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Acne and Rosacea

Medical Student Core Curriculum


in Dermatology

Last updated June 8, 2011

Module Instructions
The 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.
2

Goals and Objectives


The 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 rosacea


List common triggers for intermittent flushing in rosacea
Explain the basic principles of treatment for acne and rosacea
Recommend an initial treatment plan for a patient presenting with
comedonal and/or inflammatory acne
Practice providing patient education on topical and systemic acne
treatment
Determine when to refer a patient with acne or rosacea to a
dermatologist
3

Acne Vulgaris: Epidemiology


Acne vulgaris, often referred to as acne, is a disorder
of pilosebaceous follicles
Typically presents at ages 8-12 (often the first sign of
puberty), peaks at ages 15-18, and resolves by age 25
Affects 90% of adolescents and affects races equally
Family history is often positive
12% of women and 3% of men will have acne until their
40s
In women it is not uncommon to have a first outbreak at
20-35 years of age
4

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 comedones
Open comedones = blackheads
Closed comedones = whiteheads

Debris and bacteria collect in these clogged pores which


then leads to inflammation: papules and pustules with
erythema and edema
These pressurized follicles can rupture in the dermis,
resulting in tender deep nodulocystic acne
5

Case One
Jim Reynolds

Case One: History

PI: Jim Reynolds is an 17-year-old healthy teenager who


resents to his primary care physician with pimples on his
ce for the last 2 years. He reports a daily skin regimen of
ggressive facial cleansing with a bar soap during his morning
hower.
MH: no chronic illnesses or prior hospitalizations
lergies: no known allergies
edications: none
amily history: father and mother had acne as teenagers
ocial history: lives at home with parents, attends high school
OS: negative

Skin Exam Findings


Exam of left cheek: numerous
pustules, papules, open and
closed comedones with some
scarring
Open comedo
Closed comedo
Pustule
Inflamed papule
Scarring

Classification of Acne Vulgaris

Classification of acne is based on the


morphology

Comedonal: open and closed comedones


Inflammatory: papules and pustules
Nodulocystic: nodules and cysts

t is equally important to describe the severity


each type can be mild to severe depending on
he amount of acne) and note the presence of
carring for each patient

Case One, Question 1

ow would you describe Jims


n exam?
Mild comedonal acne without
presence of scarring
Mild inflammatory acne without
comedones
Moderate mixed comedonal
and inflammatory acne with
presence of scarring
Moderate mixed comedonal
and inflammatory acne without
presence of scarring

Case One, Question 1

swer: c
How would you describe Jims skin exam?

a. Mild comedonal acne without presence of


scarring
b. Mild inflammatory acne without comedones
c. Moderate mixed comedonal and
inflammatory acne with presence of scarring
d. Moderate mixed comedonal and inflammatory
acne without presence of scarring

How Would You Describe the


Following Patients Acne?

Remember for each patient to include the


morphology, severity and presence of
scarring

Acne Vulgaris

Acne Vulgaris

Moderate
omedonal acne
without evidence of
carring.
ote the mild postnflammatory
yperpigmentation.

Acne Vulgaris

Acne Vulgaris
Severe nodulocystic
acne with presence of
scarring

Case One, Question 2

Which is (are) related to the pathogenesis


of acne vulgaris?
a.
b.
c.
d.
e.

Androgens in the circulation


Bacteria in the hair follicle
Follicular plugging
Sebum secretion
All of the above

Case One, Question 2

nswer: e
Which is (are) related to the pathogenesis
of acne vulgaris?
a.
b.
c.
d.
e.

Androgens in the circulation


Bacteria in the hair follicle
Follicular plugging
Sebum secretion
All of the above

Acne Vulgaris: Pathogenesis

cne 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)

Case One, Question 3

Which of the following agents are effective


n treating acne vulgaris?
a.
b.
c.
d.

Oral antibiotics
Topical benzoyl peroxide
Topical retinoid creams
All of the above

Case One, Question 3

swer: d
Which of the following agents are effective
n treating acne vulgaris?
a.
b.
c.
d.

