Presentation on theme: "Medical Student Core Curriculum in Dermatology"— Presentation transcript:
1 Medical Student Core Curriculum in Dermatology Acne and RosaceaMedical Student Core Curriculumin DermatologyLast updated June 8, 2011
2 Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3 Goals and ObjectivesThe purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with acne and rosacea.By completing this module, the learner will be able to:Identify and describe the morphology of acne and rosaceaList common triggers for intermittent flushing in rosaceaExplain the basic principles of treatment for acne and rosaceaRecommend an initial treatment plan for a patient presenting with comedonal and/or inflammatory acnePractice providing patient education on topical and systemic acne treatmentDetermine when to refer a patient with acne or rosacea to a dermatologist
4 Acne Vulgaris: Epidemiology Acne vulgaris, often referred to as “acne”, is a disorder of pilosebaceous folliclesTypically presents at ages 8-12 (often the first sign of puberty), peaks at ages 15-18, and resolves by age 25Affects 90% of adolescents and affects races equallyFamily history is often positive12% of women and 3% of men will have acne until their 40sIn women it is not uncommon to have a first outbreak at years of age
5 Acne Vulgaris: Clinical Presentation Acne affects mainly the face, neck, upper trunk and upper arms (where sebaceous glands are abundant)Acne begins with “clogged pores” (pores = pilosebaceous unit), aka comedonesOpen comedones = “blackheads”Closed comedones = “whiteheads”Debris and bacteria collect in these clogged pores which then leads to inflammation: papules and pustules with erythema and edemaThese pressurized follicles can rupture in the dermis, resulting in tender deep nodulocystic acne
7 Case One: HistoryHPI: Jim Reynolds is an 17-year-old healthy teenager who presents to his primary care physician with “pimples” on his face for the last 2 years. He reports a daily skin regimen of aggressive facial cleansing with a bar soap during his morning shower.PMH: no chronic illnesses or prior hospitalizationsAllergies: no known allergiesMedications: noneFamily history: father and mother had acne as teenagersSocial history: lives at home with parents, attends high schoolROS: negative
8 Skin Exam FindingsExam of left cheek: numerous pustules, papules, open and closed comedones with some scarringOpen comedoClosed comedoPustuleInflamed papuleScarring
9 Classification of Acne Vulgaris Classification of acne is based on the morphologyComedonal: open and closed comedonesInflammatory: papules and pustulesNodulocystic: nodules and cystsIt is equally important to describe the severity (each type can be mild to severe depending on the amount of acne) and note the presence of scarring for each patient
10 Case One, Question 1 How would you describe Jim’s skin exam? Mild comedonal acne without presence of scarringMild inflammatory acne without comedonesModerate mixed comedonal and inflammatory acne with presence of scarringModerate mixed comedonal and inflammatory acne without presence of scarring
11 Case One, Question 1 Answer: c How would you describe Jim’s skin exam? Mild comedonal acne without presence of scarringMild inflammatory acne without comedonesModerate mixed comedonal and inflammatory acne with presence of scarringModerate mixed comedonal and inflammatory acne without presence of scarring
12 How Would You Describe the Following Patients’ Acne? Remember for each patient to include the morphology, severity and presence of scarring
16 Acne VulgarisSevere nodulocystic acne with presence of scarring
17 Case One, Question 2Which is (are) related to the pathogenesis of acne vulgaris?Androgens in the circulationBacteria in the hair follicleFollicular pluggingSebum secretionAll of the above
18 Case One, Question 2 Answer: e Which is (are) related to the pathogenesis of acne vulgaris?Androgens in the circulationBacteria in the hair follicleFollicular pluggingSebum secretionAll of the above
19 Acne Vulgaris: Pathogenesis Acne Vulgaris is related to 4 factors:Presence of hormones (androgens)Sebaceous gland activity (increased in presence of androgens)Plugging of the hair follicle as a result of abnormal keratinization of the upper portion (gives rise to comedones)P. acnes (bacteria) in the hair follicle (lives on the oil and breaks it down to free fatty acids which cause inflammation)
20 Case One, Question 3Which of the following agents are effective in treating acne vulgaris?Oral antibioticsTopical benzoyl peroxideTopical retinoid creamsAll of the above
21 Case One, Question 3 Answer: d Which of the following agents are effective in treating acne vulgaris?Oral antibioticsTopical benzoyl peroxideTopical retinoid creamsAll of the above
