Acne

Question 1

Tell me about P acnes

Answer 1

• Gram positive, anaerobic, microaerophilic rod in the sebaceous follicle
• Produces porphyrins: fluoresces with Woods lamp
• Density does not correlate with clinical severity
• Certain ribotypes (4 and 5)are more frequently found in acne patients

Question 2

Four contributors of acne pathogenesis

Answer 2

1. Follicular hyperkeratosis (microcomedone)
2. Hormones
3. Inflammation
4. P acnes

Question 3

What causes the black colour in open comedones

Answer 3

Melanin and lipid oxidation may be responsible for black colour

Question 4

Extra-cutaneous features of acne fulminans

Answer 4

• Bones: osteolytic bone lesions: clavicle, sternum, then can also be ankles, humerus, iliosacral joints
• Systemic: fever, arthralgias, myalgias, hepatosplenomegaly, severe malaise
• Erythema nodosum
• SAPHO syndrome can accompany
• Associated with congenital adrenal hyperplasia and anabolic steroid use (including therapeutic testosterone)

Question 5

What is PAPA syndrome and its mutation

Answer 5

• Sterile pyogenic arthritis, PG, acne conglobata

- Mutations in PSTPIP1 - proline - serine - threonine - phosphatase interacting protein 1

Question 6

Morbihan disease

Answer 6

• Distortion of the midline face and cheeks due to soft tissue swelling
• Woody induration and erythema
• ?cause: impaired lymphatic drainage and fibrosis in setting of chronic inflammation, some genetic risk
• Can be seen with rosacea
• Fluctuations in severity are common
• Does not resolve spontaneously
• Rx:
  
  • Isotretinoin 0.2-1 mg/kg/day for 4-6 months, may need longer
  • Combination with this and ketotifen (H1 antihistamine and mast cell stabiliser) or prednisone may be more beneficial

Question 7

What weeks for neonatal acne

Answer 7

Appear at ~ 2 weeks of age, and resolve by first 3 months

Question 8

What months for infantile acne

Answer 8

2-12 months of age

Question 9

Hyperandrogenism signs

Answer 9

• Hirsutism
• Coarsening of voice
• Muscular habitus
• Androgenetic alopecia
• Clitoromegaly with variable posterior labial fusion
• Increased libido

Question 10

HAIR-AN syndrome

Answer 10

Insulin resistance, acanthosis nigricans and hyperandrogenism: at increased risk of CVS disease and DM

Question 11

Acne associated with genetic syndromes

Answer 11

• Apert syndrome:
  
  • Autosomal dominant
  • Disfiguring synostoses of the bones, - hands and feet, vertebral bodies, cranium
  • Increased incidence of severe, early-onset acne that is nodulocystic and more widespread than classic acne - extensors of arms, buttocks and thighs
  • Acne typically resistant to treatment, roaccutane may be beneficial
  • Other cutaneous: seborrhoea, nail anomalies (single nail for second throug fourth digits), diffuse pigmentary dilution of hair and skin
  • Mutation ins FGFR2 - encodes fibroblast growth factor receptor 2 –> effects follicular keratinocyte proliferation, sebaceous lipogenesis, inflammatory cytokine production
• Borrone dermato-cardio-skeletal syndrome:
  
  • Autosomal recessive
  • SH3PXD2B mutation
  • Dysmorphic facies, thick skin, acne conglobata, vertebral abnormalitis, mitral valve prolapse
• PAPA
• PAPASH
• PASH

Question 12

Drug induced acne

Answer 12

• monomorphous eruption of inflammatory papules and pustules
• Medications - did you MISPLACE your meds Bae?

MEK inhibitors (trametinib)
Iodides, isoniazid
Steroids
Phenytoin, progestins
Lithium
Anabolic steroids - danazol, testosterone
Corticotropin, cyclosporin
EGFR inhibitors

Bromide, B6, B12
Azathioprine

Question 13

Chloracne

Answer 13

• several weeks after exposure to halogenated aromatic hydrocarbons
• Can be percutaneous, inhalation of ingestion
• Found in electrical conductors, insulators, insecticides, fungicides, herbicides, wood preservatives
• Comedo like lesions and yellowish cysts with minimal inflammation - malar and retroaurciular areas of head and neck, and can be on axillae and scrotum
• Can persist for several years following exposure
• Additional: grayish discolouration, hypertrichosis
• Rx: remove, topical or oral retinoids

Question 14

Radiation acne

Answer 14

• comedone like papules at sites of previous exposure to therapeutic ionizing radiation
• appear as acute phase of radiation dermatitis starts to resolve
• The rays induce epithelial metaplasia within the follicle, creating adherent hyperkeratotic plugs that are resistant to expression

Question 15

Idiopathic facial aseptic granuloma

Answer 15

• thought to be form of rosacea in children
• young - 2-4 years of age roughly
• Dermal lymphohistiocytic infiltrate with foreign body type giant cells
• > 40% have at least 2 other signs of rosacea: recurrent chalazions, facial flushing, telangiectasias, papulopustules

Question 16

Hormones

Answer 16

Second generation: levonorgesterol

Third generation: anti-androgen - cyprorone acetate, digonest, drosperidone