AcneAcne
Andrews’ Chapter 13Andrews’ Chapter 13
Ben Adams, D.O.Ben Adams, D.O.
1-18-051-18-05
Acne VulgarisAcne Vulgaris
 Chronic inflammatory disease of theChronic inflammatory disease of the
pilosebaceous follicle...
 Disease of the adolescentDisease of the adolescent
 90% of all teenagers90% of all teenagers
 May also begin in twenti...
DHT, the prominent hormonal effector on the sebaceous glandDHT, the prominent hormonal effector on the sebaceous gland
ComedoComedo
 Commonly known as theCommonly known as the blackheadblackhead
 Basic lesion of acneBasic lesion of acne
 ...
ComedoComedo
 Plugging produced by the comedoPlugging produced by the comedo
dilates the mouth of the follicledilates the...
Severity of AcneSeverity of Acne
 Typical mild acne; comedonesTypical mild acne; comedones
predominatepredominate
 More ...
TypesTypes
 Acne comedo; mild case wereAcne comedo; mild case were
eruption is composed almost entirelyeruption is compos...
EtiologyEtiology
 Keratin plug in lower infindibulum ofKeratin plug in lower infindibulum of
hair folliclehair follicle
...
PathogenesisPathogenesis
 Disruption of the follicular epitheliumDisruption of the follicular epithelium
permits discharg...
PathogenesisPathogenesis
 Effects of tetracycline are obtainedEffects of tetracycline are obtained
by the reduction of FF...
PathogenesisPathogenesis
 Androgens enlarge the sebaceousAndrogens enlarge the sebaceous
glandsglands
 In women consider...
HistologyHistology
 Acne is characterized by perifollicularAcne is characterized by perifollicular
inflammation around co...
TreatmentTreatment
 Topical medications to systemicTopical medications to systemic
therapytherapy
 No evidence that diet...
AntibacterialsAntibacterials
 Tetracycline since 1951Tetracycline since 1951
 Safest and cheapest choiceSafest and cheap...
TetracyclinesTetracyclines
 Tetracylines as sole treatment willTetracylines as sole treatment will
give a positive respon...
MinocyclineMinocycline
 More effective than tetracycline inMore effective than tetracycline in
acne vulgarisacne vulgaris...
AntibacterialsAntibacterials
 Doxycycline;Doxycycline; P.ancesP.ances resistant toresistant to
erythromycin, photosensiti...
Bacterial ResistanceBacterial Resistance
 Worsening clinical conditionWorsening clinical condition
correlates with a high...
Oral ContraceptivesOral Contraceptives
 Estradiol suppresses the uptake ofEstradiol suppresses the uptake of
testosterone...
Hormonal TherapyHormonal Therapy
 Spironolactone 25mg to 300mg/d ,Spironolactone 25mg to 300mg/d ,
antiandrogenicantiandr...
IsotretinoinIsotretinoin
 0.5 to 1 mg/kg/day qd or bid for 150.5 to 1 mg/kg/day qd or bid for 15
to 20 weeksto 20 weeks
...
IsotretinoinIsotretinoin
 Retinoids exert their physiologicRetinoids exert their physiologic
effects through two distinct...
IsotretinoinIsotretinoin
 Hypertriglyceridemia, dry mucosaHypertriglyceridemia, dry mucosa
 Nasal colonization with S.au...
Topical TreatmentTopical Treatment
 Benzoyl peroxideBenzoyl peroxide
 Topical retinoidsTopical retinoids
 Topical antib...
Benzoyl PeroxideBenzoyl Peroxide
 Available as gels, lotions, washesAvailable as gels, lotions, washes
and barsand bars
...
Topical RetinoidsTopical Retinoids
 Creams, gels, liquidsCreams, gels, liquids
 0.01%, 0.025%, 0.04%, 0.05% and0.01%, 0....
Topical AntibacterialsTopical Antibacterials
 Clindamycin 1% effective againstClindamycin 1% effective against
pustules a...
Other TopicalsOther Topicals
 Azeleic Acid; low adverse reactionsAzeleic Acid; low adverse reactions
 Salicylic acidSali...
Surgical TreatmentSurgical Treatment
 Comedone extractor brings aboutComedone extractor brings about
quick resolution of ...
Intralesional CorticosteroidsIntralesional Corticosteroids
 Effective in reducing inflammatoryEffective in reducing infla...