22 Treatment: Basic Principles Systemic and topical retinoids, systemic and topical antimicrobials, and systemic hormonal therapies are the main classes of treatmentMultiple agents are often used with activity against different pathogenic causes (e.g. topical antibiotic plus retinoid)Use topical antibiotics with benzoyl peroxide to prevent the development of antibiotic resistanceAcne scarring is difficult to treat, therefore aggressive prevention is important
23 Acne ScarringAcne should be treated aggressively to avoid permanent scarring and cystsRefer patients with difficult to control acne or the presence of scarring to dermatology
25 Common First-Line Treatments Moderate nodular without scarring: oral antibiotic with topical retinoid and topical benzoyl peroxideSevere nodular: refer to a dermatologist for oral isotretinoinScarring and keloids: refer to a dermatologist for oral isotretinoin
26 Topical Retinoids (tretinoin, all trans retinoic acid) Topical retinoids are vitamin A derivativesUsed for acne vulgaris; photodamaged skin; fine wrinkles, hyperpigmentationPatients should be warned of common adverse effects:Dryness, pruritus, erythema, scalingPhotosensitivityAvailable as a cream or gelDo not apply at the same time as benzoyl peroxide because benzoyl peroxide oxidizes tretinoin
27 Benzoyl PeroxideBenzoyl peroxide is a topical medication with both antibacterial and comedolytic propertiesAvailable as a prescription and over-the-counter, as well as in combinations with topical antibioticsPatients should be warned of common adverse effects:Bleaching of hair, colored fabric, or carpetMay irritate skin; discontinue if severeAvailable as a cream, lotion, gel, or wash
28 Topical AntibioticsUsed to reduce the number of P. acnes and reduce inflammation in inflammatory acneDo not use as monotherapy (often used with benzoyl peroxide to prevent the development of antibiotic resistance in the treatment of mild-to- moderate acne and rosacea)Erythromycin 2% (solution, gel)Clindamycin 1% (lotion, solution, gel, foam)Metronidazole 0.75%, 1% (cream, gel) is used in the treatment of rosacea
29 Topical Acne Treatment: Side Effects Topical acne treatments are often irritating and can cause dry skinWhen using retinoids or benzoyl peroxide, consider beginning on alternate days. Use a moisturizer to reduce their irritancy.Topical agents take 2-3 months to see effectPatients will often stop their topical treatment too early from “red, flakey” skin without improvement in their acnePatient education is a crucial component to acne treatment
30 Oral Antibiotics Tetracycline, doxycycline, minocycline Use for moderate to severe inflammatory acneOften combined with benzoyl peroxide to prevent antibiotic resistanceIf the patient has not responded after 3 months of therapy with an oral antibiotic, consider:Increasing the dose,Changing the treatment, orReferring to a dermatologist
31 Oral Treatment: Side Effects Tetracyclines (tetracycline, doxycycline, minocycline):Are contraindicated in pregnancy and in children <8 years oldMay cause GI upset (epigastric burning, nausea, vomiting and diarrhea can occur)Can cause photosensitivity (patients may burn easier, which can be easily managed with better sun protection). Recommend sun block with UVA coverage for all acne patients on tetracyclines
32 Oral Tetracyclines: Patient Counseling Major side effects:Tetracycline: GI upset, photosensitivityDoxycycline: GI upset, photosensitivityMinocycline: GI upset, vertigo, hyperpigmentationPatients need clear instructionsIf taking for acne, it is okay to take them with food and dairy products for tolerability of GI side effectsTake with full glass of water; avoids esophageal erosionsTetracyclines do NOT interfere with birth control pillsIt takes 2-3 months to see improvement
33 Minocycline pigmentation Pigmentation appears after months to years in a small percentage of patientsFirst noticeable on the alveolar ridge, palate, scleraSkin deposition can be brown or blue-grey. Blue-grey pigmentation may occur in scarsSkin pigmentation may not fade after discontinuationPatients on long-term minocycline should be screened; if seen on gums or sclerae, discontinueTB: check
34 Oral IsotretinoinOral isotretinoin, a retinoic acid derivative, is indicated in severe, nodulocystic acne failing other therapiesShould be prescribed by physicians with experience using this medicationTypically given in a single 5-6 month courseIsotretinoin is teratogenic and therefore absolutely contraindicated in pregnancyFemale patients must be enrolled in a FDA-mandated prescribing program in order to use this medicationTwo forms of contraception must be used during isotretinoin therapy and for one month after treatment has ended
35 Isotretinoin: Side Effects Common side effects of isotretinoin include:Xerosis (dry skin)Cheilitis (chapped lips)Elevated liver enzymesHypertriglyceridemiaIndividuals with severe acne may suffer mood changes and depression and should be monitoredSevere headache can be a manifestation of the uncommon side effect pseudotumor cerebri
36 Back to Case OneFollow-up: Jim has called the after-hours answering service very concerned about a new symptom of “dizziness”, which began after he started his new medication.
