Acne Vulgaris Qs

Acne Vulgaris

---SNAPSHOT---A 12-year-old boy with no significant past medical history presents with acne to his pediatrician's office. He has recently started practice for the wrestling team. He admits to not maintaining great hygiene, eating lots of junk food, and being stressed about an upcoming meet. On physical exam, he has dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. His pediatrician suggests that he also consider a systemic retinoid if this topical therapy does not work.

This patient has mild comedonal acne vulgaris. Acne vulgaris is classified by four lesions: open and closed comedones, papules, pustules and nodulocystic lesions. The mildest form is associated with comedones on the central area of the face. Topical retinoids are the primary treatment for acne vulgaris. They act by inhibiting the formation of microcomedones, reduction of mature comedones and decreasing inflammation. They should be applied daily to all lesions. The most common side effect is dryness and irritation. Initial control of symptoms takes at least 6-8 weeks depending on the severity. Oral antibiotics (A) are indicated in patients who have failed topical therapy and those with moderate to severe inflammatory papulopustular and nodulocystic acne. Oral retinoids (B) is indicated for severe nodulocystic acne. It is highly teratogenic and contraindicated in pregnancy. Topical zinc (D) has been explored as an antioxidant for the treatment of acne, but it has not proven effective as a monotherapy

A 15-year-old boy presents to clinic with his mother with acne on his forehead and nose. He has been using over the counter facial scrubs without relief. Physical exam shows multiple closed comedones with mild inflammation on the forehead and nose. He has no significant past medical history and does not smoke or consume alcohol. What is the most appropriate initial pharmacologic therapy? A. Oral antibiotic B. Oral retinoid C. Topical retinoid D. Topical zinc

The patient is presenting with lesions consistent with moderate inflammatory acne. First-line management should include benzoyl peroxide. Acne vulgaris is often classified by grade of severity. Medical therapies should be initiated in a step-wise fashion based on these classifications. For mild or moderate inflammatory acne, topical benzoyl peroxide should be part of initial management. Other first-line agents include topical antimicrobials and topical retinoids. For moderate inflammatory acne, oral antibiotics may be considered as well. Figure A illustrates multiple, papular-pustular lesions on the forehead seen in moderate inflammatory acne vulgaris. Incorrect Answers: Answer 2: Intralesional steroids may be a treatment option for nodular acne. Side effects include cutaneous atrophy and hypopigmentation. Answer 3: Isotretinoin is an oral retinoid (all-trans retinoic acid). It is used for treatment of severe cystic/nodular acne or moderate acne that is resistant to other treatments or is associated with significant scarring. There are many adverse effects including teratogenicity in pregnant females and hypertriglyceridemia, which precludes its use as a part of routine management. Answer 4: Photodynamic therapy involves applying a photosensitizing agent prior to exposure to light or laser. Efficacy remains under investigation; therefore, light therapies are considered adjuvant and not first-line. Additionally, some side effects include erythema and post-inflammatory dyspigmentation. Answer 5: Topical steroids are contraindicated in acne patients. While studies are inconsistent, corticosteroids have generally been shown to exacerbate or even precipitate acne. Bullet Summary: Benzoyl peroxide is a first line for treatment of mild to moderate acne vulgaris.

A 16-year-old boy is brought to the primary care physician by his mother for acne. The patient reports that over the past 2 months he has been suffering acne outbreaks. He has tried washing his face with soap and water twice a day without relief. He is part of his school's show choir, and he has become increasingly embarrassed to perform in front of people because of his acne. The patient's mother states that he is doing well in school, but she is worried that the acne is starting to affect her son's self-esteem. The patient's medical history is notable for mild, intermittent asthma. He uses an albuterol inhaler as needed. Physical examination notes multiple facial lesions as shown in Figure. Which of the following is the next best initial step in management of the patient's condition? A. Benzoyl peroxide B. Intralesional steroids C. Isotretinoin D. Photodynamic therapy E. Topical steroids