Complications of AcneComplications of Acne
 Scarring can occur despite bestScarring can occur despite best
treatmenttreat...
Acne ConglobataAcne Conglobata
 Conglobate: shaped in a roundedConglobate: shaped in a rounded
mass or ballmass or ball
...
Acne ConglobataAcne Conglobata
 Occurs most frequently in youngOccurs most frequently in young
menmen
 Follicular Occlus...
Acne FulminansAcne Fulminans
 Rare form of extremely severe cysticRare form of extremely severe cystic
acneacne
 Teenage...
SAPHO SyndromeSAPHO Syndrome
 Synovitis, Acne, Pustulosis,Synovitis, Acne, Pustulosis,
Hyperostosis, and OsteomyelitisHyp...
Tropical AcneTropical Acne
 Nodular, cystic, and pustular lesionsNodular, cystic, and pustular lesions
on back, buttocks,...
Premenstrual AcnePremenstrual Acne
 Papulopustular lesions week priorPapulopustular lesions week prior
 Estrogen-dominan...
Preadolescent AcnePreadolescent Acne
 NeonatalNeonatal
 InfantileInfantile
 ChildhoodChildhood
Neonatal AcneNeonatal Acne
 First four weeks of lifeFirst four weeks of life
 Develops a few days after birthDevelops a ...
Infantile AcneInfantile Acne
 Cases that persist beyond 4 weeks orCases that persist beyond 4 weeks or
have an onset afte...
Acne VenenataAcne Venenata
 Contact with acnegenic chemicalsContact with acnegenic chemicals
can produce comedonescan pro...
Acne CosmeticaAcne Cosmetica
 Closed comedones andClosed comedones and
papulopustules on the chin andpapulopustules on th...
Acne DetergicansAcne Detergicans
 Patients wash face with comedogenicPatients wash face with comedogenic
soapssoaps
 Clo...
Acne AestivalisAcne Aestivalis
 Aka; Mallorca acneAka; Mallorca acne
 Rare, females 25-40 yrsRare, females 25-40 yrs
 S...
Excoriated AcneExcoriated Acne
 Aka; picker’s acneAka; picker’s acne
 Girls, minute or trivial primaryGirls, minute or t...
Acneiform EruptionsAcneiform Eruptions
 Originate from skin exposure toOriginate from skin exposure to
various industrial...
Gram Negative FolliculitisGram Negative Folliculitis
 Occurs in patients treated withOccurs in patients treated with
anti...
Acne KeloidalisAcne Keloidalis
 Folliculitis of the deep levels of the hairFolliculitis of the deep levels of the hair
fo...
Hidradenitis SuppurativaHidradenitis Suppurativa
 Disease of the apocrine glandDisease of the apocrine gland
 Axillae, g...
Hidradenitis SuppurativaHidradenitis Suppurativa
 Most frequently axillae of youngMost frequently axillae of young
womenw...
Hidradenitis SuppurativaHidradenitis Suppurativa
 Oral antibiotics, culture S. aureus,Oral antibiotics, culture S. aureus...
Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens
 Aka;Aka; Dissecting cellulitis of the scalpDissecti...
Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens
 Tx; intralesional steroids,Tx; intralesional steroi...
Acne vs. RosaceaAcne vs. Rosacea
 acneacne  rosacearosacea
RosaceaRosacea
 Chronic inflammatory eruption of theChronic inflammatory eruption of the
flush areas of the faceflush are...
RosaceaRosacea
Ocular RosaceaOcular Rosacea
 Blepharitis, conjunctivitisBlepharitis, conjunctivitis
 Keratitis, iritis, episcleritisKer...
Ocular rosacea occurs inOcular rosacea occurs in
about 58% of rosacea patientsabout 58% of rosacea patients
Chronically inflamed eyelidChronically inflamed eyelid
margins may be confused withmargins may be confused with
seborrheic...
Granulomatous RosaceaGranulomatous Rosacea
 Midface, perioral, lateral mandibleMidface, perioral, lateral mandible
areasa...
Rosacea EtiologyRosacea Etiology
 Vasomotor liabilityVasomotor liability
 Hot liquids, ETOH, steroids (oral andHot liqui...
Differential Diagnosis RosaceaDifferential Diagnosis Rosacea
 Acne VulgarisAcne Vulgaris
 Lupus erythematosusLupus eryth...