37 Case One, Question 4Which of the following treatment regimens was most likely prescribed for Jim’s acne?Isotretinoin 1mg/kg/day divided BIDMinocycline 100mg po BIDTetracycline 500mg po once dailyNone of the above
38 Case One, Question 4 Answer: b Which of the following treatment regimens was prescribed for Jim’s acne?Isotretinoin 1mg/kg/day divided BID (main side effects include xerosis, cheilitis, elevated liver enzymes, hypertriglyceridemia)Minocycline 100mg po BID (can cause vestibular toxicity, manifested as dizziness, ataxia, nausea and vomiting)Tetracycline 500mg po once daily (common side effects include GI upset and photosensitivity)None of the above
39 Patient EducationPatient education and setting expectations are important components of effective acne treatmentLack of adherence is the most common cause of treatment failureWith the patient, the physician should develop the therapeutic regimen with the highest likelihood of adherenceAcne treatment is only treating new lesions, not the ones already there
40 Patient Education (cont.) Patients should use only the prescribed medications and avoid potentially drying over-the-counter products, such as astringent, harsh cleansers or antibacterial soapsRecommend daily moisturizer when patients are using solutions and gels because they have more drying effects than creams and ointmentsOveraggressive washing and the use of particulate abrasive scrubs often exacerbates acne and should be avoidedCosmetics are often labeled as “non-comedogenic” or “oil-free” if they do not cause or exacerbate acne
42 Case Two: HistoryHPI: Ms. Garcia is a 22-year-old woman who was referred to the dermatology clinic for new onset acnePMH: no major illness or hospitalizations, no pregnanciesAllergies: allergic to penicillin (rash)Medications: occasional multivitaminFamily history: noncontributorySocial history: lives in the city and attends collegeHealth-related behaviors: gained 40 pounds over the past 4 years despite a healthy diet and exercise habitsROS: new upper lip and chin hair growth, irregular menstrual cycles since menarche, last period was 4 months ago
43 Case Two: Skin ExamModerate comedonal and inflammatory acne of cheeks and jaw line. Also with scattered terminal hairs on the upper lip and lower chin.Hair loss noted on frontal and parietal scalp.
44 Case Two, Question 1Ms. Garcia was given spironolactone and her acne improved. Why did this medication work?Spironolactone has anti-androgenic effectsSpironolactone has anti-comedonal activitySpironolactone when used appropriately has anti-bacterial activityThe diuretic effect of spironolactone eliminated sodium resulting in less sebum
45 Case Two, Question 1 Answer: a Ms. Garcia was given spironolactone and her acne resolved. Why did this medication work?Spironolactone has anti-androgenic effectsSpironolactone has anti-comedonal activity (not true)Spironolactone when used appropriately has anti-bacterial activity (not true)The diuretic effect of spironolactone eliminated sodium resulting in less sebum (not true)
46 Case Two, Question 2Based on the history and exam, what is the most likely diagnosis?Cushing SyndromeGram negative folliculitisPolycystic ovarian syndromeS. aureus folliculitis
47 Case Two, Question 2 Answer: c Based on the history and exam, what is the most likely diagnosis?Cushing Syndrome (manifestations of excessive corticosteroids, which results in central obesity, muscle wasting, thin skin, hirsutism, purple striae)Gram negative folliculitis (multiple tiny yellow pustules develop on top of acne vulgaris as a result of long-term antibiotic administration)Polycystic ovarian syndromeS. aureus folliculitis (multiple follicular pustules and papules)
48 Polycystic Ovarian Syndrome Ms Garcia most likely has polycystic ovarian syndrome (PCOS)Affected individuals must have two out of the following three criteria: (1) oligo- and/or anovulation, (2) hyperandrogenism (clinical and/or biochemical), and (3) polycystic ovaries on sonographic examination*In addition to hormonal acne, increased circulating androgens also results in hirsutismWomen with PCOS also have a greater degree with insulin resistance which can cause acanthosis nigricans* Based on definition from the Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004
