acne andrews’ chapter 13 ben adams, d.o. 1-31-06

AcneAcne

Andrews’ Chapter 13Andrews’ Chapter 13

Ben Adams, D.O.Ben Adams, D.O.

1-31-061-31-06

Acne VulgarisAcne Vulgaris Abnormal keratinization Abnormal keratinization

(follicular retention (follicular retention hyperkeratosis)hyperkeratosis)

Chronic inflammatory Chronic inflammatory disease of the disease of the pilosebaceous folliclespilosebaceous follicles

Comedones, papules, Comedones, papules, pustules, cysts, nodules, pustules, cysts, nodules, and often scarsand often scars

Face, neck, upper trunk, Face, neck, upper trunk, and upper armsand upper arms

Disease of the adolescentDisease of the adolescent 90% of all teenagers affected90% of all teenagers affected May also begin in twentiesMay also begin in twenties Usually involution by 25Usually involution by 25 Occurs primarily in oily Occurs primarily in oily

(seborrheic) areas of the skin(seborrheic) areas of the skin Face occurs; cheeks> Face occurs; cheeks>

nose>forehead>chinnose>forehead>chin Ears; comedones in concha, cysts Ears; comedones in concha, cysts

in lobulesin lobules Retroauricular and nuchal cystsRetroauricular and nuchal cysts

DHT, the prominent hormonal effector on the sebaceous glandDHT, the prominent hormonal effector on the sebaceous gland

ComedoComedo

Commonly known as Commonly known as the blackhead or the blackhead or whitehead whitehead

Basic lesion of acne Basic lesion of acne Produced by Produced by

hyperkeratosis of the hyperkeratosis of the lining of the follicles lining of the follicles

Retention of keratin Retention of keratin and sebumand sebum

ComedoComedo

Plugging produced Plugging produced by the comedo by the comedo dilates the mouth dilates the mouth of the follicle of the follicle

Papules are formed Papules are formed by inflammation by inflammation around the around the comedonescomedones

Severity of AcneSeverity of Acne

Mild acne; comedones predominate Mild acne; comedones predominate More severe cases; pustules and More severe cases; pustules and

papules predominate, heal with scar papules predominate, heal with scar formation if deep formation if deep

Acne Conglobata; suppurating cystic Acne Conglobata; suppurating cystic lesions predominate, and severe lesions predominate, and severe scarring resultsscarring results

TypesTypes

Acne comedo; mild case were Acne comedo; mild case were eruption is composed almost entirely eruption is composed almost entirely of comedones on an oily skin of comedones on an oily skin

Papular acne; inflammatory papules, Papular acne; inflammatory papules, most common in young men with most common in young men with coarse, oily skincoarse, oily skin

Atrophic acne; residual atrophic pits Atrophic acne; residual atrophic pits and scars and scars

EtiologyEtiology

Keratin plug in lower infundibulum of Keratin plug in lower infundibulum of hair follicle (makes the environment hair follicle (makes the environment more anaerobic) more anaerobic)

Androgenic stimulation of sebaceous Androgenic stimulation of sebaceous glands, proliferation of glands, proliferation of P. acnesP. acnes which metabolizes sebum to produce which metabolizes sebum to produce free fatty acids free fatty acids

PathogenesisPathogenesis

Disruption of the follicular epithelium Disruption of the follicular epithelium permits discharge of the follicular permits discharge of the follicular contents into the dermis contents into the dermis

Causes the formation of Causes the formation of inflammatory papules, pustules, and inflammatory papules, pustules, and nodulocystic lesionsnodulocystic lesions

FFA are chemotactic to components FFA are chemotactic to components of inflammationof inflammation


TLR-2 is activated by TLR-2 is activated by P.acnes P.acnes and and stimulates pro-inflammatory stimulates pro-inflammatory cytokinescytokines

IL-1, a pro-inflammatory cytokine, IL-1, a pro-inflammatory cytokine, may promote follicular plugging and may promote follicular plugging and microcomedo formationmicrocomedo formation

Certain topical retinoids have been Certain topical retinoids have been show to downregulate TLR-2 show to downregulate TLR-2 expressionexpression