Inflammatory rosaceaInflammatory rosacea
 Papules andPapules and
pustules arepustules are
characteristiccharacteristic
Rosacea TreatmentRosacea Treatment
 Long-term oral tetracycline isLong-term oral tetracycline is
suppressive, required fo...
RosaceaRosacea
RhinophymaRhinophyma
RhinophymaRhinophyma
 Men over 40Men over 40
 Pilosebaceous gland hyperplasia withPilosebaceous gland hyperplasia with
f...
Pyoderma FacialePyoderma Faciale
 Postadolescent girls, reddish cyanoticPostadolescent girls, reddish cyanotic
erythema w...
Perioral DermatitisPerioral Dermatitis
 Papulosquamous eruptionPapulosquamous eruption
 Clear zone around vermillion bor...
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
Acne Andrews' Chapter 13 Ben Adams, D.O.
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Acne Andrews' Chapter 13 Ben Adams, D.O.

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Acne Andrews' Chapter 13 Ben Adams, D.O.

  1. 1. AcneAcne Andrews’ Chapter 13Andrews’ Chapter 13 Ben Adams, D.O.Ben Adams, D.O. 1-18-051-18-05
  2. 2. Acne VulgarisAcne Vulgaris  Chronic inflammatory disease of theChronic inflammatory disease of the pilosebaceous folliclespilosebaceous follicles  Comedones, papules, pustules,Comedones, papules, pustules, cysts, nodules, and often scarscysts, nodules, and often scars  Face, neck, upper trunk, and upperFace, neck, upper trunk, and upper armsarms
  3. 3.  Disease of the adolescentDisease of the adolescent  90% of all teenagers90% of all teenagers  May also begin in twentiesMay also begin in twenties  Usually involution by 25Usually involution by 25  Occurs primarily inOccurs primarily in oily{seborrheic} areas of the skinoily{seborrheic} areas of the skin  Face occurs; cheeks>Face occurs; cheeks> nose>forehead>chinnose>forehead>chin  Ears; comedones in concha, cystsEars; comedones in concha, cysts in lobulesin lobules  Retroauricular and nuchal cystsRetroauricular and nuchal cysts
  4. 4. DHT, the prominent hormonal effector on the sebaceous glandDHT, the prominent hormonal effector on the sebaceous gland
  5. 5. ComedoComedo  Commonly known as theCommonly known as the blackheadblackhead  Basic lesion of acneBasic lesion of acne  Produced by hyperkeratosis of theProduced by hyperkeratosis of the lining of the follicleslining of the follicles  Retention of keratin and sebumRetention of keratin and sebum
  6. 6. ComedoComedo  Plugging produced by the comedoPlugging produced by the comedo dilates the mouth of the follicledilates the mouth of the follicle  Papules are formed by inflammationPapules are formed by inflammation around the comedonesaround the comedones
  7. 7. Severity of AcneSeverity of Acne  Typical mild acne; comedonesTypical mild acne; comedones predominatepredominate  More severe cases; pustules andMore severe cases; pustules and papules predominate, heal with scarpapules predominate, heal with scar if deepif deep  Acne Conglobata; suppurating cysticAcne Conglobata; suppurating cystic lesions predominate, and severelesions predominate, and severe scarring resultsscarring results
  8. 8. TypesTypes  Acne comedo; mild case wereAcne comedo; mild case were eruption is composed almost entirelyeruption is composed almost entirely of comedones on an oily skinof comedones on an oily skin  Papular acne; inflammatory papules,Papular acne; inflammatory papules, most common in young men withmost common in young men with coarse, oily skincoarse, oily skin  Atrophic acne; residual atrophic pitsAtrophic acne; residual atrophic pits and scarsand scars
  9. 9. EtiologyEtiology  Keratin plug in lower infindibulum ofKeratin plug in lower infindibulum of hair folliclehair follicle  Androgenic stimulation of sebaceous,Androgenic stimulation of sebaceous, proliferation of propionbacteriumproliferation of propionbacterium acnes which metabolizes sebum toacnes which metabolizes sebum to produce free fatty acidsproduce free fatty acids