49 Androgens in AcneIn many post adolescent women, antiandrogen therapy can improve acneThese women have hormonal acne; their serum hormone levels are usually normalHormonal acne lesions are often perioral and along the jaw lineMany women report a pre-menstrual flareNot all women with hormonal acne are tested for hyperandrogenismHowever, it should be considered in the female patient whose acne is severe, sudden in onset, or associated with hirsutism or irregular menses
50 More Examples of Hormonal Acne Inflammatory acne on the lateral and inferior face, especially along the jawline
51 Treatment of Hormonal Acne Commonly used agents to treat hormonal acne include:Spironolactone 50mg -100mg dailyOral contraceptivesThe following oral contraceptives have been approved by the FDA for treatment of acne: Yaz, Ortho Tri-cyclen, EstrostepThere is good evidence and consensus opinion that other estrogen-containing OCPs are also effective
53 Case Three: HistoryHPI: Ms. Johnson is a 33-year-old woman who presented to clinic with “red cheeks” for the last yearPMH: migraine headaches since childhoodAllergies: noneMedications: noneFamily history: not contributorySocial history: lives in an apartment, works as a cashier at a grocery storeHealth related behaviors: drinks 1/2 pint of vodka per day, no tobacco or drug useROS: negative
54 Case Three, Question 1How would you describe Ms. Johnson’s skin exam?
55 Case Three, Question 1Facial erythema with papules and pustules on the nose and cheeks as well as some scattered papules and pustules on the forehead and chin.No comedones are noted.
56 Case Three, Question 2 What is the most likely diagnosis? Bacterial folliculitisPellagra from niacin deficiencyRosaceaSeborrheic dermatitisSystemic lupus erythematosus
57 Case Three, Question 2 Answer: c What is the most likely diagnosis? Bacterial folliculitis (Would expect multiple follicular pustules and papules for a shorter duration, without background of erythema)Pellagra from niacin deficiency (Erythema and edema which fade with a dusky brown-red coloration on sun-exposed areas. Lesions become hyperkeratotic and scaly)RosaceaSeborrheic dermatitis (Would expect erythematous patches and plaques with greasy, yellowish scale accentuated on the central face)Systemic lupus erythematosus (Rash of SLE does not present with pustules)
58 Acne Rosacea: The Basics Acne rosacea, also called rosacea, is a chronic inflammatory condition located at the “flush” areas of the face (nose, cheeks > brow, chin)Papules and pustules superimposed on a background of telangiectasias and general erythemaMore common in womenAge of onset 30-50s (later than acne vulgaris)Affected persons flush easilyPatients often report very sensitive skin
59 Case Three, Question 3Which of the following might trigger Ms. Johnson’s rosacea?AlcoholHeat/hot beveragesHot, spicy foodsSunlightAll of the above
60 Case Three, Question 3 Answer: e Which of the following might trigger Ms. Johnson’s rosacea?AlcoholHeat/hot beveragesHot, spicy foodsSunlightAll of the above
61 Rosacea Triggers Alcohol Sunlight Hot beverages (heat) Hot, spicy food If it makes you flush it can flare rosaceaIncludes emotional stressUnlike acne vulgaris, rosacea is not related to androgens
62 Clinical Features of Rosacea Rosacea is typically located on the mid face including the nose and cheeks with occasional involvement of the brow, chin, eyelids, and eyesPatients have erythema and telangiectasiasPatients can have papules and pustulesThe absence of comedones helps to distinguish acne vulgaris from rosaceaMay also present with rhinophyma (dermal and sebaceous gland hyperplasia of the nose)Patients can have ocular rosacea: keratitis, blepharitis, conjunctivitis
63 The Following Photos Illustrate Different Types of Rosacea
64 Erythematotelangietatic Rosacea Erythema and telangiectasias scattered on the nose and cheeks.There are no papules, pustules, or comedones present.
