Page 145 - TNFlipTest

Toronto Notes 2019 Acneiform Eruptions Acneiform Eruptions
Acne Vulgaris/Common Acne
Clinical Presentation
• acommoninflammatorypilosebaceousdiseasecategorizedwithrespecttoseverity ■ Type I: comedonal, sparse, no scarring
■ Type II: comedonal, papular, moderate ± little scarring
■ Type III: comedonal, papular, and pustular, with scarring
■ Type IV: nodulocystic acne, risk of severe scarring • sitesofpredilection:face,neck,upperchest,andback
Pathophysiology
• hyperkeratinizationatthefollicularostia(opening)blocksthesecretionofsebumleadingtothe formation of microcomedones
• androgenspromoteexcesssebumproduction
• Propionibacterium acnes metabolize sebum to free fatty acids and produces pro-inflammatory
mediators
Epidemiology
• ageofonsetinpuberty(10-17yrinfemales,14-19yrinmales)
• in prepubertal children consider underlying hormonal abnormality (e.g. late onset congenital adrenal
hyperplasia)
• incidencedecreasesinadulthood
• geneticpredisposition:majorityofindividualswithcysticacnehaveparent(s)withhistoryofsevere
acne
Differential Diagnosis
• folliculitis,keratosispilaris(upperarms,face,thighs),perioraldermatitis,rosacea
Dermatology D11
Treatment of Acne Scars
• Tretinoin creams
• Glycolic acid
• Chemical peels for superficial scars
• Injectable fillers (collagen, hyaluronic acid)
for pitted scars
• Fraxel laser
• CO2 laser resurfacing
Acne Myths Debunked
• Eating greasy food and chocolate does not cause or worsen acne
• Blackheads (comedones) are black because of oxidized fatty acids, not dirt
• Acne is not caused by poor hygiene; on the contrary, excessive washing of face can be an aggravator
Antibiotics are used in inflammatory skin conditions since they also have anti- inflammatory properties (e.g. macrolides in acne). Topical antibiotics may also be used to treat secondary bacterial superinfections (e.g. impetigo)
Acne Exacerbating Factors
• Systemic medications: lithium, phenytoin, steroids, halogens, androgens, iodides, bromides, danazol
• Topical agents: steroids, tars, ointments, oily cosmetics
• Mechanical pressure or occlusion, such as leaning face on hands
• Emotional stress
A combination of topical retinoids and topical erythromycin or clindamycin is more effective than either agent used alone
Intralesional Injections
Intralesional corticosteroid injections are effective in the treatment of individual acne nodules
Isotretinoin and Pregnancy
• Use of Isotretinoin during pregnancy is associated with spontaneous abortion and major birth defects such as facial dysmorphism and cognitive impairment
• Pregnancy should be ruled out before starting isotretinoin
• Patients should use 2 forms of contraception while on isotretinoin
Table 10. Management of Acne
Compound/Drug Class Product Names
MILD ACNE: Topical Therapies OTC
Notes
Helps prevent P. acnes resistance, is a bactericidal agent (targets P. acnes) and is comedolytic
Used when patients cannot tolerate a topical retinoid due to skin irritation
High rate of resistance when used as monotherapy
Backbone of topical acne therapy
All regimens should include a retinoid unless patient cannot tolerate
Allows for greater adherence and efficacy
Combines different mechanisms of action to increase efficacy and maximize tolerability
Use caution with regard to drug interactions: do not use with isotretinoin
Sun sensitivity
Antibiotics require 3 mo of use before assessing efficacy
After 35 yr of age, estrogen/progesterone should only be considered in exceptional circumstances, carefully weighing the risk/benefit ratio with physician guidance
May cause hyperkalemia if concurrent renal dx Black box warning for breast cancer
See Table 27 for full side effect profile
Most adverse effects are temporary and will resolve when the drug is discontinued
Baseline lipid profile (risk of hypertriglyceridemia), LFTs and β-hCG before treatment
May transiently exacerbate acne before patient sees improvement
Refractory cases may require multiple courses of isotretinoin
Benzoyl peroxide (BPO) Salicylic acid
Solugel, Benzac, Desquam, Fostex Akurza® Cream, DermalZone
MILD ACNE: Prescription Topical Therapies
Antimicrobials Retinoids
Combination products
MODERATE ACNE
Tetracycline/Minocycline/ Doxycycline
Cyproterone acetate-ethinyl estradiol
Spironolactone (source ADA)
SEVERE ACNE Isotretinoin
Clindamycin (Dalacin T), Erythromycin
Vitamin A Acid (Tretinoin, Stieva-A, Retin A) Adapalene (Differin)
Clindoxyl (Clindamycin and BPO) Benzaclin (Clindamycin and BPO) Tactuo (Adapalene and BPO)
Biacna (Clindamycin and Tretinoin) Benzamycine (BPO and Erythromycin)
Sumycin/Minocin/Vibramycin
Diane-35® Aldactone
Accutane®, Clarus®, Epuris®