  10. 10. PathogenesisPathogenesis  Disruption of the follicular epitheliumDisruption of the follicular epithelium permits discharge of the follicularpermits discharge of the follicular contents into the dermiscontents into the dermis  Causes the formation ofCauses the formation of inflammatory papules, pustules, andinflammatory papules, pustules, and nodulocystic lesionsnodulocystic lesions  FFA are chemotactic to componentsFFA are chemotactic to components of inflammationof inflammation
  11. 11. PathogenesisPathogenesis  Effects of tetracycline are obtainedEffects of tetracycline are obtained by the reduction of FFAby the reduction of FFA  Antibiotics do not produce involutionAntibiotics do not produce involution of the inflammatory lesions present,of the inflammatory lesions present, but inhibit the formation of newbut inhibit the formation of new lesionslesions  Topical retinoic acid acts onTopical retinoic acid acts on keratinization, causing horny cells tokeratinization, causing horny cells to lose their stickinesslose their stickiness
  12. 12. PathogenesisPathogenesis  Androgens enlarge the sebaceousAndrogens enlarge the sebaceous glandsglands  In women consider hyperandrogenicIn women consider hyperandrogenic statestate
  13. 13. HistologyHistology  Acne is characterized by perifollicularAcne is characterized by perifollicular inflammation around comedonesinflammation around comedones  Exudate of lymphocytes and PMNsExudate of lymphocytes and PMNs  Plasma cells, foreign body giant cells,Plasma cells, foreign body giant cells, and proliferation of fibroblastsand proliferation of fibroblasts  Large cysts and epithelial-lined sinusLarge cysts and epithelial-lined sinus tractstracts
  14. 14. TreatmentTreatment  Topical medications to systemicTopical medications to systemic therapytherapy  No evidence that dietary habitsNo evidence that dietary habits influence acneinfluence acne
  15. 15. AntibacterialsAntibacterials  Tetracycline since 1951Tetracycline since 1951  Safest and cheapest choiceSafest and cheapest choice  250 to 500mg QD to QID250 to 500mg QD to QID  Gradual reduction in doseGradual reduction in dose  Take on empty stomachTake on empty stomach  Calcium and iron decreaseCalcium and iron decrease absorptionabsorption  Constant or intermittent tx monthsConstant or intermittent tx months to yearsto years
  16. 16. TetracyclinesTetracyclines  Tetracylines as sole treatment willTetracylines as sole treatment will give a positive response in 70%give a positive response in 70%  May take 4-6 weeks for responseMay take 4-6 weeks for response  Vaginitis and perianal itching in 5%Vaginitis and perianal itching in 5% due to Candida albicansdue to Candida albicans  Staining of growing teeth precludesStaining of growing teeth precludes use in pregnancy and children < 9 oruse in pregnancy and children < 9 or 1010
  17. 17. MinocyclineMinocycline  More effective than tetracycline inMore effective than tetracycline in acne vulgarisacne vulgaris  50 to 100mg QD or BID50 to 100mg QD or BID  Absorption less affected by milk andAbsorption less affected by milk and foodfood
  18. 18. AntibacterialsAntibacterials  Doxycycline;Doxycycline; P.ancesP.ances resistant toresistant to erythromycin, photosensitivity can occurerythromycin, photosensitivity can occur  Erythromycin; consider in young andErythromycin; consider in young and pregnant who cannot use tetracyclinepregnant who cannot use tetracycline  Clindamycin; works well, but can causeClindamycin; works well, but can cause pseudomembranous colitispseudomembranous colitis  Sulfonamides; phototoxicity, Scalded skinSulfonamides; phototoxicity, Scalded skin
  19. 19. Bacterial ResistanceBacterial Resistance  Worsening clinical conditionWorsening clinical condition correlates with a high MIC forcorrelates with a high MIC for erythromycin and tetracycline for P.erythromycin and tetracycline for P. acnesacnes  Resistance lost after 2 months afterResistance lost after 2 months after withdrawal of antibioticwithdrawal of antibiotic  Avoid use of different oral and topicalAvoid use of different oral and topical antibiotics at the same timeantibiotics at the same time
