Adnexal Diseases Past Paper PDF

Adnexal Diseases Lisa Long, PA-C UNM PA Program  Learning Objectives 1. Describe the etiologies, risk factors, and presentation of the conditions listed below: a. Acne Vulgaris b. Rosacea c. Hidradenitis Suppurativa d. Folliculitis...

Adnexal Diseases Lisa Long, PA-C UNM PA Program  Learning Objectives 1. Describe the etiologies, risk factors, and presentation of the conditions listed below: a. Acne Vulgaris b. Rosacea c. Hidradenitis Suppurativa d. Folliculitis e. Pilonidal Disease 2. Formulate a management plan for the dermatological conditions listed above, including use of diagnostics and pharmaceuticals. 3. Describe preventive measures to avoid the skin conditions listed above. 4. Describe the prognosis for the skin conditions listed above.  Acne Vulgaris A common pilosebaceous disorder that affects 85% of people between the ages of 12-24 and 15-35% of adults Clinical presentation can range from mild comedonal acne to severe nodulocystic acne Psychosocial repercussions, including depression, anxiety, and social withdrawal should be considered Pathogenesis Acne Vulgaris: Pathogenesis Dermatology Essentials, 2nd Edition  Acne Vulgaris Why is this happening? 4 Main Contributing Factors  Acne Vulgaris: 4 Main Factors 1. Abnormal Keratinization Keratinocytes are proliferating too fast Keratinocytes are more cohesive than normal “Top layer of skin cells are thicker and stickier than normal” Acne.org  Acne Vulgaris: 4 Main Factors 2. Increased sebum production Increased levels of androgens cause increase in sebum production “ A change in hormones cause more oil production” Acne.org  Acne Vulgaris: 4 Main Factors 3. Propionibacterium acnes overgrowth P. acnes love an oily environment! “The bacteria that causes acne loves the excess oil” Sciencephotogallery.com  Acne Vulgaris: 4 Main Factors 4. Inflammation P. acnes induce inflammation by activating toll-like receptor 2, located on the surface of keratinocytes and macrophages. This causes a release of inflammatory mediators such as IL-1, IL-8, IL-12, and TNF-alpha. “The increase in bacteria cause inflammation”  Acne Vulgaris Additional Triggers Stress Personal care products ○ Foundations, hair spray, pomades ○ Recommend mineral based, non comedogenic products Mechanical ○ Sports gear, masks, musical instruments Medications ○ Anabolic steroids, prednisone, bromides (found in sedatives and cold medicine), lithium, progesterone only contraceptives Diet ○ Mild association between skim milk intake and increase in acne ○ Recommend eating healthy, whole foods and decrease sugar intake  Acne Vulgaris Moderate Mild Severe  Acne Vulgaris: Evaluation and Treatment Start with counseling, very important! Ask them about their skin care regimen or routine Do they know how to wash their face? What products are they using? ○ Too many can worsen acne ○ Keep it simple Do they pick at their pimples? Is today a good day or a bad day? Do they want their acne to improve? Emphasize that the amount of improvement they will see reflects the amount of effort they put in. Consistency is key!!!  Acne Vulgaris: Evaluation and Treatment History Sex, consider transgender identity if appropriate Age ○ If between 2-7 yo consider hyperandrogenism (precocious puberty) Lifestyle, hobbies, occupation Current and previous treatments, including OTC products Use of personal care products Menstrual hx, birth control Medications PMH Family hx of acne  Acne Vulgaris: Evaluation Physical Exam Distribution of acne- look in all locations! ○ Face (T-zone, cheeks, jawline, forehead) ○ Neck, chest, back, upper arms Degree of involvement ○ Mild, moderate, or severe Lesion morphology ○ Comedones ○ Inflammatory papules and pustules ○ Nodules and cysts ○ Scarring  Acne Vulgaris: Treatment Recommended regimen for most acne patients Wash face with warm water twice daily ○ CeraVe, Cetaphil, Vanicream gentle cleansers ○ Depending on type of acne may recommend a benzoyl peroxide wash, sulfur wash, or salicylic wash Apply a moisturizer with SPF 30+ every morning ○ Prevents PIH Apply a non-comedogenic moisturizer in the evening after washing and after after applying any topical treatments ○ CeraVe, Cetaphil, Vanicream  Acne Vulgaris: Treatment Types of treatment: Topical Retinoids ▪ HOW: Comedolytic, decreases hyperproliferation, and has anti-inflammatory effects, so…it’s the most important tx for acne! ▪ WHO: Works well for comedonal acne all the way up to moderate-severe inflammatory acne ▪ WHEN: Start every other night working up to nightly ▪ Contraindicated in pregnancy ▪ SE: Redness, dryness, photosensitivity, retinoid dermatitis ▪ Ex: Retin-A, Tretinoin, Adapalene  Acne Vulgaris: Treatment Types of treatment: Topical Antimicrobials ○ HOW: decreases P. acnes ○ WHO: Appropriate for mild-moderate inflammatory acne ○ WHEN: Once to twice daily, depending on type and severity ○ SE: Dryness, redness, irritation ○ EX: Benzoyl Peroxide (BPO) comes in wash or topical cream/gel. Can be irritating so recommend starting will low percentage, 4%. Can find OTC or can be prescribed. Antibiotic: Clindamycin 1% lotion is my favorite. Must be prescribed ○ They work really well when used together. Wash with a BPO wash, dry the area, then apply topical antibiotic. This also helps decrease antibiotic resistance!  