inflammatory acne* of cheeks and jawlines with scattered terminal hairs *hair loss* noted on frontal and parietal scalp

minocycline pigmentation -- timing

months to years in small percentage of pts

*nodulocystic*

nodules and cysts

*infantile acne*

onset 6 weeks to 1 year self-limited, true acne with comedones

*neonatal acne*

onset birth to 6 weeks usually self-limited; not true acne, no comedones

*comedonal*

open and closed comedones

*inflammatory*

papules and pustules

keratin and sebum

plug the hair follicle and accumulate leading to hyperkeratosis (comedone formaiton)

oral antibiotics -- contraindicated in:

pregnancy and in children < 8-y/o

P. acnes

proliferates in the sebaceous follicle (release proinflammatory cytokines)

oral antibiotics -MOA -applications -forms (3) -ADRs

reduce P. acnes colonization of the skin and follicles *moderate to severe inflammatory acne* tetracycline, doxycycline, minocycline GI upset (epigastric burning, N/V, diarrhea) *photosensitivity* vertigo, dizziness, hyperpigmentation

topical antibiotics -MOA -ADRs

reduce the number of P. acnes and reduce inflammation irritating, can cause dry skin -begin on alternative days if pair with retinoid or peroxide -use moisturizer

oral isotretinoin -MOA -applications -ADRs

retinoic acid derivative that *targets all four pathophysiologic factors* severe, nodulocystic acne failing other therapies xerosis, cheilitis, elevated LFTs, hypertriglyceridemia *teratogenic*

It is equally important to describe the ____________ and the presence of _______________ for each patient.

severity scarring

minocycline pigmentation -- morphology

skin deposition can be brown or blue-grey

oral contraceptives -MOA -ADRs

suppress LH production, increase SHBG, inhibit 5-alpha reductase nausea, vomiting, abnormal menses, weight gain

mild acne -- comedones with few inflammatory lesions -initial -alternative

topical retinoid or benzoyl peroxide combination therapy with topical retinoid or topical abx

topical retinoids (tretinoin, trans-retinoic acid) -MOA -ADRs

vitamin A derivatives that act by *normalizing the desquamation of follicular epithelium* to prevent new comedones and promote clearing of existing comedones dryness, pruritus, erythema, photosensitivity

closed comedone

whitehead

acne vulgaris -- epidemiology -disorder of:

"acne" disorder of *pilosebaceous follicles* -affects 90% of adolescents -all races equally affected

acne vulgaris -- morphology

"clogged pores", aka comedones

A 16-year-old male presents to your office for his health maintenance visit. He has not used any treatment for his acne (see photo). The MOST appropriate initial treatment plan is: a. Start oral doxycycline, topical tretinoin and benzoyl peroxide wash and see him in follow-up in 3 months b. Start oral doxycycline, topical tretinoin and benzoyl peroxide wash and see him in follow-up in 6 months c. Start topical tretinoin and benzoyl peroxide wash and see him in follow-up in 3 months d. Start topical tretinoin and benzoyl peroxide wash and see him in follow-up in 6 months

*A*

Acne rosacea can be differentiated from acne vulgaris by which of the following features? a. Absence of comedones b. Distribution limited to the face (Individuals can have acne vulgaris limited to the face) c. Inflammatory papules and pustules (Seen in both acne rosacea and acne vulgaris) d. Irritation from topical products (True in both acne rosacea and acne vulgaris)

*A*

Ms. Garcia was given spironolactone and her acne improved. Why did this medicaiton work? A) anti-androgenic effects B) anti-comedonal activity C) anti-bacterial activity D) diuretic effect eliminated sodium resulting in less sebum

*A*

Which of the following diagnoses BEST describes the patient in the photo? a. Erythematotelangietatic Rosacea b. Papulopustular Rosacea c. Phymatous Rosacea d. Ocular Rosacea

*A*

A 14-year-old girl (see photo) presents to your office with her mother. How would you describe her skin lesions? a. Nodulocystic acne b. Primarily comedonal acne c. Primarily inflammatory acne d. Rosacea e. She does not have acne

*B*

Oral tetracyclines are not used in children younger than 8 years of age because: a. Risk of bleaching of the hair b. Risk of damage to tooth enamel and developing bones c. Risk of hyperkalemia d. Risk of hyperpigmentation of the skin

*B*

You decide to prescribe Ryan an oral abx, Minocycline 100 mg PO BID. Which set of side effects do you want Ryan to be aware of? A) depressive symptoms B) dizziness, ataxia, N/V C) GI upset, photosensitivity D) xerosis, cheilitis, elevated liver enzymes, hypertriglyceridemia

*B* C -- seen with any of the tetracycline abx D -- known side effects associated with Isotretinoin

A 52-year-old male presents with erythematous papules and pustules on his cheeks and nose for several years (see photo). He also is embarrassed by the erythema on his nose and worries that his friends think he's an alcoholic. The most appropriate next step is: a. Clobetasol cream twice daily b. Ketoconazole cream twice daily c. Metronidazole cream twice daily d. Moisturizers 2-3 times daily

*C*

Based on Ms. Garcia's H&P, what is the most likely diagnosis? A) cushing syndrome B) gram neg. folliculitis C) PCOS D) Staph. aureus folliculitis

*C*

*mid childhood acne*

1 year to 7 years

PCOS -- two out of the following three criteria:

1) oligo- and/or anovulation 2) hyperandrogenism 3) polycystic ovaries on sonographic exam