  20. 20. Oral ContraceptivesOral Contraceptives  Estradiol suppresses the uptake ofEstradiol suppresses the uptake of testosterone by the sebaceoustestosterone by the sebaceous glandsglands  Oral contraceptives containingOral contraceptives containing androgenic progesterones mayandrogenic progesterones may exacerbate acneexacerbate acne  EES and Norgestimate is approvedEES and Norgestimate is approved for txfor tx  (Ortho Tri-cyclen, Estrostep,(Ortho Tri-cyclen, Estrostep, Yazmine)Yazmine)
  21. 21. Hormonal TherapyHormonal Therapy  Spironolactone 25mg to 300mg/d ,Spironolactone 25mg to 300mg/d , antiandrogenicantiandrogenic  Steroids for severe inflammatorySteroids for severe inflammatory acneacne
  22. 22. IsotretinoinIsotretinoin  0.5 to 1 mg/kg/day qd or bid for 150.5 to 1 mg/kg/day qd or bid for 15 to 20 weeksto 20 weeks  Leads to a remission that may lastLeads to a remission that may last months to yearsmonths to years  teratogenicteratogenic
  23. 23. IsotretinoinIsotretinoin  Retinoids exert their physiologicRetinoids exert their physiologic effects through two distinct familieseffects through two distinct families of nuclear receptorsof nuclear receptors  RARs and retinoid X receptors (RXRs)RARs and retinoid X receptors (RXRs)  Affects sebum production,Affects sebum production, comedongenesis, P. acne,comedongenesis, P. acne, keratinization, not related to RARkeratinization, not related to RAR and RXR affinityand RXR affinity
  24. 24. IsotretinoinIsotretinoin  Hypertriglyceridemia, dry mucosaHypertriglyceridemia, dry mucosa  Nasal colonization with S.aureus inNasal colonization with S.aureus in 90%90%  Worsening of acne common in firstWorsening of acne common in first monthmonth  Monitor HCG, lipids, LFT’sMonitor HCG, lipids, LFT’s
  25. 25. Topical TreatmentTopical Treatment  Benzoyl peroxideBenzoyl peroxide  Topical retinoidsTopical retinoids  Topical antibacterialsTopical antibacterials  Salicyclic acid, Azeleic acidSalicyclic acid, Azeleic acid
  26. 26. Benzoyl PeroxideBenzoyl Peroxide  Available as gels, lotions, washesAvailable as gels, lotions, washes and barsand bars  2.5% to 10%2.5% to 10%  Potent antibacterial effectPotent antibacterial effect  May decrease antibacterial resistanceMay decrease antibacterial resistance  Decrease frequency of application ifDecrease frequency of application if irritation occursirritation occurs
  27. 27. Topical RetinoidsTopical Retinoids  Creams, gels, liquidsCreams, gels, liquids  0.01%, 0.025%, 0.04%, 0.05% and0.01%, 0.025%, 0.04%, 0.05% and 0.1%0.1%  Cream base may be less irritatingCream base may be less irritating  Affect follicular keratinizationAffect follicular keratinization  ComedolyticComedolytic  Apply qhs, may take 8 to 12 weeksApply qhs, may take 8 to 12 weeks
  28. 28. Topical AntibacterialsTopical Antibacterials  Clindamycin 1% effective againstClindamycin 1% effective against pustules and small papulopustularpustules and small papulopustular lesionslesions  Erythromycin 3%Erythromycin 3%  Both equally effective, combined withBoth equally effective, combined with bezoyl peroxide can decreasebezoyl peroxide can decrease resistanceresistance
  29. 29. Other TopicalsOther Topicals  Azeleic Acid; low adverse reactionsAzeleic Acid; low adverse reactions  Salicylic acidSalicylic acid  Abrasive cleaners, astringents makeAbrasive cleaners, astringents make the skin dry and susceptible tothe skin dry and susceptible to irritantsirritants
  30. 30. Surgical TreatmentSurgical Treatment  Comedone extractor brings aboutComedone extractor brings about quick resolution of comedones andquick resolution of comedones and pustulespustules  In Isotretinoin pts macrocomedonesIn Isotretinoin pts macrocomedones present at week 10 to 15 of therapypresent at week 10 to 15 of therapy
  31. 31. Intralesional CorticosteroidsIntralesional Corticosteroids  Effective in reducing inflammatoryEffective in reducing inflammatory papules, pustules, and smaller cystspapules, pustules, and smaller cysts  Kenalog-10 (triamcinolone 10mg/ml)Kenalog-10 (triamcinolone 10mg/ml)  Diluted with NS to 5 or 2.5mg/mlDiluted with NS to 5 or 2.5mg/ml