Effects of tetracycline are obtained Effects of tetracycline are obtained by the reduction of FFA by the reduction of FFA

Antibiotics do not produce involution Antibiotics do not produce involution of the inflammatory lesions present, of the inflammatory lesions present, but inhibit the formation of new but inhibit the formation of new lesions lesions

Topical retinoic acid acts on Topical retinoic acid acts on keratinization, causing horny cells to keratinization, causing horny cells to lose their adhesiveness lose their adhesiveness


Androgens enlarge the sebaceous Androgens enlarge the sebaceous glands glands

In women consider hyperandrogenic In women consider hyperandrogenic statestate

HistologyHistology

Acne is characterized by perifollicular Acne is characterized by perifollicular inflammation around comedones inflammation 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 fibroblasts and proliferation of fibroblasts Large cysts and epithelial-lined sinus Large cysts and epithelial-lined sinus

tracts tracts

TreatmentTreatment

Topical medications to systemic Topical medications to systemic therapytherapy

No evidence that dietary habits No evidence that dietary habits influence acne influence acne

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 decrease absorptionCalcium and iron decrease absorption Constant or intermittent tx months to Constant or intermittent tx months to

yearsyears

TetracyclinesTetracyclines

Tetracyclines as sole treatment will Tetracyclines as sole treatment will give a positive response in 70% give a positive response in 70%

May take 4-6 weeks for response May 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 precludes Staining of growing teeth precludes

use in pregnancy and children < 9 or use in pregnancy and children < 9 or 1010

MinocyclineMinocycline

More effective than More effective than tetracycline in acne tetracycline in acne vulgaris vulgaris

50 to 100mg QD or 50 to 100mg QD or BIDBID

Absorption less Absorption less affected by milk affected by milk and foodand food

Post-extraction view of wisdom teeth from a 22-year-old student. Discolored roots were attributed to minocycline therapy for acne. The patient had taken tetracycline from age 15 to age 18, when he was switched to minocycline, 50 to 100 mg per day. With the exception of sporadic use (or none at all) in the summer, he had taken minocycline for 4 years.

AntibacterialsAntibacterials

Doxycycline; Doxycycline; P.acnesP.acnes resistant to resistant to erythromycin, photosensitivity can occur erythromycin, photosensitivity can occur

Erythromycin; consider in young and Erythromycin; consider in young and pregnant who cannot use tetracyclinepregnant who cannot use tetracycline

Clindamycin; works well, but can cause Clindamycin; works well, but can cause pseudomembranous colitis pseudomembranous colitis

Sulfonamides; phototoxicity, Scalded skinSulfonamides; phototoxicity, Scalded skin

Bacterial ResistanceBacterial Resistance

Worsening clinical condition Worsening clinical condition correlates with a high MIC for correlates with a high MIC for erythromycin and tetracycline for erythromycin and tetracycline for P. P. acnes acnes

Resistance lost after 2 months after Resistance lost after 2 months after withdrawal of antibioticwithdrawal of antibiotic

Avoid use of different oral and topical Avoid use of different oral and topical antibiotics at the same timeantibiotics at the same time

Oral Contraceptives Oral Contraceptives

Estradiol suppresses the uptake of Estradiol suppresses the uptake of testosterone by the sebaceous glandstestosterone by the sebaceous glands

Oral contraceptives containing androgenic Oral contraceptives containing androgenic progesterones may exacerbate acneprogesterones may exacerbate acne

EES and Norgestimate is approved for txEES and Norgestimate is approved for tx

(Ortho Tri-cyclen, Estrostep, Yazmine(Ortho Tri-cyclen, Estrostep, Yazmine) )

Hormonal TherapyHormonal Therapy

Spironolactone 25mg to 300mg/d, Spironolactone 25mg to 300mg/d, antiandrogenic antiandrogenic

Steroids for severe inflammatory Steroids for severe inflammatory acneacne

IsotretinoinIsotretinoin

0.5 to 1 mg/kg/day qd or bid for 15 to 0.5 to 1 mg/kg/day qd or bid for 15 to 20 weeks20 weeks