Acne Vulgaris: Treatment Types of treatment: Oral Antibiotics ○ HOW: Anti-inflammatory at lower dose, anti-microbial at higher dose ○ WHO: Used in patients over 8 yo with moderate-severe acne, especially if back, chest, and arms are involved ○ WHEN: once to twice daily, typically used for 3-6 months ○ EX: Tetracyclines (Doxycycline or Minocycline) ○ SE Doxycycline: GI (nausea, vomiting, diarrhea, so recommend taking with glass of water and meal), photosensitivity. ○ SE Minocycline: GI, hyperpigmentation of scars, on shins, or sun exposed areas, discoloration of teeth, vertigo. ○ Contraindicated in pregnancy and under the age of 8 ○ If patient has an allergy consider azithromycin, erythromycin, or bactrim  Acne Vulgaris: Treatment Types of Treatment: Hormonal HOW: inhibit ovarian androgen production which decreases sebum production WHO: females presenting with acne on the jawline, typically flares with menses WHEN: once daily EX: OCPs: FDA-approved for acne: Ortho Tri-Cyclen, Yaz, Estrostep CI: Risks outweigh the benefits if: ○ >35 and smoker ○ History of HTN, diabetes, venous thromboembolism, ischemic heart disease, stroke, current breast cancer or other malignancy  Acne Vulgaris: Treatment Types of Treatment: Antiandrogen (Oral) HOW: androgen antagonist, so decrease sebum production WHO: for hormonal acne, think jawline, typically female only WHEN: 50-200 mg/day EX: Spironolactone Contraindications Spironolactone: renal insufficiency, hyperkalemia, pregnancy, and hx or family hx of breast cancer SE: urinary frequency, orthostatic hypotension, hyperkalemia, irregular menses, breast tenderness, gynecomastia Works well when combined with Yaz Potassium monitoring no longer required if under 45 yo and no history of elevated potassium. Otherwise, potassium checked every 3-6 months.  Acne Vulgaris: Treatment Types of Treatment: Oral Retinoid HOW: Works on all 4 components of acne and decreases the size of sebaceous glands, exact MOA is unknown WHO: Typically used for moderate-severe acne, or recalcitrant acne WHEN: Taken daily for ~6 months, dosed at 0.5-1 mg/kg/day; cumulative dose is 120-150 mg/kg EX: Isotretinoin, “Accutane” SE: Commen: cheilitis, mucosal dryness (nose and eyes), xerosis, headaches, slow healing CI: pregnancy or intending to become pregnant, hypertriglyeridemia, hx severe depression, personal or family hx of IBD  Acne Vulgaris: Treatment Types of Treatment: Oral Isotretinoin Teratogen (craniofacial and cardiac defects), female patients are required to be two forms of birth control and must have monthly pregnancy tests Fasting lipid panel and LFTs monitored for all patients Recommend avoidance of alcohol and following a healthy diet All patients must register with iPledge  Acne Vulgaris: Treatment MILD MODERATE SEVERE Mostly inflammatory: BPO Oral abx, + topical retinoid, Isotretinoin wash/Clindamycin lotion, +/- BPO/Clindamycin lotion topical retinoid Comedonal: topical retinoid Hormonal: anti androgen Topical BPO + oral abx + +/- OCP + topical retinoid topical retinoid (female) Isotretinoin if resistant to previously tried tx plan, scarring, or fhx of scarring  Acne Vulgaris: Patient Education Explain the importance of compliance!!! Help patient understand that the medications won’t “cure” the condition, they will help control the condition. When they see improvement they need to continue treatment. Treatment plan may be modified at fu, but if they stop, the acne will return. Explain that symptoms may get worse before they get better. Don’t fault the medications, they are doing their job. If this happens push through. With patience and consistency, results will be seen!!! Rosacea  Rosacea Inflammatory dermatosis that usually appears in the 4th decade of life Rosacea is chronic and recurrent Seen in all skin types, most common in lighter skin tones Diagnosis is made clinically, based on visible assessment and patient hx  Rosacea: Pathogenesis Related to vascular hyper-reactivity leading to vasodilation It is unclear why vasodilation causes rosacea, one possible reason may be that