  32. 32. Complications of AcneComplications of Acne  Scarring can occur despite bestScarring can occur despite best treatmenttreatment  Pitted scars, wide-mouthedPitted scars, wide-mouthed depressions and keloidsdepressions and keloids  Chemical peels, CO2 LaserChemical peels, CO2 Laser resurfacing, scar excision,resurfacing, scar excision,
  33. 33. Acne ConglobataAcne Conglobata  Conglobate: shaped in a roundedConglobate: shaped in a rounded mass or ballmass or ball  Severe form of acne characterized bySevere form of acne characterized by numerous comedones, largenumerous comedones, large abscesses with sinuses, groupedabscesses with sinuses, grouped inflammatory nodulesinflammatory nodules  SuppurationSuppuration  Cysts on forehead, cheeks, and neckCysts on forehead, cheeks, and neck
  34. 34. Acne ConglobataAcne Conglobata  Occurs most frequently in youngOccurs most frequently in young menmen  Follicular Occlusion Triad: acneFollicular Occlusion Triad: acne conglobata, hidradenitis suppurativa,conglobata, hidradenitis suppurativa, cellulitis of the scalpcellulitis of the scalp  Heals with scarringHeals with scarring  Treatment; oral isotretinoin for 5Treatment; oral isotretinoin for 5 monthsmonths
  35. 35. Acne FulminansAcne Fulminans  Rare form of extremely severe cysticRare form of extremely severe cystic acneacne  Teenage boys, chest and backTeenage boys, chest and back  Rapid degeneration of nodulesRapid degeneration of nodules leaving ulcerationleaving ulceration  Fever, leukocytosis, arthralgias areFever, leukocytosis, arthralgias are commoncommon  Tx; oral steroids, isotretinoinTx; oral steroids, isotretinoin
  36. 36. SAPHO SyndromeSAPHO Syndrome  Synovitis, Acne, Pustulosis,Synovitis, Acne, Pustulosis, Hyperostosis, and OsteomyelitisHyperostosis, and Osteomyelitis  Acne fulminans, acne conglobata,Acne fulminans, acne conglobata, pustular psoriasis, and palmoplantarpustular psoriasis, and palmoplantar pustulosispustulosis  Chest wall is most site ofChest wall is most site of musculoskeletal complaintsmusculoskeletal complaints
  37. 37. Tropical AcneTropical Acne  Nodular, cystic, and pustular lesionsNodular, cystic, and pustular lesions on back, buttocks, and thighson back, buttocks, and thighs  Face is sparedFace is spared  Young adult military stationed inYoung adult military stationed in tropicstropics
  38. 38. Premenstrual AcnePremenstrual Acne  Papulopustular lesions week priorPapulopustular lesions week prior  Estrogen-dominant contraceptiveEstrogen-dominant contraceptive pills will diminishpills will diminish
  39. 39. Preadolescent AcnePreadolescent Acne  NeonatalNeonatal  InfantileInfantile  ChildhoodChildhood
  40. 40. Neonatal AcneNeonatal Acne  First four weeks of lifeFirst four weeks of life  Develops a few days after birthDevelops a few days after birth  Facial papules or pustulesFacial papules or pustules
  41. 41. Infantile AcneInfantile Acne  Cases that persist beyond 4 weeks orCases that persist beyond 4 weeks or have an onset afterhave an onset after  R/O acne cosmetic, acne venenata,R/O acne cosmetic, acne venenata, drug-induced acnedrug-induced acne
  42. 42. Acne VenenataAcne Venenata  Contact with acnegenic chemicalsContact with acnegenic chemicals can produce comedonescan produce comedones  Chlorinated hydrocarbons, cuttingChlorinated hydrocarbons, cutting oils, petroleum oil, coal taroils, petroleum oil, coal tar  Radiation therapyRadiation therapy
  43. 43. Acne CosmeticaAcne Cosmetica  Closed comedones andClosed comedones and papulopustules on the chin andpapulopustules on the chin and cheekscheeks  May take months to clear afterMay take months to clear after stopping cosmetic productstopping cosmetic product  Pomade Acne; blacks, males, due toPomade Acne; blacks, males, due to greases or oils applied to hairgreases or oils applied to hair