This patient presents with mild, noninflammatory acne that has not responded to salicylic acid, and topical retinoids have caused excessive drying. The next best step in management is topical benzoyl peroxide and clindamycin. Mild acne typically presents with erythematous papules that are scattered. Topical retinoids are the first-line therapy for non-inflammatory (i.e., comedonal) acne that is mild. In patients who do not experience symptom relief or find the retinoids to be too irritating to the skin, a potential alternative is topical benzoyl peroxide with an antibiotics. Clindamycin is a common antibiotic choice. Oral treatments are reserved for moderate or severe inflammatory acne with nodules and pustules. Figure A shows scattered erythematous papules, consistent with mild noninflammatory acne. Incorrect Answers: Answer 1: Oral spironolactone may be used for moderate or severe acne in women who have hyperandrogenism (since spironolactone is an anti-androgen). This would be useful, for example, in polcystic ovarian syndrome, where acne is due to excess androgen's effects on sebum production. Answer 2: Oral doxycycline is a common antibiotic that reduces Propionibacterium acnes, which is thought to contribute to acne. This should be used only for inflammatory acne, which this patient does not have, and overuse can cause antibiotic resistance. Answer 3: Oral isotretinoin should only be used for moderate or severe refractory, nodular acne. It is teratogenic, so use in women of childbearing age necessitates effective contraception. Answer 5: Hormonal oral contraception is useful for moderate or severe acne in women. Although this patient does report some hormonal pattern to her symptoms, her mild lesions do not warrant this treatment. Furthermore, this option is contraindicated in someone with migraine with aura. Bullet Summary: Topical retinoids are the first-line treatment for mild noninflammatory acne, but topical benzoyl peroxide and clindamycin may be used instead if the retinoids cause excessive drying.

A 16-year-old female presents to her primary care physician with worsening facial acne over the last several months. She states that she first developed sparse pimples around age 12, and she used over-the-counter face cleansers containing salicylic acid with moderate improvement. She was prescribed a topical retinoid two months ago when her acne first started to worsen, but she has been unable to use it consistently due to excessive skin drying. She still feels that her acne is poorly controlled. She states that her skin seems to break out more around her menstrual period, which occurs every 28 days. The patient has a past medical history of migraines with aura, for which she sometimes takes sumatriptan. Her mother has a history of hypertension, and her father died of a myocardial infarction at age 51. The patient is a junior in high school and plays varsity soccer. She denies use of alcohol, tobacco, and drugs and has never been sexually active. Her temperature is 98.2°F (36.7°C), pulse is 70/min, blood pressure is 117/61 mmHg, respirations are 14/min, and oxygen saturation is 99% on room air. Cardiopulmonary exam is unremarkable. A representative portion of her facial skin exam is shown in Figure A. Which of the following is the best next step in management? A. Oral spironolactone B. Oral doxycycline C. Oral isotretinoin D. Topical benzoyl peroxide and clindamycin E. Hormonal oral contraception

