Dermatology Quiz on Acne and Related Disorders

Adnexal Diseases

• This presentation covers various skin conditions affecting hair follicles and glands.
• The learning objectives include describing the etiologies, risk factors, and presentations of specific conditions like acne vulgaris, rosacea, folliculitis, and hidradenitis suppurativa.
• A management plan will be formulated, including diagnostics and pharmaceuticals.
• Preventive measures and prognoses for the listed conditions will be studied.

Acne Vulgaris

• Acne vulgaris is a common pilosebaceous disorder affecting 85% of people aged 12-24 and 15-35% of adults.
• Clinical presentations range from mild comedonal acne to severe nodulocystic acne.
• Psychosocial repercussions like depression, anxiety, and social withdrawal can occur and need to be considered.

Acne Vulgaris: Pathogenesis

• Acne vulgaris involves the following stages:
  • Microcomedo: Sebaceous lobule gets clogged.
  • Comedo: Follicular plug obstructs the follicle.
  • Inflammatory papule/pustule: Bacteria and inflammation begin to grow.
  • Nodule/cyst: The condition worsens with deep-seated inflammation.

Acne Vulgaris: 4 Main Contributing Factors

• Abnormal Keratinization: Excessive proliferation of keratinocytes creates a thickened, sticky layer leading to clogged pores.
• Increased Sebum Production: Increased androgen levels stimulate sebaceous glands to produce excess oil, creating a breeding ground for bacteria.
• Propionibacterium acnes Overgrowth: This bacterium thrives in the oily environment, exacerbating inflammation.
• Inflammation: P. acnes triggers an inflammatory response by activating immune cells and mediators in the affected area.

Acne Vulgaris: Additional Triggers

• Stress
• Personal care products (like foundations, hair products that are comedogenic)
• Mechanical irritants (sports gear, masks)
• Medications (like anabolic steroids, prednisone, certain cold medicines).
• Diet (some association between skim milk intake and increased acne).

Acne Vulgaris: Evaluation and Treatment

• History: Gathering patient information regarding sex, age, lifestyle, current treatments, use of personal care products, menstrual history, medications, and family history of acne is crucial for a thorough evaluation.
• Physical Exam: The physical exam assesses distribution, degree of involvement, and lesion morphology including comedones, inflammatory papules and pustules, nodules, and cysts, and scarring.
• Treatment: Different treatment options are available depending on the severity. Topical retinoids, topical antimicrobials, oral antibiotics, hormonal therapies, and oral retinoids are some possibilities.

Rosacea:

• Rosacea is a chronic and recurrent inflammatory dermatosis.
• It most commonly appears in the 4th decade of life and impacts all skin types although it's most apparent in individuals with fair skin tones.
• It's diagnosed clinically through assessment of visible signs and patient history

Rosacea: Pathogenesis

• Rosacea is linked to vascular hyper-reactivity resulting in vasodilation.
• Some studies suggest a correlation between the presence of Demodex mites in the sebaceous follicles and rosacea.

Rosacea: 4 Types

• Erythematotelangiectatic Rosacea: Characterized by recurrent flushing, telangiectasias (small, visible blood vessels), which are typically not found on nasal folds.
• Papulopustular Rosacea: Visible pink to red papules and pustules develop most often on the central face (nose, forehead, cheeks, chin).
• Phymatous Rosacea: Thickening and irregularity in the skin, most frequent on the nose, cheeks, forehead, and chin. More common in men than women.
• Ocular Rosacea: Symptoms involve burning, stinging, or a feeling of a foreign body in the eye, along with photophobia (sensitivity to light).

Rosacea: Treatment

• Erythematotelangiectatic: Laser or light therapy, topical vasoconstrictors, gentle skincare routine, and sunscreen.
• Papulopustular: Topical treatments (such as ivermectin, metronidazole, oxymetazoline, azelaic acid, BPO+Clindamycin) may be used in conjunction with or as a follow up to oral antibiotics (doxycycline).
• Phymatous: Oral and topical treatments can potentially inhibit progression, but may not reverse existing thickening. Surgical options like excision or electrosurgery may be necessary.
• Ocular: Oral Doxycycline, sunglasses, and referral to an ophthalmologist.

