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What is acne?
Chronic inflammatory condition of the face that is associated with formation of comedones
What is rosacea?
Chronic inflammatory condition of the face that is associated with vascular hyper-reactivty
What is perioral dermatitis?
Papulopustular condition surrounding the periorificial areas of the face
  • Not associated with diffused erythema or comedones
A pilosebaceous unit consists of two connected structural units?
  • Hair follicle
  • Sebaceous gland
What are the types of pilosebaceous units? (3)
  • Terminal hair follicles
    -Long hair 
  • Vellus hair follicles
    -Miniature hairs 
  • Sebaceous follicles
    -No visible hairs
    -Very large glands with very small associated hairs
    -Found in acne prone areas 
Sebum is produced by sebaceous glands through what type of mechanism?
Holocrine (cells die and become part of the secretion itself)
Sebum is made up of what?
Liquid lipid material
  • Triglycerides
  • Hydrolysis products
  • Wax esters
  • Squalene 
The regulation of sebaceous glands is highly dependent on what?
  • Why might acne increase at birth?
Glands depend on androgen
  • Active at birth due to maternal androgens 
When are sebaceous glands most active?
  • Start at age 7
  • Increase with puberty
  • Decrease in 20's
Which acid inhibits sebaceous gland activity?
Retinoic acid
What is acne vulgaris?
Acne
  • Inflammatory disease of pilosebaceous unit characterized by presence of comedones 
When does acne peak?
  • How long can it persist? 
Peaks in middle-to-late teenage years
  • Can persist into twenties and thirties
What are the pathogenic factors of acne? (4)
  • Abnormal follicular keratinization
    -Blocks follicular opening 
  • "Over-production" of sebum
    -Larger and more productive glands than normal 
  • Over-growth of follicular bacteria
    -Contributes to inflammation 
  • Inflammation
    -May develop with comedones 
What bacteria is colonizes human hair follicles and is a big contributor to acne?
Propionibacterium acnes
  • Hint: Pepperoni is greasy 
What age is most common for acne onset?
  • Where are acne lesions found
Onset between 9 and 11 years
  • Lesions found on areas with most sebaceous secretion:
    Face, shoulders, upper back and upper chest 
What is the main lesion as a result of acne?
  • What are they? 
Comedones
  • Microcysts formed as a result of blockage of the follicular unit 
What are the two types of comedones?
  • Which are more likely to give rise to inflammation? 
  • Closed comedones ("white heads")
    -These are more likely to give rise to inflammation 
  • Open comedones ("black heads")
In addition to comedones, what inflammatory lesions exist with acne? (4)
  • Papules
  • Pustules
  • Nodules
  • Cysts
Summarize the natural history of acne
  • Tends to improve in late teens and early twenties
  • Inflammatory lesions heal leaving scars if acne is moderate to severe
Describe the different between mild, moderate and severe acne
All have comedones
  • Mild: Only comedones
    -A few papules, pustules 
  • Moderate:
    -Comedones, papules, pustules 
  • Severe:
    -Scarring, nodules, cysts
    -Comedones, papules, pustules 
What is the main differential diagnosis for acne vulgaris? (2)
  • Rosacea
  • Perioral dermatitis
Name and describe treatments for mild acne (4)
  • Hygienic advice
    -Gentle cleansing with non-alkaline synthetic detergent
    -Avoid comedogenic cosmetics 
  • Treat comedones
    -Retinoic acid
    -Surgical extraction 
  • Decrease sebum production
    -Retinoic acid
  • Decrease bacterial overgrowth
    -Topical antibiotics
    -Topical benzoyl peroxide
    -Topical azelaic acid
How does retinoic acid work?
Acts as a keratolytic
  • Promotes desquamation of keratinized layers
Name and describe treatments for moderate acne (4)

With moderate, you switch from topical to oral agents
  • Oral antibiotics
    -Tetracycline
    -Doxycycline
    -Minocycline 
  • Oral contraceptive pills
    -Decrease sebum production by anti-androgen effects 
  • Oral retinoic acid
    -Accutane 
  • Intralesional steroid injection
    -Rarely indicated, only for resistant papules, pustules or nodules
    -Kenolog is used, risk of dermal atrophy 
Anti-acne oral antibiotics can rarely cause what serious condition?