Isotretinoin Indications · Severe inflammatory acne (eg, nodular) · Moderate inflammatory acne that forms scars or is treatment resistant Mechanism of action · Normalizes follicular epithelial proliferation & desquamation · Decreases sebum production · Inhibits Cutibacterium acnes proliferation & inflammation Ad verse effects · Teratogenic · Pseudotumor cerebri · Hypertriglyceridemia · Transaminase elevation · Dry skin or mucous membranes · Acne fulminans (initial worsening of acne) Laboratory monitoring · Pregnancy test · Liver function test · Lipid panel Isotretinoin is an oral vitamin A analogue used to treat severe nodulocystic acne or milder acne that produces scars or has failed less aggressive treatments (eg, topical therapy with oral antibiotics, hormone therapy). Isotretinoin inhibits comedogenesis, decreases sebum production, inhibits the proliferation of Cutibacterium acnes, and decreases the C acnes-triggered inflammatory response. Because it treats multiple pathogenic pathways, it is typically used as monotherapy. Because isotretinoin is a teratogen, it is absolutely contraindicated during pregnancy. Exposure can cause spontaneous abortion and severe fetal anomalies. Patients and prescribers must comply with an online risk- management program. For women, 2 negative pregnancy tests are required prior to initiation, and monthly pregnancy testing is required during treatment, which usually lasts several months. In addition, patients must commit to either no sexual contact or use of 2 forms of contraception while on isotretinoin; therefore, this patient taking oral contraceptives should also use barrier contraception. (Choice B) Ocular adverse effects of isotretinoin include dry eyes (due to meibomian gland dysfunction), decreased night vision, corneal opacities, and pseudotumor cerebri, which may lead to headache, vision changes, and papilledema. However, a baseline eye examination is not usually needed, unless the patient reports ocular symptoms. (Choice C) There is no evidence that isotretinoin causes depression and suicide. A baseline psychiatric examination is not typically performed unless the patient reports a history of psychiatric illness, is symptomatic, or has a family history of depression or suicide. (Choice D) Tetracyclines (eg, doxycycline) should not be administered with isotretinoin due to the risk for idiopathic intracranial hypertension (pseudotumor cerebri). Isotretinoin is typically used as monotherapy because it targets every aspect of acne pathogenesis. (Choice E) Tuberculin skin testing is recommended prior to the initiation of certain immunosuppressive therapies (eg, biologic disease-modifying agents for rheumatoid arthritis). Isotretinoin is not an immunosuppressant, so testing is not necessary. Educational objective: Isotretinoin is indicated for severe nodulocystic acne or milder acne that produces scars or has failed less- aggressive treatments (eg, topical therapy with oral antibiotics or hormone therapy). It is teratogenic; therefore, women require pregnancy testing prior to and periodically during therapy and must use 2 forms of contraception.

A 16-year-old girl comes to the office due to severe acne on her face and upper back. The patient has a 2-year history of acne that has worsened over the past several weeks. She has used benzoyl peroxide cleansers, topical retinoids, and oral antibiotics with only minimal relief. The patient is sexually active and takes a combined oral contraceptive. Examination findings are shown in the image above. Two serum hG levels are negative, and the remainder of the laboratory evaluation is normal. Oral isotretinoin therapy is planned. Which of the following additional interventions is most appropriate in this patient? A. Additional barrier contraceptive use B. Baseline complete eye examination C. Baseline psychiatric evaluation D. Concomitant oral doxycycline therapy E. Tuberculin skin testing prior to treatment

The girl has examination findings consistent with acne vulgaris. Acne vulgaris is the most common cutaneous disorder affecting adolescents and young adults. It is a disease of pilosebaceous follicles. Four factors are involved: follicular hyperkeratinization, increased sebum production, Propionibacterium acnes within the follicle, and inflammation. The microcomedo is considered the precursor for the clinical lesions of acne vulgaris, including closed comedones, open comedones, and inflammatory papules, pustules, and nodules. Acne vulgaris typically affects those areas of the body that have the largest, hormonally responsive sebaceous glands, including the face, neck, chest, upper back, and upper arms. Young adolescents often have primarily comedonal acne consisting of noninflammatory lesions (closed or open comedones) involving the forehead, nose and chin. And as the acne progresses, patients develop inflammatory lesions (papules, pustules, and nodules) Common features of acne rosacea (A) include erythema, telangiectasias, and papules or pustules on the central face. There are no comedones in acne rosacea. Perioral dermatitis (C) is characterized by small, grouped, erythematous papules in a perioral (or occasionally perinasal or periorbital) distribution. When the perioral skin is involved, a rim of spared skin is usually seen around the vermilion border of the lip. Sebaceous hyperplasia (D) is due to visible enlargement of sebaceous glands. It most commonly occurs in adults with a history of oily skin. These growths are umbilicated yellowish papules are most commonly found on the forehead and cheeks.