  44. 44. Acne DetergicansAcne Detergicans  Patients wash face with comedogenicPatients wash face with comedogenic soapssoaps  Closed comedonesClosed comedones  TX; wash only once or twice a dayTX; wash only once or twice a day with non-comedogenic soapwith non-comedogenic soap
  45. 45. Acne AestivalisAcne Aestivalis  Aka; Mallorca acneAka; Mallorca acne  Rare, females 25-40 yrsRare, females 25-40 yrs  Starts in spring, resolves by fallStarts in spring, resolves by fall  Small papules on cheeks, neck,Small papules on cheeks, neck, upper bodyupper body  Comedones and pustules are sparseComedones and pustules are sparse or absentor absent  Tx; retinoic acid, abx don’t helpTx; retinoic acid, abx don’t help
  46. 46. Excoriated AcneExcoriated Acne  Aka; picker’s acneAka; picker’s acne  Girls, minute or trivial primaryGirls, minute or trivial primary lesions are made worse by squeezinglesions are made worse by squeezing  Crusts, scarring, and atrophyCrusts, scarring, and atrophy  TX; eliminate magnifying mirror, r/oTX; eliminate magnifying mirror, r/o depressiondepression
  47. 47. Acneiform EruptionsAcneiform Eruptions  Originate from skin exposure toOriginate from skin exposure to various industrial chemicalsvarious industrial chemicals  Papules and pustules not confined toPapules and pustules not confined to usual sites of acne vulgarisusual sites of acne vulgaris  Chlorinated hydrocarbons, oils, coalChlorinated hydrocarbons, oils, coal tartar  Oral meds; iodides, bromides,Oral meds; iodides, bromides, lithium, steroids (steroid acne)lithium, steroids (steroid acne)
  48. 48. Gram Negative FolliculitisGram Negative Folliculitis  Occurs in patients treated withOccurs in patients treated with antibiotics for acne over a long-termantibiotics for acne over a long-term  Enterobactor, Klebsiella, ProteusEnterobactor, Klebsiella, Proteus  Anterior nares colonizedAnterior nares colonized  Tx; isotretinoin, AugmentinTx; isotretinoin, Augmentin
  49. 49. Acne KeloidalisAcne Keloidalis  Folliculitis of the deep levels of the hairFolliculitis of the deep levels of the hair follicle that progresses into a perifolliculitisfollicle that progresses into a perifolliculitis  Occurs at nuchal area in blacks or AsianOccurs at nuchal area in blacks or Asian menmen  Not associated with acne vulgarisNot associated with acne vulgaris  Hypertrophic connective tissue becomesHypertrophic connective tissue becomes sclerotic, free hairs trapped in the dermissclerotic, free hairs trapped in the dermis contribute to inflammationcontribute to inflammation  Tx; intralesional Kenalog, surgeryTx; intralesional Kenalog, surgery
  50. 50. Hidradenitis SuppurativaHidradenitis Suppurativa  Disease of the apocrine glandDisease of the apocrine gland  Axillae, groin, buttocks, also areolaAxillae, groin, buttocks, also areola  Obesity and genetic tendency toObesity and genetic tendency to acneacne  Tender red nodules become fluctuantTender red nodules become fluctuant and painfuland painful  Rupture, suppuration, formation ofRupture, suppuration, formation of sinus tractssinus tracts
  51. 51. Hidradenitis SuppurativaHidradenitis Suppurativa  Most frequently axillae of youngMost frequently axillae of young womenwomen  Men usually groin and perianal areaMen usually groin and perianal area  Follicular keratinization with pluggingFollicular keratinization with plugging of the apocrine duct; dilation andof the apocrine duct; dilation and inflammationinflammation  DDx; Furuncles are unilateral, andDDx; Furuncles are unilateral, and not associated with comedones,not associated with comedones, Bartholin cyst, scrofuloderma,Bartholin cyst, scrofuloderma, actinomycosis, granuloma inguinaleactinomycosis, granuloma inguinale
  52. 52. Hidradenitis SuppurativaHidradenitis Suppurativa  Oral antibiotics, culture S. aureus,Oral antibiotics, culture S. aureus, gram-negativesgram-negatives  Intralesional steroids, surgeryIntralesional steroids, surgery  Isotretinoin helpful in some casesIsotretinoin helpful in some cases