Rosacea: Recommended Skin Care

• Wash with gentle soap (like Cetaphil or CeraVe) and warm water, avoiding harsh scrubs.
• Use products with humectants (like glycerin) and occlusives (like petrolatum) in moisturizers to help hydrate the skin.
• Avoid alcohol, menthols, and other irritating ingredients.
• Use physical sunscreen (SPF 30+) and reapply frequently.

Periorificial Dermatitis:

• It's a rosacea variant.
• Lesions are usually found around the mouth and nose and may include papules, pustules, and eczematous patches.
• It affects children and adults.

Periorificial Dermatitis: Treatment

• Similar treatment to papulopustular rosacea, but may take 4-8 weeks of oral antibiotics.
• Children typically respond to topical metronidazole, but may require oral antibiotics.

Folliculitis:

• An infection of hair follicles.
• Often presents as follicular papules or pustules on an erythematous base.
• Commonly affecting areas with terminal hairs—the scalp, beard, trunk, buttocks, and thighs, although less often in axillae and groin.
• Can be itchy and painful. Normal skin flora and S. aureus are commonly implicated.

Folliculitis: Treatment

• Treatment varies based on the type of folliculitis.
• Benign cases typically respond to topical benzoyl peroxide (BPO) and topical clindamycin with or without oral antibiotics like doxycycline.
• If persistent or recurs, cultures are beneficial to identify the exact cause, guiding an appropriate treatment response.
• In cases of fungal folliculitis, oral antifungal medications may be required.

Hidradenitis Suppurativa:

• A chronic inflammatory disorder that starts in hair follicles.
• Marked by inflammation that ruptures the follicle, releasing bacteria into the surrounding area.
• Subsequently, abscesses, draining sinus tracts, and scarring may develop.

Hidradenitis Suppurativa: History & Pathogenesis

• Patients may experience itching, burning, stinging, increased sweating or oozing in the days or weeks leading up to development of cysts or boils.
• Common triggers include menses, hormonal changes, stress, smoking, obesity
• Genetic factors, hormones, and lifestyle choices play important roles in this condition.
• This condition usually starts in or around puberty.

Hidradenitis Suppurativa: Evaluation

• Patients are evaluated considering physical sensitivity. The examination involves checking axillae, groin, and inframammary crease.
• The condition presents in Hurley stages. -Stage 1: Isolated, deeper nodules that can last for months and may ooze. -Stage 2: Multiple lesions that involve mild scarring and sinus tracts. -Stage 3: Diffuse lesions, multiple abscesses, and significant scarring.

Hidradenitis Suppurativa: Treatment

• Mild (Hurley Stage 1): Washing with a benzoyl peroxide wash, Clindamycin lotion, spironolactone, and potentially intralesional injections of triamcinolone.
• Moderate-Severe (Stages 2-3): Similar to mild cases but with additional treatment options like topical and oral retinoids, switching medication regimens to include a biological (like adalimumab), and surgical interventions.
  • Surgical considerations include local excision, deroofing or wide-area surgical excision.

Pilonidal Disease:

• A cyst found in the upper gluteal cleft, characterized by a malodorous discharge through sinus tracts, possible association with HS.
• This is usually addressed with incision and drainage followed by oral antibiotics, and surgical removal for severely affected cases.

Follicular Tetrad:

• A combination of acne conglobata, dissecting cellulitis, and hidradenitis suppurativa.

Cases

• Presented cases illustrate clinical scenarios for acne vulgaris, rosacea, and/or hidradenitis suppurativa.
• They include details regarding patient age, symptoms, duration, and family history, facilitating differential diagnosis and appropriate treatment planning.

Test your knowledge on common skin disorders like Acne Vulgaris, periorificial dermatitis, and hidradenitis suppurativa. This quiz covers treatment duration, causes, contributing factors, and psychosocial impacts. Perfect for aspiring dermatologists or anyone interested in skin health.