A 16-year-old girl is in the clinic because of bumps on her face. She noted these for the past couple of weeks that seem to worsen whenever she gets her period. On physical examination, there are multiple open and closed comedones on the nose and multiple erythematous papules and pustules on the nose and cheeks. Which of the following is the most likely diagnosis? A. Acne rosacea B. Acne vulgaris C. Perioral dermatitis D. Sebaceous hyperplasia

This patient is presenting with persistent acne vulgaris that is refractory to topical benzoyl peroxide and retinoids. The next step in management is topical antibiotics. Acne vulgaris typically presents with erythema, pustules, and comedones typically in young males going through puberty. The management of acne vulgaris, in order, is the following: 1. Topical benzoyl peroxide and topical retinoids 2. Topical antibiotics 3. Oral antibiotics 4. Isoretinoin It is important to try a therapy for a proper duration before switching to a more invasive therapy. Figure A demonstrates acne vulgaris with comedones. Incorrect Answers: Answer 1: Continue current therapy for 1 more month is unnecessary as this patient's symptoms have not improved at all with 1 month of therapy. Continuing current therapy would be appropriate if the patient had only given a few days to the therapy. Answer 2: Dietary interventions have not been shown to improve outcomes in acne vulgaris. Answer 3: Isoretinoin is the last-line therapy for acne vulgaris. It should not be given to pregnant women as it is teratogenic. Female patients taking isoretinoin should be on reliable birth control. Answer 4: Oral antibiotics would be indicated after topical antibiotics fail. Bullet Summary: The management of acne vulgaris in order is: 1. topical benzoyl peroxide/retinoids 2. topical antibiotics 3. oral antibiotics 4. isoretinoin.

A 17-year-old boy presents to his primary care physician with a chief concern of "bad" skin that has not improved despite home remedies. The patient states that he has had lesions on his face that have persisted since he was 13 years of age. He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school. Physical exam is notable for the findings in Figure A. The patient is started on benzoyl peroxide and topical retinoids. He returns 1 month later stating that his symptoms are roughly the same. Which of the following is the next best step in management? A. Continue current therapy for 1 more month B. Dietary intervention C. Isoretinoin D. Oral antibiotics E. Topical antibiotics

This patient has worsening inflammatory acne vulgaris despite appropriate initial treatment. Acne is characterized by obstruction of the pilosebaceous follicle by abnormal kératinocyte proliferation (ie, hyperkeratinization) in association with the excessive accumulation of sebum. The resulting comedone is colonized by Cutibacterium acnes, which triggers an inflammatory response. Initial management of inflammatory acne includes a topical retinoid (eg, tazarotene, tretinoin), which inhibits comedogenesis, and benzoyl peroxide, which has bactericidal activity against C acnes. However, when this initial regimen is ineffective, a topical antibiotic (eg, clindamycin) may be added. Oral antibiotics (eg, doxycycline) are also effective and useful when topical agents are ineffective or impractical (eg, widespread inflammatory acne affecting the back). (Choice A) Androgens enhance sebum production and facilitate C acnes colonization. Spironolactone is an antiandrogenic agent that can be used to treat women whose inflammatory acne does not respond to topical treatment or who have androgen excess (eg, polycystic ovary syndrome). Because it can cause feminization of male fetuses, it is contraindicated in sexually active women who do not use contraception. This patient is not on maximum topical therapy; spironolactone is not indicated at this time. (Choice C) Topical hydrocortisone is a corticosteroid used to treat inflammatory dermatoses (eg, eczema, psoriasis) but is not indicated in acne. The inflammatory change in acne is due to bacteria and usually improves with antibiotic therapy. (Choice D) Topical salicylic acid is a comedolytic agent that has mild anti-inflammatory properties. It can be considered for inflammatory acne in patients who do not tolerate retinoids; however, retinoids are more effective and generally preferred. (Choice E) Oral isotretinoin is typically used to treat severe, inflammatory nodulocystic acne, but it is teratogenic and can cause serious adverse effects (hypertriglyceridemia, pseudotumor cerebri); women who are sexually active must be on 2 forms of contraception. Educational objective: Inflammatory acne is treated with topical retinoids and benzoyl peroxide. When this regimen is inadequate, the addition of topical or oral antibiotics is recommended.

