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D12 Dermatology
Important Controversies Associated with Isotretinoin Therapy for Acne
Am J Clin Dermatol 2013;14:71-76
Main Points:
1. The evidence on whether isotretinoin causes depression and suicide is inconsistent; however, numerous controlled studies have shown an improvement in anxiety and depression scores in those taking isotretinoin.
Acneiform Eruptions Toronto Notes 2019 Perioral Dermatitis
Clinical Presentation
• discreteerythematousmicropapulesthatoftenbecomeconfluent,forminginflammatoryplaqueson perioral, perinasal, and periorbital skin
• commonlysymmetrical,rimofsparingaroundvermillionborderoflips
Epidemiology
• 15-40yrold,occasionallyinyoungerchildren • predominantlyfemales
Differential Diagnosis
• contactdermatitis,rosacea,acnevulgaris
Management
• avoidalltopicalsteroids
• topical:metronidazole0.75%gelor0.75-1%creamtoaffectedareabid
• systemic:tetracyclinefamilyantibiotic(utilizedforitsanti-inflammatoryproperties)
• occasionaluseofanon-steroidalanti-inflammatorycream(i.e.tacrolimusorpimecrolimus)
Rosacea
Clinical Presentation
• dome-shapedinflammatorypapules±pustules
• flushing,non-transienterythema,andtelangiectasia
• distribution:typicallyoncentralfaceincludingforehead,nose,cheeks,andchin;rarelyonscalp,neck,
and upper body
• characterizedbyremissionsandexacerbations
• exacerbatingfactors:heat,cold,wind,sun,stress,drinkinghotliquids,alcohol,caffeine,spices
• allformsofrosaceacanprogressfrommildtomoderatetosevere
• rarelyinlongstandingrosacea,signsofthickening,indurationandlymphedemaintheskincandevelop • phyma:adistinctswellingcausedbylymphedemaandhypertrophyofsubcutaneoustissue,particularly
affecting the nose (rhinophyma)
• ocularmanifestations:blepharoconjunctivitis,keratitis,iritis
Pathophysiology
• unknown
Epidemiology
• althoughfoundinallskintypes,highestprevalenceinfair-skinnedpeople • 30-50yrold;F>M
Differential Diagnosis
• acnevulgaris,seborrheicdermatitis,perioraldermatitis,contactdermatitis
Management
• triggeravoidanceanddailysunscreenuseforlong-termmanagement
• avoidtopicalcorticosteroids
• telangiectasia:treatedbyphysicalablation;electricalhyfrecators,vascularlasers,andintensepulsed
light therapies
• phymas: treated by physical ablation or removal; paring, electrosurgery, cryotherapy, laser therapy (CO2,
2. ThereisnoassociationbetweenIBDand isotretinoin use. Only one study showed
a significantly increased risk of UC. When considering using isotretinoin in a patient with IBD or with a strong family history, consider involving a gastroenterologist.
Figure 3. Rosacea distribution
Rosacea can be differentiated from acne by the absence of comedones, a predilection for the central face and symptoms of flushing
Guidelines for the Diagnosis of Rosacea
J Drugs Dermatol 2012;11(6):725-730
Presence of one or more of the following primary features:
• Flushing(transienterythema)
• Nontransienterythema
• Papulesandpustules
• Telangiectasia
May include one or more of the following secondary features:
• Burningorstinging
• Dryappearance
• Edema
• Phymatouschanges
• Ocularmanifestations
• Peripherallocation
argon, Nd:YAG)
Table 11. Specific Rosacea Treatments
1st Line
Oral tetracyclines
Topical metronidazole
Oral erythromycin (250-500 mg PO bid) Topical azelaic acid
Topical Ivermectin
2nd Line
Topical clindamycin
Topical erythromycin 2% solution Topical benzoyl peroxide
Oral metronidazole
3rd Line
Oral retinoids
© Joshua Lai 2014