Oral antibiotics
Topical benzoyl peroxide
Topical retinoid creams
All of the above

Treatment: Basic Principles

ystemic and topical retinoids, systemic and topical


ntimicrobials, and systemic hormonal therapies
re the main classes of treatment
ultiple agents are often used with activity against
fferent pathogenic causes (e.g. topical antibiotic
us retinoid)
se topical antibiotics with benzoyl peroxide to
revent the development of antibiotic resistance
cne scarring is difficult to treat, therefore
ggressive prevention is important

Acne Scarring

cne should be
eated aggressively
o avoid permanent
carring and cysts
efer patients with
fficult to control
cne or the presence
f scarring to
ermatology

Common First-Line Treatments

Mild comedonal: topical retinoid, +/- topical


benzoyl peroxide

Mild papular/pustular: topical retinoid,


opical antibiotics (clindamycin,
erythromycin), topical benzoyl peroxide

Moderate papular/pustular: oral antibiotics


with topical retinoid and benzoyl peroxide

Common First-Line Treatments

Moderate nodular without scarring: oral


antibiotic with topical retinoid and topical
benzoyl peroxide

Severe nodular: refer to a dermatologist for


oral isotretinoin

Scarring and keloids: refer to a


dermatologist for oral isotretinoin

Topical Retinoids
(tretinoin, all trans retinoic acid)

Topical retinoids are vitamin A derivatives


Used for acne vulgaris; photodamaged skin; fine
wrinkles, hyperpigmentation
Patients should be warned of common adverse
effects:
Dryness, pruritus, erythema, scaling
Photosensitivity

Available as a cream or gel


Do not apply at the same time as benzoyl peroxide
because benzoyl peroxide oxidizes tretinoin

Benzoyl Peroxide

Benzoyl peroxide is a topical medication with both


ntibacterial and comedolytic properties
Available as a prescription and over-the-counter,
s well as in combinations with topical antibiotics
Patients should be warned of common adverse
ffects:
Bleaching of hair, colored fabric, or carpet
May irritate skin; discontinue if severe

Available as a cream, lotion, gel, or wash

Topical Antibiotics

Used to reduce the number of P. acnes and


educe inflammation in inflammatory acne
Do not use as monotherapy (often used with
benzoyl peroxide to prevent the development of
antibiotic resistance in the treatment of mild-tomoderate acne and rosacea)
Erythromycin 2% (solution, gel)
Clindamycin 1% (lotion, solution, gel, foam)

Metronidazole 0.75%, 1% (cream, gel) is used in


he treatment of rosacea

Topical Acne Treatment:


Side Effects

opical acne treatments are often irritating and can


ause dry skin

When using retinoids or benzoyl peroxide, consider


beginning on alternate days. Use a moisturizer to
reduce their irritancy.

opical agents take 2-3 months to see effect


atients will often stop their topical treatment too early
om red, flakey skin without improvement in their
cne
atient education is a crucial component to acne
eatment

Oral Antibiotics

etracycline, doxycycline, minocycline


se for moderate to severe inflammatory acne
ften combined with benzoyl peroxide to prevent
ntibiotic resistance
the patient has not responded after 3 months of
erapy with an oral antibiotic, consider:

Increasing the dose,


Changing the treatment, or
Referring to a dermatologist

Oral Treatment: Side Effects

etracyclines (tetracycline, doxycycline,


inocycline):
Are contraindicated in pregnancy and in children
<8 years old
May 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

al Tetracyclines: Patient Counseling


ajor side effects:
Tetracycline: GI upset, photosensitivity
Doxycycline: GI upset, photosensitivity
Minocycline: GI upset, vertigo, hyperpigmentation

atients need clear instructions


If taking for acne, it is okay to take them with food and
dairy products for tolerability of GI side effects
Take with full glass of water; avoids esophageal erosions
Tetracyclines do NOT interfere with birth control pills
It takes 2-3 months to see improvement