Gram-negative folliculitis
  • Sudden development of inflammatory pustules 
Name and describe treatments for severe acne (1)
  • Give a general strategy as well 
Do everything in mild and moderate treatment except do isotretinoin
  • Oral isotretinoin
    -Treatment for severe acne
    -Most effective mediation, 80% remission rate
What is mechanism of action for isotretinoin?
Binds retinoic acid receptor (RAR) and decreases sebum production
What are contraindications of isotretinoin? (2)
  • Unmanaged depression
  • Pregnancy
What are the adverse effects of isotretinoin? (6)
  • Dry skin and cheilitis
  • Teratogenicity
  • Psychiatric disturbances (causal relationship not proven)
  • Pseudotumor cerebri (avoid concurrent use of tetracyclines)
  • GI
  • Myalgia, MSK
Define rosacea again
  • What are the primary lesions of rosacea? (2)
Chronic inflammatory dermatosis of adults characterized by prominent central facial flushing and erythema
  • Erythema
  • Telangiectasia 
Describe age of onset for rosacea
  • Is there a racial division?
Blushing in 20s becomes fixed erythema in 30s/40s and finally rosacea in 40s/50s
  • Affects all races, more common in whites 
What is the pathogenesis of rosacea?
Unknown, however:
  • Genetic predisposition
  • Microvascular dilatation
  • Demodex folliculorum mites
  • Increased production of canthelicidins (activates innate immunity)
What is the primary underlying abnormality in rosacea?
Vascular
  • Not follicular
  • However, papulopustular inflammation is centered on pilosebaceous unit... (counterintuitive)
Are there comedones in rosacea?
No
  • Only in acne 
What occurs late in rosacea?
  • What mechanism causes this? 
Rhinophyma
  • Occurs due to sebaceous hyperplasia and fibrosis
For rosacea:
  • Males or females most likely?
  • Distributed where? 
  • Females
  • Distributed in central area of face (e.g. chin, forehead, nose)
Name and explain the types of rosacea? (3 cutaneous, 1 ocular)
  • Erythematotelangiectatic rosacea
    -Happens in people that have history of easy flushing (e.g. alcohol, emotion) that becomes permanent
  • Papulopustular rosacea
    -Rosacea with papules/pustules
  • Phymatous rosacea
    -Sebaceous glands become larger and skin gets oilier 
    -Connective tissue hypertrophy
    -Often occurs on nose 
  • Ocular rosacea
    -Conjunctivitis, iritis, keratitis
What is natural history of rosacea?
Unlike acne, it gets worse, not better
  • Can progress from erythma subtype to papulopustular subtype 
What is on the differential for rosacea? (2)
  • Acne vulgaris
  • Perioral dermatitis 
For the management of rosacea, what are general measures? (1)
Avoid sun
For the management of rosacea, what are therapies for specific lesion types? (4)
  • Telangiectasia
  • Erythema
  • Inflammatory papules/pustules
  • Phymatous rosacea 
  • Telangiectasia
    -Laser ablation, electrodessication 
  • Erythema
    -Systemic tetracyclines, cold compress 
  • Inflammatory papules/pustules
    -Topical metronidazole
    -Topical azeleic acid 
    -Oral antibiotics
    -Oral isotretinoin 
  • Phymatous rosacea
    -Tetracyclines: mild to moderately effective
    -Surgical de-bulking 
For perioral dermatitis, describe the lesions
Chronic inflammation in orificial areas
  • Papules, pustules, erythema 
Perioral dermatitis primarily affects what demographic?
Females of childbearing age
Are there comedones in perioral dermatitis?
No
  • Only in acne 
What is the treatment for perioral dermatitis? (1)
System tetracyclines
What are the 3 types of childhood acne?
  • Neonatal acne
  • Infantile acne
  • Early onset acne vulgaris
What is neonatal acne? Explain.
  • Acne (open and closed comedones)
  • Related to hormonal activity in utero
  • Resolves 1-3 months after delivery
  • NO TREATMENT REQUIRED 
What is infantile acne? Explain.
Develops at 3-6 months and may be extensive or inflammatory
  • May resolve spontaneously or persist
  • Does not require treatment 
What is early onset acne vulgaris? Explain.
Standard acne that begins a few years earlier than normal (age of 6 or 7 years)
  • May be associated with androgen excess syndrome
  • Treatment required 
What are the 3 types of follicular occlusion triad?
  • Acne conglobata
  • Hidradenitis suppurativa
  • Dissecting cellulitis of scalp
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