  53. 53. Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens  Aka;Aka; Dissecting cellulitis of the scalpDissecting cellulitis of the scalp  Uncommon suppurative diseaseUncommon suppurative disease  Nodules suppurate and undermine toNodules suppurate and undermine to form sinusesform sinuses  Scarring and alopeciaScarring and alopecia  Adult black men most common,Adult black men most common, vertex and occiputvertex and occiput
  54. 54. Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens  Tx; intralesional steroids,Tx; intralesional steroids, isotretinoin, oral abx, surgicalisotretinoin, oral abx, surgical incision and drainageincision and drainage
  55. 55. Acne vs. RosaceaAcne vs. Rosacea  acneacne  rosacearosacea
  56. 56. RosaceaRosacea  Chronic inflammatory eruption of theChronic inflammatory eruption of the flush areas of the faceflush areas of the face  Erythema, papules, pustules,Erythema, papules, pustules, telangiectasia, hypertrophy of thetelangiectasia, hypertrophy of the sebaceous glandssebaceous glands  Usually mid-faceUsually mid-face  Women ages 30-50Women ages 30-50
  57. 57. RosaceaRosacea
  58. 58. Ocular RosaceaOcular Rosacea  Blepharitis, conjunctivitisBlepharitis, conjunctivitis  Keratitis, iritis, episcleritisKeratitis, iritis, episcleritis  C/o gritty, stinging sensationC/o gritty, stinging sensation
  59. 59. Ocular rosacea occurs inOcular rosacea occurs in about 58% of rosacea patientsabout 58% of rosacea patients
  60. 60. Chronically inflamed eyelidChronically inflamed eyelid margins may be confused withmargins may be confused with seborrheic dermatitisseborrheic dermatitis 
  61. 61. Granulomatous RosaceaGranulomatous Rosacea  Midface, perioral, lateral mandibleMidface, perioral, lateral mandible areasareas  Noncaseating granulomasNoncaseating granulomas
  62. 62. Rosacea EtiologyRosacea Etiology  Vasomotor liabilityVasomotor liability  Hot liquids, ETOH, steroids (oral andHot liquids, ETOH, steroids (oral and topical) ie: perioral dermatitistopical) ie: perioral dermatitis  Demodex folliculorumDemodex folliculorum not causativenot causative
  63. 63. Differential Diagnosis RosaceaDifferential Diagnosis Rosacea  Acne VulgarisAcne Vulgaris  Lupus erythematosusLupus erythematosus  Bromoderma, iodermaBromoderma, ioderma  Papular syphilidPapular syphilid
  64. 64. Inflammatory rosaceaInflammatory rosacea  Papules andPapules and pustules arepustules are characteristiccharacteristic
  65. 65. Rosacea TreatmentRosacea Treatment  Long-term oral tetracycline isLong-term oral tetracycline is suppressive, required for ocularsuppressive, required for ocular rosacearosacea  Topical metronidazoleTopical metronidazole  Sunscreens, avoidance of flushingSunscreens, avoidance of flushing triggerstriggers  Flash lamped pumped dye laser forFlash lamped pumped dye laser for telangiectasiastelangiectasias
  66. 66. RosaceaRosacea RhinophymaRhinophyma
  67. 67. RhinophymaRhinophyma  Men over 40Men over 40  Pilosebaceous gland hyperplasia withPilosebaceous gland hyperplasia with fibrosis, inflammation, andfibrosis, inflammation, and telangiectasiatelangiectasia  Treatment is surgeryTreatment is surgery
  68. 68. Pyoderma FacialePyoderma Faciale  Postadolescent girls, reddish cyanoticPostadolescent girls, reddish cyanotic erythema with abscesses and cystserythema with abscesses and cysts  Distinguished from acne by absenceDistinguished from acne by absence of comedones, rapid onset, fulminantof comedones, rapid onset, fulminant course and absence of acne on thecourse and absence of acne on the back and chestback and chest  Tx; oral steroids followed byTx; oral steroids followed by isotretinoinisotretinoin
  69. 69. Perioral DermatitisPerioral Dermatitis  Papulosquamous eruptionPapulosquamous eruption  Clear zone around vermillion borderClear zone around vermillion border  Women 23-35yrsWomen 23-35yrs  Etiology; ?topical steroids,Etiology; ?topical steroids, fluorinated toothpastefluorinated toothpaste  Tx; d/c topical steroids, oral tcn ifTx; d/c topical steroids, oral tcn if pustulespustules

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