Minocycline pigmentation

mentation appears after months


years in a small percentage of
ients

st noticeable on the alveolar


ge, palate, sclera

n deposition can be brown or


e-grey. Blue-grey pigmentation
y occur in scars

n pigmentation may not fade


er discontinuation

tients on long-term minocycline


ould be screened; if seen on
ms or sclerae, discontinue

Oral Isotretinoin

al isotretinoin, a retinoic acid derivative, is indicated in


vere, nodulocystic acne failing other therapies
ould be prescribed by physicians with experience using
s medication
pically given in a single 5-6 month course
tretinoin is teratogenic and therefore absolutely
ntraindicated in pregnancy
Female patients must be enrolled in a FDA-mandated
prescribing program in order to use this medication
Two forms of contraception must be used during isotretinoin
therapy and for one month after treatment has ended

Isotretinoin: Side Effects

ommon side effects of isotretinoin include:

Xerosis (dry skin)


Cheilitis (chapped lips)
Elevated liver enzymes
Hypertriglyceridemia

ndividuals with severe acne may suffer mood


hanges and depression and should be monitored
evere headache can be a manifestation of the
ncommon side effect pseudotumor cerebri

Back to Case One


Follow-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.

Case One, Question 4

Which of the following treatment regimens


was most likely prescribed for Jims acne?
a. Isotretinoin 1mg/kg/day divided BID
b. Minocycline 100mg po BID
c. Tetracycline 500mg po once daily
d. None of the above

Case One, Question 4

swer: b
Which of the following treatment regimens was
rescribed for Jims acne?
a. Isotretinoin 1mg/kg/day divided BID (main side effects
include xerosis, cheilitis, elevated liver enzymes,
hypertriglyceridemia)
b. Minocycline 100mg po BID (can cause vestibular toxicity,
manifested as dizziness, ataxia, nausea and vomiting)
c. Tetracycline 500mg po once daily (common side effects
include GI upset and photosensitivity)
d. None of the above

Patient Education

atient education and setting expectations are


mportant components of effective acne
eatment

Lack of adherence is the most common cause of


treatment failure
With the patient, the physician should develop
the therapeutic regimen with the highest
likelihood of adherence
Acne treatment is only treating new lesions, not
the ones already there

Patient Education (cont.)

atients should use only the prescribed medications and


void potentially drying over-the-counter products, such
s astringent, harsh cleansers or antibacterial soaps

Recommend daily moisturizer when patients are using


solutions and gels because they have more drying effects
than creams and ointments

veraggressive washing and the use of particulate


brasive scrubs often exacerbates acne and should be
voided
osmetics are often labeled as non-comedogenic or
il-free if they do not cause or exacerbate acne

Case Two
Ms. Emily Garcia

Case Two: History

PI: Ms. Garcia is a 22-year-old woman who was referred to


e dermatology clinic for new onset acne
MH: no major illness or hospitalizations, no pregnancies
ergies: allergic to penicillin (rash)
edications: occasional multivitamin
mily history: noncontributory
cial history: lives in the city and attends college
alth-related behaviors: gained 40 pounds over the past 4
ars despite a healthy diet and exercise habits
OS: new upper lip and chin hair growth, irregular
enstrual cycles since menarche, last period was 4 months

Case Two: Skin Exam

oderate comedonal and


ammatory acne of cheeks
d jaw line. Also with scattered
minal hairs on the upper lip
d lower chin.

ir loss noted
frontal and
rietal scalp.

Case Two, Question 1

Ms. Garcia was given spironolactone and her


cne improved. Why did this medication
work?
a. Spironolactone has anti-androgenic effects
b. Spironolactone has anti-comedonal activity
c. Spironolactone when used appropriately has
anti-bacterial activity
d. The diuretic effect of spironolactone eliminated
sodium resulting in less sebum

Case Two, Question 1

swer: a
Ms. Garcia was given spironolactone and her
cne resolved. Why did this medication work?
a. Spironolactone has anti-androgenic effects
b. Spironolactone has anti-comedonal activity (not
true)
c. Spironolactone when used appropriately has
anti-bacterial activity (not true)
d. The diuretic effect of spironolactone eliminated
sodium resulting in less sebum (not true)

Case Two, Question 2

Based on the history and exam, what is


he most likely diagnosis?
a.
b.
c.
d.