small amounts of plasma leak for the vessel when vasodilation occurs, stimulating an immune response Some studies suggest an association between Demodex mite (resides in the sebaceous follicle) and rosacea  Rosacea: 4 Types Erythematotelangictatic Recurrent flushing, (Vascular) telangiectasias, spares nasolabial folds Papulopustular Pink to red papules and (Inflammatory) inflammatory pustules Phymatous Hypertrophy and irregular thickening of the nose, forehead, cheeks, chin, or ears; most common in men Symptoms: Burning, stinging, pruritus, “feels like I Ocular have a piece of dirt in my eye”, photophobia. Signs: telangiectasias of sclera, periorbital edema, conjunctivitis  Rosacea: Treatment Erythematotelangiectatic Rosacea Laser or intense pulsed light therapy Use of topical vasoconstrictors (Rhofade) Recommend a gentle skin care regimen and regular use of a physical sunscreen Avoiding triggers may also help  Rosacea: Treatment Papulopustular Rosacea Topical therapy (in conjunction with oral, or maintenance after oral therapy) ○ Ivermectin 1% cream (Soolantra), anti inflammatory ○ Metronidazole 0.75%-1% gel (Metrogel), anti inflammatory ○ Oxymetazoline 1% cream (Rhofade), alpha agonist, vasoconstrictor ○ Sodium Sulfacetamide wash ○ Azelaic acid 15%, anti inflammatory ○ BPO + Clindamycin 1%  Rosacea: Treatment Papulopustular Rosacea Oral therapy (discontinue or taper to lowest effective dose) ○ Doxycycline 100 mg BID for 4-8 weeks, then ○ Doxycycline 40-50 mg daily for ~12 weeks ○ Try and decrease down to 20-50 mg TIW ○ If severe, Isotretinoin 10-40 mg daily for 4-6 months Combination therapy offers best outcome!  Rosacea: Treatment Phymatous Rosacea Oral and topical treatment of rosacea may inhibit the progression, but will not reverse Some evidence that Isotretinoin will reduce the thickening Surgical excision Electrosurgery  Rosacea: Treatment Ocular Rosacea Oral Doxycycline 40 mg daily Recommend sunglasses when outdoors Referral to Ophthalmology  Rosacea: Treatment Recommended Skin Care Wash with warm water and use a gentle soap (CeraVe, Cetaphil, Vanicream) Avoid using gritty scrubs, loofas, wash clothes; use fingers when washing Apply physical sunscreen daily, SPF 30+, and reapply every 2 hrs when outside Moisturizing is very important! Products that contain humectants (glycerin) and occlusives (petrolatum) help keep moisture in the skin Avoid astringents and toners Avoid products with alcohol, menthols, camphor, witch hazel, fragrance  Rosacea: Patient Education Reassure patient that this is a benign condition Rosacea is a chronic condition so be sure patient understands that it can’t be “cured,” only controlled Compliance is important!!! Educate on the importance of sun avoidance and any triggers they may have identified Periorificial Dermatitis  Periorificial Dermatitis Variant of Rosacea Lesions present around mouth and nose > eyes Combination of papules, pustules, and eczematous patches Present in children and adults  Periorificial Dermatitis: treatment Treatment is same as for papulopustular rosacea, but typically requires 4- 8 weeks of oral antibiotics For pediatric patients: topical metronidazole +/- oral abx Folliculitis  Folliculitis An infection of hair follicles Follicular papules or pustules with an erythematous base Pruritic, can be painful Usually in areas with terminal hairs (scalp and beard), but also common on trunk, buttocks, and thighs. Less common in axillae and groin. Normal flora is MC cause, S. aureus is next most common  Folliculitis: treatment Varies with type Start with BPO 10% wash, followed by topical Clindamycin, +/- oral antibiotics (doxycycline) If persistent, culture then treat with appropriate abx If fungal type oral anti fungal meds are usually required ”Hot Tube” folliculitis Hidradenitis Suppurativa  Hidradenitis Suppurativa: Pathogenesis An inflammatory disorder that begins in the hair follicle. Significant inflammation leads to rupture of the follicle, releasing keratin and bacteria into the surrounding area. This leads to abscess formation, draining sinus tracts, and eventually scarring. Genetics, hormones, and lifestyle all play a role in HS ○ 30-40% report a first degree relative with HS ○ Androgens seem to play a role ○ Obesity and smoking worsen HS Typically begins around puberty 3:1 women to men ratio HS can have a significant psychosocial component, please consider this when treating!  