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13.03.07 Dermatology teaching - Acne

Classification
  • Vulgaris
    • Standard
  • Excoriee
    • Scratched
  • Conglobata
  • Fulmigans
    • Scarring
    • Secondary infection
    • Death
  • Infantile


Comedones
  • Open
    • Sebum oxidation => Blackhead
  • Closed
    • Accumulation => Inflammation
    • Infection (Propionibacterium acnes)


Treatments

  • Topical
    • Retionoids - Good for comodomal acne
      • Adapalene
      • Retinoic acid
    • Azelaic acid
    • Antimicrobials - Good for inflammatory acne
      • Benzoyl peroxide (cf bleaching)
      • Antibiotics
        • Clindamycin
        • Erythromycin
    • Combination creams
      • Duac
      • Benzamycin
      • Isotrexin
      • Epiduo
      • Acnisal
  • Oral antibiotics
    • Combine with topical retinoid
    • Tetracyclins
      • Lymecycline
      • Oxytetracycline
      • Doxycycline
      • Minocycline
    • Erythromycin
  • Hormones
    • Dianette
      • Cyproterone acetate (anti-androgen/progestogen) and ethinylestradiol
      • As effective as COCP, but never used just for contraception
    • COCP
  • Isotretinoin (Roacutane)
    • Only dermatologists can prescribe
    • Give 120 mg/kg total dose, over 4 months
    • Side effects
      • Pregnancy category X
      • Dry skin (everywhere)
      • Photosensitivity
      • Joint pain
      • Nosebleeds
      • Can make acne worse initially
        • => Acne fulmigans
        • Cover with low-dose pred.
      • ? Depression (no evidence but be careful)


Triggers
  • Diet
    • Generally no
    • ? Low glycaemic index may help
    • ? Milk / Fatty foods
  • Stress
    • Doesn't trigger new eruptions
  • Facial hygiene
    • Wash OD, non-oily
    • No more required
  • Smoking
    • No link established
  • Sweating
    • Exacerbates
  • Premenstrual
    • Exacerbates in 70% of women


Indications for patch testing

  • Contact dermatitis
  • Eczema not improving
  • Hand/foot eczema
  • Eczema unusual site


Notes
  • Androgens
    • Testosterone
    • DHT
    • Dehydroepiandrosterone sulfate (DHEAS)
      • Suphate ester of DHEA - Major circulating form
      • Made in Adrenals / Brain
      • cf pre-pubertal acne
  • Pilosebaceous
    • Epidermal invagination
    • Hair follicle, sebaceous gland, arrector pili muscle
  • All treatments take a couple of months to work
  • No COCP if migraines (thrombosis association)
  • Check for causes of raised androgens
    • PCOS - Any 2 of:
      • Oligoovulation and/or anovulation
      • Excess androgen activity
      • Polycystic ovaries (by gynecologic ultrasound)
  • Acne rosacea
    • Not real acne
    • Eryhthema
    • Papular/Pustular rash
    • No comidones (doesn't involve PSU)
  • Perioral dermatitis
    • From topical steroids
  • Chronic idiopathic urticaria
    • Appear to be allergic to everything
  • Patch testing (Type IV) vs serum IgE testing (Type I)
  • Garlic allergy
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