Cushing Syndrome
Gram negative folliculitis
Polycystic ovarian syndrome
S. aureus folliculitis

Case Two, Question 2

swer: c
Based on the history and exam, what is the most
kely diagnosis?

a. Cushing Syndrome (manifestations of excessive


corticosteroids, which results in central obesity, muscle
wasting, thin skin, hirsutism, purple striae)
b. Gram negative folliculitis (multiple tiny yellow pustules
develop on top of acne vulgaris as a result of long-term
antibiotic administration)
c. Polycystic ovarian syndrome
d. S. aureus folliculitis (multiple follicular pustules and

Polycystic Ovarian Syndrome

s Garcia most likely has polycystic ovarian syndrome


COS)
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 hirsutism
Women with PCOS also have a greater degree with insulin
resistance which can cause acanthosis nigricans

d on definition from the Rotterdam ESHRE/ASRM-Sponsored PCOS

Androgens in Acne

many post adolescent women, antiandrogen therapy


an improve acne
These women have hormonal acne; their serum hormone
levels are usually normal
Hormonal acne lesions are often perioral and along the jaw
line
Many women report a pre-menstrual flare

ot all women with hormonal acne are tested for


yperandrogenism
However, it should be considered in the female patient whose
acne is severe, sudden in onset, or associated with hirsutism
or irregular menses

More Examples of Hormonal Acne

flammatory acne on the lateral and inferior face,


specially along the jawline

Treatment of Hormonal Acne

Commonly used agents to treat hormonal


acne include:

Spironolactone 50mg -100mg daily

Oral contraceptives
The following oral contraceptives have been
approved by the FDA for treatment of acne: Yaz,
Ortho Tri-cyclen, Estrostep
There is good evidence and consensus opinion that
other estrogen-containing OCPs are also effective

Case Three
Ms. Sherri Johnson

Case Three: History

PI: Ms. Johnson is a 33-year-old woman who


resented to clinic with red cheeks for the last year
MH: migraine headaches since childhood
llergies: none
Medications: none
amily history: not contributory
ocial history: lives in an apartment, works as a cashier
t a grocery store
ealth related behaviors: drinks 1/2 pint of vodka per
ay, no tobacco or drug use

Case Three, Question 1


How would you describe
Ms. Johnsons skin
exam?

Case Three, Question 1


Facial 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.

Case Three, Question 2

What is the most likely diagnosis?


a.
b.
c.
d.
e.

Bacterial folliculitis
Pellagra from niacin deficiency
Rosacea
Seborrheic dermatitis
Systemic lupus erythematosus

Case Three, Question 2

wer: c
hat 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)
Rosacea
Seborrheic 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)

Acne Rosacea: The Basics

Acne rosacea, also called rosacea, is a chronic


nflammatory condition located at the flush areas of
he face (nose, cheeks > brow, chin)
Papules and pustules superimposed on a
ackground of telangiectasias and general erythema
More common in women
Age of onset 30-50s (later than acne vulgaris)
Affected persons flush easily
Patients often report very sensitive skin

Case Three, Question 3

Which of the following might trigger Ms.


Johnsons rosacea?
a.
b.
c.
d.
e.

Alcohol
Heat/hot beverages
Hot, spicy foods
Sunlight
All of the above

Case Three, Question 3

nswer: e
Which of the following might trigger Ms.
Johnsons rosacea?
a.
b.
c.
d.
e.

Alcohol
Heat/hot beverages
Hot, spicy foods
Sunlight
All of the above

Rosacea Triggers

Alcohol
Sunlight
Hot beverages (heat)
Hot, spicy food
If it makes you flush it can flare rosacea
Includes emotional stress

Unlike acne vulgaris, rosacea is not related


to androgens

Clinical Features of Rosacea

osacea is typically located on the mid face including the


ose and cheeks with occasional involvement of the brow,
hin, eyelids, and eyes
atients have erythema and telangiectasias
atients can have papules and pustules
he absence of comedones helps to distinguish acne
ulgaris from rosacea
ay also present with rhinophyma (dermal and sebaceous
and hyperplasia of the nose)
atients can have ocular rosacea: keratitis, blepharitis,
onjunctivitis

The Following Photos


Illustrate Different
Types of Rosacea

rythematotelangietatic Rosacea
Erythema and
telangiectasias
scattered on the nose
and cheeks.
There are no
papules, pustules, or
comedones present.