A 17-year-old girl comes to the office due to worsening acne. The patient has scattered papules and pustules with mild-to-moderate redness on the cheeks. The lesions are not painful, and there is no scarring. The patient has been using topical retinoid and benzoyl peroxide for 2 months without improvement. She is sexually active and is not using consistent contraception. On examination, there is moderate pustular acne with erythema on the cheeks. Which of the following is the best next step in management of this patient? A. Add oral spironolactone B. Add topical clindamycin C. Add topical hydrocortisone D. Add topical salicylic acid E. Switch to oral isotretinoin

Topical retinoids are pregnancy class C and should generally be avoided in pregnancy. Acne vulgaris is a very common disorder of the pilosebaceous follicles. Age of onset is usually between 10-17 years in females and 14-19 years in males. Acne tends to be more severe in males. Family history of acne is a strong risk factor for the development of acne. Other risk factors include certain medications (e,g, phenytoin, lithium, glucocorticoids, androgens), emotional stress, and occlusion and pressure on the skin. No conclusive evidence has correlated diet with increased risk or worsening of acne. Acne is caused by keratin plugs, which allows androgens and Propionibacterium acnes to interact. Acne lesions are usually located in areas with the largest, hormonally-responsive glands such as the face, neck, chest, upper back, and upper arms. Comedones are the main lesion associated with acne. Comedones can be open (blackheads) or closed (whiteheads). Other lesions include papules, pustules, and nodules. Severe acne is characterized by sinus tracts, caused by merged nodules. The severity of acne is based on lesion type, scarring, presence of sinus tracts, therapeutic response, and psychological impact of acne. The diagnosis of acne is based on physical examination. However, if there is high clinical suspicion for an underlying disorder, such as polycystic ovarian syndrome, certain laboratory tests may be required. Topical retinoids, topical antibiotics, or benzoyl peroxide are usually first-line medications for management of mild to moderate inflammatory acne. Oral antibiotics in combination with a topical retinoid and benzoyl peroxide are recommended for moderate to severe acne. Severe, recalcitrant, nodular acne is an indication for oral isotretinoin. Oral isotretinoin is pregnancy class X. Topical azelaic acid (A), topical clindamycin (B), and oral erythromycin (D) are all pregnancy safety class B and are generally considered safe to used during pregnancy if treatment during pregnancy is necessary.

A 22-year-old gravida 1, para 0 woman presents to her obstetrician seeking advice on safe treatment of her acne. She has had acne for many years but is not using any treatment currently due to her fears of potential pregnancy complications. Which of the following medications should this patient avoid? A. Oral erythromycin B. Topical azelaic acid C. Topical clindamycin D. Topical retinoids

Acne is a chronic inflammatory skin disease that is the most common skin disorder in the United States. Therapy targets the four factors responsible for lesion formation: increased sebum production, hyperkeratinization, colonization by Propionibacterium acnes, and the resultant inflammatory reaction. Oral isotretinoin is appropriate treatment for patients with moderate to severe acne that is predominantly nodulocystic and resulting in scars. However, it is also a potent teratogen. Patients must agree to pregnancy tests before and during use as well as two lines of contraception unless continuously abstinent. Other side effects are elevated cholesterol, triglycerides, LFTs, as well as depression, joint pain, and skin dryness. Recall the other treatments for acne. Benzoyl peroxide is a useful first line approach for comedones. Topical tretinoin can be used with benzoyl peroxide in severe cases. Topical antibiotics (erythromycin or clindamycin) are useful for inflammatory cysts and may also be given systemically. Controversies associated with isotretinoin therapy for acne include the risk of depression or suicide, inflammatory bowel disease, and the iPledge program. A small amount of patients experience depression which stops after the drug is discontinued. Despite the iPledge program, a small number of women still become pregnant on the drug. Benzoyl peroxide, not isotretinoin, is the first line approach for comedones (D). Isotretinoin is associated with developing depression not bipolar disorder (C). Patients require a pregnancy test prior to beginning the medication, not after initiating the medication (A)