Jim Reynolds in a 17-y/o healthy teenager who presents to his PCP with "pimples" on his face for the last 2 years. He reports a daily skin regimen of aggressive facial cleansing with a bar soap during his morning shower. Father and mother had acne as teenagers. No other medical history. How would you describe Jim's skin exam? A) mild comedonal acne without presence of scarring B) mild inflammatory acne without comedones C) moderate mixed comedonal and inflammatory acne with presence of scarring D) moderate mixed comedonal and inflammatory acne without presence of scarring

*C*

When prescribing medications for acne vulgaris, an important step is to establish reasonable expectations with the patient. How long might the patient have to wait before seeing improvements in his/her acne? a. 1-2 weeks b. 3-4 weeks c. 2-3 months d. 4-6 months

*C*

Which of the following treatments would you recommend for Jim? A) salicylic acid 2% facial wash B) tetracycline oral abx C) combo. therapy with benzoyl peroxide and topic retinoid cream D) combo. therapy of oral isotretinoin and hormone therapy E) no tx necessary at this time

*C*

An 18-year-old white female returns to your clinic for acne. She has comedones that have improved with topical retinoid therapy and benzoyl peroxide, but she still gets pustules and inflammatory papules. She plays field hockey. You decide to prescribe doxycycline 100 mg twice daily. Which of the following side effects do you need to warn her about? a. Decreased efficacy of birth control pills b. Hyperpigmentation c. Hypertriglyceridemia d. Photosensitivity e. Staining of the teeth

*D*

Which of the following medications is indicated to treat acne in a pregnant woman? a. Oral doxycycline b. Oral isotretinoin c. Oral minocycline d. Topical clindamycin

*D*

Which of the following patients would be most appropriate to refer to a dermatologist? a. Patient has both comedonal acne and few inflammatory lesions on the face, chest, and back. b. Patient has no improvement in moderate acne after 1 month of treatment with topical retinoid. c. Patient is a post-adolescent female with new onset acne. d. Patient has extensive nodular lesions with cysts and diffuse scarring.

*D*

A 15-year-old female presents to clinic with acne with 30-40 comedones on the forehead, cheeks, and chin, with very few erythematous papules, and no scarring. She reports that topical benzoyl peroxide is not working for her despite using it according to instructions for 6 months. She has no involvement of chest or back and has normal menstrual periods. Which of the following is the BEST addition to her acne treatment at this time? a. Oral Isotretinoin b. Oral Minocycline c. Oral Spironolactone d. Topical antibiotic e. Topical retinoid

*E*

Ryan has used a combination therapy of 5% benzoyl peroxide and a topical retinoid for the past year without significant improvement. What other treatment strategies can you consider? A) topical abx B) oral abx C) oral isotretinoin D) refer to dermatologist E) all of the above

*E* -severe acne can require combination therapy -derm. referral for tx with oral isotretinoin is necessary in acne failing other therapies

in addition to scarring, pts develop:

*post inflammatory hyperpigmentation* -hyperpigmented macules that persist following inflammation in the skin

Ryan Townsend is a 15-year old healthy teenager who presents to his PCP for evaluation of progressively worsening acne over the last three years. Currently on OTC 10% benzoyl peroxide wash and topical retinoid. Older brother had acne as a teenager. How would describe Ryan's skin? -- nodules, cyst within skin, and scarring

*severe nodulocystic* acne with presence of scarring

preadolescent ance

7-12 years or menarche in girls common

periorificial dermaitis -morphology -clinical features -treatment (pts > 8, pts < 8-y/o)

erythematous papules and pustules with scaling around mouth, nose, and eyes presents with pruritus or burning *prior or current use of topical steroids* taper use of topical steroids oral tetracycline for pts > 8, oral erythromycin for pts < 8

A mother calls the advice line at your PCP, and she is concerned that her 5-year-old son has "acne". she says he has "pimples and white heads and red marks" on his cheeks.

acne between the ages of 1 and 7 years old is called *"mid-childhood acne"* and is very rare. excess androgens that warrant workup -- adrenal tumors, gonadal tumors, CAH, Cushing syndrome

cystic or scarring acne should be treated:

aggressively to prevent permanent sequelae *refer* pts with difficult to control acne or the presence of scarring to dermatology

minocycline pigmentation -- distribution

alveolar ridge, palate, sclera

spironolactone -MOA -ADRs

androgen-receptor blocker, inhibitor of 5-alpha reductase diuresis, hyperkalemia, irregular menstrual periods

increase in sebum production due to:

androgens

in many post-adolescent women, what improves their acne?

antiandrogen therapy

open comedone

blackhead (oxidation of FAs)

benzoyl peroxide -MOA -ADRs

both antibacterial and comedolytic properties -acts via *generation of free radicals that oxidize proteins* in the P. acnes cell wall bleaching of hair, colored fabric; irritate skin

severe acne -- extensive inflammatory lesions with diffuse scaring -initial -inadequate response

combo. therapy with oral abx, tpical retinoid and BP +/- topical abx consider oral isotretinoin, derm. referral, hormonal therapy for females

moderate acne -- comedones with marked # of inflammatory lesions -initial -inadequate response

combo. therapy with topical retinoid and BP +/- topical abx consider oral abx, derm referral, hormonal therapy for females

acne rosacea -morphology -triggers -treatment

easy flushing, erythema, telangiectasias, phymatous changes alcohol, sunlight, spicy food -*NOT related to hormones* topical and oral treatments (will NOT reverse erythema and flushing) -should use sunscreen