Papulopustular Rosacea
Erythema with papules
and pustules on the
nose and chin.
Patient also has
erythematous patches
on the cheeks bilaterally.

Phymatous Rosacea
Facial erythema,
scattered papules,
pustules on the nose,
forehead, cheeks and
chin. Thickened,
highly sebaceous skin.
This patient also has
severe rhinophyma.

Rosacea Treatment

Therapy is often long-term


Rosacea is chronic, controllable, but not
curable
All patients should use sunscreen daily
Most treatments are directed at specific
indings manifested by rosacea patients
See the following slides for recommendations
egarding rosacea treatment

Rosacea Treatment (cont.)

r patients with papulopustular rosacea and


e erythrotelangiectatic type, topical products
e often used:
Metronidazole, sodium sulfacetamide, azelaic
acid and sulfur cleansers and creams

addition to topical products, oral antibiotics


tracyclines) are used for pustular and
pular lesions
sers and light devices are useful for treating
e erythema and telangiectasias, but the cost
not covered by insurance, limiting their
ailability

Rosacea Treatment (cont.)

sotretinoin is
considered in severe
cases
These patients should
be referred to a
dermatologist
Surgical approaches are
used to treat
rhinophyma

Back to
Case Three

Case Three, Question 4

Which of the following


eatments would you
ecommend for Ms. Johnson?

a.
b.
c.
d.

Avoidance of alcohol
Oral tetracycline
Use sunscreen daily
All of the above

Case Three, Question 4

swer: d
Which of the following
reatments would you
ecommend for Ms. Johnson?

a.
b.
c.
d.

Avoidance of alcohol
Oral tetracycline
Use sunscreen daily
All of the above

Case Three, Question 5


True or False, topical
and oral antibiotics are
the best treatment for
the erythema of
rosacea.

Case Three, Question 5

nswer: False
The medical management of rosacea may
not diminish the erythema
Laser therapy may be helpful for
telangiectasias and erythema
Photoprotection is also helpful in treating
the erythema of rosacea

Ask About Ocular Symptoms

Ask all patients with rosacea about any


ocular symptoms
Consider referral to ophthalmology and/or
dermatology if suspect ocular involvement
Signs and symptoms of
ocular rosacea include:
blepharitis, conjunctivitis,
iritis, scleritis, hypopyon,
and keratitis

ake Home Points: Acne Vulgaris

Acne vulgaris is characterized by open and closed


omedones, papules, pustules, nodules, and cysts
nclude the morphology, severity and presence of scarring
when describing acne
Pathogenesis of acne vulgaris is related to the presence of
ndrogens, excess sebum production, the activity of P.
cnes, and follicular hyperkeratinization
Systemic and topical retinoids, systemic and topical
ntimicrobials, and systemic hormonal therapies are the
main classes of treatment for acne vulgaris
Untreated acne can result in permanent scarring

Take Home Points: Rosacea

osacea is a chronic inflammatory condition of the face,


hich may present with easy flushing, erythema,
langiectasias, papules and pustules, and/or phymatous
hanges
any patients with rosacea have ocular involvement
nlike acne vulgaris, rosacea does not present with
omedones and is unrelated to hormones
opical and oral treatments often improve the papules and
ustules of rosacea, but will not reverse the underlying
rythema and flushing
l patients with rosacea should use sunscreen

Acknowledgements

his module was developed by the American


cademy of Dermatology Medical Student Core
urriculum Workgroup from 2008-2012.
rimary authors: Sarah D. Cipriano, MD, MPH; Eric
einhardt, MD; Timothy G. Berger, MD, FAAD;
anade Shinkai, MD, PhD, FAAD.
eer reviewers: Rebecca B. Luria, MD, FAAD; Cory
. Dunnick, MD, FAAD.
evisions and editing: Sarah D. Cipriano, MD, MPH;
ohn Trinidad. Last revised June 2011.

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horge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD,
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