65 Papulopustular Rosacea Erythema with papules and pustules on the nose and chin.Patient also has erythematous patches on the cheeks bilaterally.
66 Phymatous RosaceaFacial erythema, scattered papules, pustules on the nose, forehead, cheeks and chin. Thickened, highly sebaceous skin.This patient also has severe rhinophyma.
67 Rosacea Treatment Therapy is often long-term Rosacea is chronic, controllable, but not curableAll patients should use sunscreen dailyMost treatments are directed at specific findings manifested by rosacea patientsSee the following slides for recommendations regarding rosacea treatment
68 Rosacea Treatment (cont.) For patients with papulopustular rosacea and the erythrotelangiectatic type, topical products are often used:Metronidazole, sodium sulfacetamide, azelaic acid and sulfur cleansers and creamsIn addition to topical products, oral antibiotics (tetracyclines) are used for pustular and papular lesionsLasers and light devices are useful for treating the erythema and telangiectasias, but the cost is not covered by insurance, limiting their availability
69 Rosacea Treatment (cont.) Isotretinoin is considered in severe casesThese patients should be referred to a dermatologistSurgical approaches are used to treat rhinophyma
71 Case Three, Question 4Which of the following treatments would you recommend for Ms. Johnson?Avoidance of alcoholOral tetracyclineUse sunscreen dailyAll of the above
72 Case Three, Question 4 Answer: d Which of the following treatments would you recommend for Ms. Johnson?Avoidance of alcoholOral tetracyclineUse sunscreen dailyAll of the above
73 Case Three, Question 5True or False, topical and oral antibiotics are the best treatment for the erythema of rosacea.
74 Case Three, Question 5 Answer: False The medical management of rosacea may not diminish the erythemaLaser therapy may be helpful for telangiectasias and erythemaPhotoprotection is also helpful in treating the erythema of rosacea
75 Ask About Ocular Symptoms Ask all patients with rosacea about any ocular symptomsConsider referral to ophthalmology and/or dermatology if suspect ocular involvementSigns and symptoms of ocular rosacea include: blepharitis, conjunctivitis, iritis, scleritis, hypopyon, and keratitis
76 Take Home Points: Acne Vulgaris Acne vulgaris is characterized by open and closed comedones, papules, pustules, nodules, and cystsInclude the morphology, severity and presence of scarring when describing acnePathogenesis of acne vulgaris is related to the presence of androgens, excess sebum production, the activity of P. acnes, and follicular hyperkeratinizationSystemic and topical retinoids, systemic and topical antimicrobials, and systemic hormonal therapies are the main classes of treatment for acne vulgarisUntreated acne can result in permanent scarring
77 Take Home Points: Rosacea Rosacea is a chronic inflammatory condition of the face, which may present with easy flushing, erythema, telangiectasias, papules and pustules, and/or phymatous changesMany patients with rosacea have ocular involvementUnlike acne vulgaris, rosacea does not present with comedones and is unrelated to hormonesTopical and oral treatments often improve the papules and pustules of rosacea, but will not reverse the underlying erythema and flushingAll patients with rosacea should use sunscreen
78 AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary authors: Sarah D. Cipriano, MD, MPH; Eric Meinhardt, MD; Timothy G. Berger, MD, FAAD; Kanade Shinkai, MD, PhD, FAAD.Peer reviewers: Rebecca B. Luria, MD, FAAD; Cory A. Dunnick, MD, FAAD.Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad. Last revised June 2011.
79 ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web- Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:Chambers Henry F, "Chapter 46. Protein Synthesis Inhibitors and Miscellaneous Antibacterial Agents" (Chapter). Brunton LL, Lazo JS, Parker KL: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 11e:Feldman S, Careccia R, Barham KL, Hancox J. Diagnosis and Treatment of Acne. Am Fam Physician. 2004;69:James WD, Berger TG, Elston DM, “Chapter 13. Acne” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: ,
80 ReferencesRotterdam 1: revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod ;19:41–47.Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 16. Amenorrhea" (Chapter). Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG: Williams Gynecology:Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Sigfried EC, et al. Guidelines of care for acne vulgaris management. J AM Acad Dermatol ;56:Zaenglein Andrea L, Graber Emmy M, Thiboutot Diane M, Strauss John S, "Chapter 78. Acne Vulgaris and Acneiform Eruptions" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: