Acne, Rosacea, HS etc Flashcards
What are indications for hormonal investigation in acne?
Sudden onset acne Late onset acne Pre-pubertal onset acne Acne persisting into adulthood Very severe acne Therapy resistant acne or rapid relapse after isotretinoin Unusual features; - Many comedones - Hyperseborrhoea - Periorifical distribution
Also in women only if signs of hyperandrogenism;
- Irregular menses
- Hirsuitism
- Alopecia
- Acanthosis nigricans
Extracutaneous signs of virilisation;
- Clitoromegally
- Increased muscle mass
- Deep voice
symptoms of;
Pituitary tumour – visual field defects, headache, galactorrhea
PCOS – obesity, oligomenorrhoea, infertility, insulin resistance
Cancer – Wt loss, abdominal distention, post-menopausal bleeding etc
T/F
skin with acne fluoresces under Woods lamp
True
due to porphyrins produced by P acnes
orange-red
What are the patho-aetiological factors in acne?
Increased sebum production (seborrhoea)
Hypercornification of pilosebaceous duct (results in comedones)
Abnormality of skin flora esp Propionibacterium Acnes colonization
Inflammation
What is ‘physiological acne’?
Some use this to mean mild teenage acne
Some authors include ongoing occasional acne spots in adults as physiological acne
What is late-onset acne?
acne adultorum or acne Tarda
begins after age 25
Affects 20% of women (mostly in 30s) and 10% of men
50% have FHx of late onset acne (acne adultorum or acne Tarda)
Men more likely to get late onset cystic, scarring or conglobate acne
What are the associations of acne?
XYY syndrome Aperts syndrome SAPHO, PAPA and PAPASH syndromes Acne keloidalis nuchae Follicular occlusion tetrad Dariers disease – may have nodular or conglobate acne Hormonal imabalance; - PCOS - HAIR-AN - Late adrenal hyperplasia or adrenal tumour - Ovarian tumour Depression Seborrhoea alone linked to acromegally and Parkinsonism
Which factors trigger or exacerbate acne?
Stress Humidity Sweating Menstrual cycle Androgen excess Chemicals - oil, tar, asbestos, halogentaed hydrocoarbons Drugs - cortocosteroids, anabolic steroids, acneiform rcns Cosmetics/pomades Detergents Diet - milk, high GI, chocolate Smoking - unclear
T/F
UV makes acne worse
False
no evidence for this
How are comedones classified?
Closed comedones have no visible skin opening – may need to stretch skin to see – about 1mm
‘sandpaper comedones’ – multiple very small whiteheads esp on forehead
Macrocomedones – large white/black heads bigger than 1mm diameter
‘submarine’ comdones – deep large closed comedones >5mm diameter – often become inflammatory nodules
‘secondary’ comedones part of acne due to an external factor
What hormone tests should be considered in unusal presentations of acne?
Hormone profile – do at 8am on day 3 of menstrual cycle (not on OCP for at least 2 months) o Total and free testosterone o 17(OH) progesterone o SHBG o DHEAS o Androstenedione o Prolactin o LH and FSH o Oestradiol o TFTs o 8am cortisol If Cushings suspected order dexamethasone suppression test (alternative is 24hr urinary cortisol repeated x 2) Oral glucose tolerance test – Identifies insulin resistance in PCOS, HAIR-AN or overweight pts IGF1 – raised in acromegally
What tests other than hormones might be prudent in acne pts?
Baseline
- Lipid profile
- Fasting BSL
- FBC, ELFT (esp potassium if spironolactone planned)
If depression/fatigue symptoms;
TFTs, iron studies, vitamin-D to rule out organic cause
Imaging
USS ovaries if Raised testosterone/hirsuitism/AGA(MPHL)/irregular periods/raised LH
CT or MRI imaging of adrenals
MRI brain – if hyperprolacinaemia
What are DDs of acne?
Rosacea (older pts, flushing, no comedones, nodules, cysts or scarring) Possible to have acne and rosacea
Periorificial dermatitis (itchy, dry, no comedones)
Acne excoriee
Pityrosporum folliculitis (esp upper trunk)
Candida folliculitis
Staph epidermidis folliculitis
Demodex folliculitis
Milia
Plane warts
DH can present as vesiculopustular facial eruption – v itchy
Linear IgA may rarely present as popular facial rash, no comedones
Acne agminata (light brown lesions, apple jelly diascopy)
Adenoma sebaceoum (tuberous sclerosis)
Micropapular facial sarcoid
Zinc deficiency facial eruption (esp after prolonged TPN)
Acne necrotica (varioliformis) – see below
Behcets disease
Acneiform drug eruptions
Dental sinus
Cervicofacial actinomycosis
Can be acneiform lesions with giant comedones in folliculotropic MF/follicular mucinosis
Inflamed epidermoid cyst
What are poor prognsotic factors for acne?
Fam Hx Early onset Hyperseborroea Site – truncal acne Scarring Persistant/ resistant to Rx
How can acne be graded?
Can use an assessment tool Otherwise at least document o Inflammatory or non-inflammatory o Comedonal o Nodular (‘nodulocystic’) o Mild/mod/severe
T/F
Retinoids are important for all types of acne
True
as they act on microcomedones – precursors of comedones and inflammatory lesions
topical retinoid options;
Tretinoin cream/gel 0.025-0.1% (Retin-A, Stieva-A); 1st gen
Isotretinoin 0.05% gel (Isotrex); 1st gen
Tazarotene 0.1% cream (Zorac); 3rd gen (may be more effective than adapalene)
Adapalene 0.1% cream/gel (Differin); 3rd gen
T/F
Topical retinoids in early pregnancy are high risk for birth defects
False
2015 BJD Rw confirms no evidence of birth defects or any other pregnancy problem in women exposed to topical retinoids in first trimester – can reassure women exposed by accident
but should still avoid if preg/planned preg
Which antibiotics can be used for acne?
Tetracyclines 1st line
Doxycycline 50-200mg/day - 50mg just as good as higher doses
Minocycline 100-200mg/day - not much used as AEs
Erythro 1st line if age under 12/pregnant/breast feeding
- EES 400/800mg BD or 500mg erythro BD
Trmethoprim 3rd line 400-600mg/day in divided dose
Cepahlexin ??500mg TDS
Co-trimoxazole - side effects limit use
Azithromycin 250mg 3x per week - not used much as resistance could be problematic
Ciprofloxacin - not used much as resistance could be problematic
Dapsone 100-300mg daily hase some evidence
What are the indications for hormonal treatments in women with acne?
Failed antibiotics or CIs/AEs to antibiotics
Significant premenstrual flares
Clinical or laboratory hyperandrogenism (after investigation)
Want menstrual control or contraception as well as acne Rx
o Isotretinoin not appropriate
T/F
All women on spironolactone need monitoring for hyperkalaemia
False
Recent paper suggests Routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne
Only need to monitor for hyperkalaemia if age>50, renal, liver or cardiac impairment or also taking OCP containing drosepirenone
T/F 3mg drospirenone (as in Yaz/Yasmin) is eqial to 1mg CPA or 25 mg spironolactone
True
Which pts are at risk of a poor response to isotretinoin for acne?
Younger pts Adult women Males Extensive truncal Dx Severe disease macrocomedones Unusual variants Staph colonization Poor absorption – degree of cheilitis is good indicator of absorption (dose-dependent)
What are the indications for oral steroid use in acne?
Settling severe acne while starting isotretinoin
Settling acne fulminans prior to starting isotretinoin
Managing early flare on isotretinoin
Treating acne due to or flared by a hyperactive hypothlamus-pituitary-adrenal axis – e.g. Adrenal hyperplasia, functional adrenal hyperplasia due to chronic stress
T/F
ILCS can be used for active acne
True
good for nodules less than 7 days old
Triamcinolone 2.5mg/ml (A10 diluted 1:4)
Inject 0.025-0.1 ml into middle of lesion
T/F
Cryotherapy can be used for active acne
True
15-30sec DFTC good for nodules older than 7 days
T/F
PDT can be used for active acne
True
Up to 68% improvement demonstrated
Can us ALA or metvix with red light
Painful. Can be oedema, crusting, pustular eruption and pigment change
Topical ALA and broadband (?daylight) light may also help
T/F
Chemical peels can be used for active acne
False
no good evidence for them
T/F
Treatment with oral antibiotics (with exception of rifampicin) does not increase pregnancy rates under co-administration of OCPs
True
T/F
Drugs which inhibit CYP450 3A4 can stop OCP from working
False
Inducers of CYP450 3A4 can stop OCP from working
How can you test for use of exogenous testosterone?
Urine testosterone:epitestosterone ratio
– ratio>6 strongly suggest exogenous testosterone
What are predictors of good or poor adherence to therapy in acne?
Good adherence predictors; Older/more mature female married Good Dr-Pt relationship Shame, embarrassment Once daily drug Gel formulation Isotretinoin
Poor adherence risks; Smoking, alcohol, unemployment Younger age, single, male Psychosocial morbidity – low DLQI, anxiety, depression High cost treatments Dosing more than once a day
What causes should you consider if there is a poor response to acne therapy?
Poor pt education by Dr Poor adherence – may be intolerance or AEs to treatment or not pts preferred Rx Inadequate dose Resistant P. Acnes Development of gram neg folliculitis Wrong diagnosis Refractory subtype consider if unerlying trigger factor that hasnt been addressed eg anabolic steroids, fats, tars