Hidradenitis Suppurativa: History Patients typically report a prodrome of itching, burning, stinging, or increased sweating one to two days prior to developing a cyst or boil Triggers ○ Menses ○ Hormonal changes ○ Stress ○ Smoking Onset typically begins at or shortly after puberty Fhx of HS Lesions often described as oozing and smelly May be chronic or intermittent  Hidradenitis Suppurativa: PE Be sensitive!! Patients are very uncomfortable showing anyone, even providers their condition! If the patient is comfortable, examine axillae, groin, and inframammary crease HS is classified into ”Hurley Stages” 1-3 JAAD 5/2020  Hidradenitis Suppurativa: Evaluation Hurley Stage 1: isolated, deep-seated nodule that can last for months and may drain a purulent discharge +/- and odor. No sinus tract formation or scarring Is present.  Hidradenitis Suppurativa: Evaluation Hurley Stage 2: multiple lesions with mild scarring and sinus tract formation. Hidradenitis Suppurativa: Evaluation Hurley Stage 3: diffuse involvement of the area, with multiple abscesses and significant scarring.  Hidradenitis Suppurativa: Treatment Patient Education Discuss weight reduction if appropriate Recommend reducing friction and moisture ○ Wear loose fitting clothes ○ Use powders to help control moisture ○ Use antiseptic soaps such as Chlorhexidine or Hibiclens ○ If excessive sweating is a concern, recommend topical aluminum chloride (DrySol) Apply warm compresses to active lesions Smoking Cessation  Hidradenitis Suppurativa: Treatment Mild or Hurley Stage 1 Wash daily with BPO 10% wash Apply topical Clindamycin 1% lotion after washing with BPO Spironolactone 50 mg BID Doxycycline 100 mg BID for flares. May have to use for an extended period if flares are continuous Intralesional triamcinolone (5mg/ml) injections into early inflammatory lesions If close to Hurley stage 2, begin discussing treatment with biologics (adalimumab)  Hidradenitis Suppurativa: Treatment Moderate-Severe or Hurley Stage 2-3 Same as mild, plus… Now is the time to consider switching to a biological medication ○ This can stop development of new lesions and the progression of tracts as well as preventing further scarring Surgical treatment can be considered ○ Local excision with secondary intention healing If not a candidate for biologic treatment, can consider oral retinoids (acitretin) Journal of the American Academy of Dermatology 2019 8191-101DOI: (10.1016/j.jaad.2019.02.068)  Pilonidal Disease Cyst located in the upper gluteal cleft Sinus tracts are often present Hx of draining a malodorous discharge May be associated with HS, acne conglobate, and dissecting cellulitis (follicular occlusion tetrad) No treatment required unless the cyst is irritated. Incision & Drainage, oral antibiotics, surgical removal of cyst and sinus tracts are options depending on severity. Follicular Tetrad Cases A 53 yo female presents to clinic with a 10 year intermittent hx of pimple like bumps on her cheeks and forehead. She says she has also noticed that her face has become more red, especially when she drinks red wine. A 12 yo boy presents with his mother to clinic with concerns about acne that has recently developed on his forehead. He says he does not wash his face regularly and has not tried any OTC or prescription medications. He is not that worried about it, but his mother is afraid he will develop cystic acne given his father’s hx of severe, scarring acne. She would like to know if he is a candidate for Accutane. An 18 yo female with a hx of metabolic disease presents to clinic with a 4 year history of “bumps” in her both of her armpits and some in her bikini area. She says that they hurt, smell bad, and ooze. She is unable to have a relationship because she is so embarrassed of the lesions. She has never discussed the problem with anyone, not even her PCP. She also admits to smoking ½ pack of cigarettes per day and drinking 2-4 drinks daily. A 42 yo female presents to clinic with acne primarily on her jawline. It started about 9 months ago and she describes it as hard pimples that are tender and can’t be popped. She had acne as a teenager, but only an occasional pimple since then. She does not take any medications and is otherwise healthy. She is only using a gentle cleanser and sunscreen daily, no OTC or prescriptions for acne at this time. A 24 yo male presents with a 3 year hx of pustular acne on his face, back, and chest. He denies the use of anabolic steroids and is not taking any other medications. He is using an acne “kit” that his mother bought him, but he’s not sure what exactly is in it, only that it has three steps. He tries to use it regularly, but given his work schedule it’s hard to keep up with it. He saw a Dermatologist when he was in high school and thinks he was given a cream and a pill for a few months. He doesn’t think they helped. He denies using tobacco products, but states that he drinks and uses marijuana regularly. Thank You!