A 28-year-old woman presents to your office with a long history of acne and she is desperate for the correct treatment. She has suffered from acne her entire life and nothing has seemed to work. Her past treatments include benzoyl peroxide, topical tretinoin, and oral and topical antibiotics, yet there was no improvement. She has no significant past medical history. Her physical examination is within normal limits with the exception of prominent scarring and nodulocystic acne. You begin her on the most appropriate treatment for this clinical scenario. Regarding this medication, which of the following is true? A. Patients should have a pregnancy test after starting the medication B. Prior to starting the medication, the patient must agree to use two forms of contraception C. The medication is associated with development of bipolar disorder D. The medication is indicated as a first-line approach for comedone

This patient presents with new onset acne without comedones after recent exposure to glucocorticoids, most consistent with steroid-induced acne. Steroid-induced acne may occur after systemic or topical exposure to glucocorticoids and is thought to be a result of increased sebum production. In contrast to acne vulgaris, it often lacks comedones and is more monomorphous. Treatment includes standard topical therapies for acne (benzoyl peroxide with clindamycin, salicylic acid, etc.) and cessation of the offending drug. Figure A shows diffuse pink papules on the forehead, consistent with steroid-induced acne. Incorrect Answers: Answer 2: Comedogenic face cream can cause or worsen acne vulgaris, but it is unlikely to result in such a diffuse presentation. Furthermore, such products often lead to formation of comedones, rather than the more monomorphic lesions seen in this patient. Answer 3: Polycystic ovary syndrome (PCOS) can lead to acne as a result of androgen excess. However, such acne is often centered on the jawline and chin. Although this patient does have a history of infertility, she states she has regular periods, making PCOS less likely. Answer 4: Acne vulgaris is most common amongst teenagers and tends to present with comedones or cystic lesions. While it can be seen in adults, it typically does not occur so rapidly and diffusely. Answer 5: Vancomycin is an antibiotic commonly used in the hospital setting for broad gram-positive coverage, including methicillin resistant Staphylococcus aureus (MRSA). It has not been linked to the development of acne. Bullet Summary: Glucocorticoid use can cause steroid-induced acne, which typically presents as monomorphic papules without comedones.

A 32-year-old female presents to her primary care physician with new onset, progressively worsening acne over the last two weeks. She states that she had acne as a teenager, but it had long since resolved until this episode. She wonders if her acne is due to a new face cream, which she started using several weeks ago. Past medical history is significant for systemic lupus erythematosus (SLE), and last month she was admitted to the hospital for massive hemoptysis, which was found to be diffuse alveolar hemorrhage due to an SLE flare. During her lengthy hospital stay, she received pulse-dosed intravenous glucocorticoids. She also received vancomycin for a suspected infection. The patient's history is also notable for one year of infertility, for which she is seeing a specialist. She has regular menses every 28 to 30 days. At this visit, the patient's temperature is 98.4°F (36.9°C), pulse is 70/min, blood pressure is 131/78 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are normal, and there are diffuse papules on her face, with a representative photo shown in Figure A. What is the most likely etiology of this patient's skin condition? A. Glucocorticoid use B. Comedogenic face cream C. Polycystic ovary syndrome D. Acne vulgaris E. Vancomycin use

Reducing the amount of skin oil is accomplished by reducing the size of the sebaceous glands and thus decreasing sebum production. Close monitoring is required with isotretinoin due to the potential for significant side effects including: harmful birth defects, depression, increased risk of suicide, and inflammatory bowel disease. Also, dry skin, dry mouth, pruritus, and myalgias are among other side effects that have been reported. Killing bacteria (A) is the mechanism of action of antibiotics such as the tetracyclines that are commonly used. However, the secondary effect of isotretinoin is elimination of Cutibacterium acnes since these bacteria are dependent on sebum for survival. Reducing the effects of hormones (C) is the mechanism of action of low dose birth control pills. Unplugging skin pores and preventing them from getting replugged (D) is the mechanism of action of tretinoin and other retinoids.

The drug isotretinoin was pulled from the market in 2009 but is still available in limited form. This is a treatment for recalcitrant acne that works by which of the following mechanism of action? A. Killing bacteria B. Reducing the amount of skin oil C. Reducing the effects of hormones D. Unplugging skin pores and preventing them from getting replugged