Leads to a remission that may last Leads to a remission that may last months to years months to years

teratogenicteratogenic


Retinoids exert their physiologic Retinoids exert their physiologic effects through two distinct families effects 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, comedongenesis, P. acneP. acne, , keratinization, not related to RAR and keratinization, not related to RAR and RXR affinity RXR affinity


HypertriglyceridemHypertriglyceridemia, dry mucosa ia, dry mucosa

Nasal colonization Nasal colonization with S.aureus in with S.aureus in 90%90%

Worsening of acne Worsening of acne common in first common in first monthmonth

Monitor HCG, Monitor HCG, lipids, LFT’slipids, LFT’s

Topical TreatmentTopical Treatment

Benzoyl peroxideBenzoyl peroxide Topical retinoidsTopical retinoids Topical antibacterialsTopical antibacterials Salicylic acid, Azelaic acidSalicylic acid, Azelaic acid

Benzoyl PeroxideBenzoyl Peroxide

Available as gels, lotions, washes and Available as gels, lotions, washes and barsbars

2.5% to 10%2.5% to 10% Potent antibacterial effectPotent antibacterial effect May decrease antibacterial May decrease antibacterial

resistanceresistance Decrease frequency of application if Decrease frequency of application if

irritation occursirritation occurs

Topical RetinoidsTopical Retinoids

Creams, gels, liquidsCreams, gels, liquids 0.01%, 0.025%, 0.04%, 0.05% and 0.01%, 0.025%, 0.04%, 0.05% and

0.1%0.1% Cream base may be less irritating Cream 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

Topical AntibacterialsTopical Antibacterials

Clindamycin 1% effective against Clindamycin 1% effective against pustules and small papulopustular pustules and small papulopustular lesions lesions

Erythromycin 3%Erythromycin 3% Both equally effective, combined Both equally effective, combined

with benzoyl peroxide can decrease with benzoyl peroxide can decrease resistance resistance

Other TopicalsOther Topicals

Azelaic Acid; low adverse reactionsAzelaic Acid; low adverse reactions Salicylic acidSalicylic acid Abrasive cleaners, astringents make Abrasive cleaners, astringents make

the skin dry and susceptible to the skin dry and susceptible to irritantsirritants

Surgical TreatmentSurgical Treatment

Comedone extractor brings about Comedone extractor brings about quick resolution of comedones and quick resolution of comedones and pustulespustules

In Isotretinoin pts macrocomedones In Isotretinoin pts macrocomedones present at week 10 to 15 of therapypresent at week 10 to 15 of therapy

Intralesional CorticosteroidsIntralesional Corticosteroids

Effective in reducing inflammatory Effective 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

Complications of AcneComplications of Acne

Scarring can occur Scarring can occur despite best despite best treatmenttreatment

Pitted scars, wide-Pitted scars, wide-mouthed mouthed depressions and depressions and keloidskeloids

Chemical peels, Chemical peels, CO2 Laser CO2 Laser resurfacing, scar resurfacing, scar excision,excision,

Complications of AcneComplications of Acne

Abrupt onset following administration of Abrupt onset following administration of high-dose dexamethasonehigh-dose dexamethasone

Drug-induced acne due to isoniazidDrug-induced acne due to isoniazid

Acne ConglobataAcne Conglobata

Conglobate: shaped in a rounded Conglobate: shaped in a rounded mass or ballmass or ball

Severe form of acne characterized by Severe form of acne characterized by numerous comedones, large numerous comedones, large abscesses with sinuses, grouped abscesses with sinuses, grouped inflammatory nodulesinflammatory nodules

SuppurationSuppuration Cysts on forehead, cheeks, and neck Cysts on forehead, cheeks, and neck

Acne ConglobataAcne Conglobata Occurs most frequently in Occurs most frequently in

young menyoung men Follicular Occlusion Triad: Follicular Occlusion Triad:

acne conglobata, acne conglobata, hidradenitis suppurativa, hidradenitis suppurativa, dissecting cellulitis of the dissecting cellulitis of the scalpscalp

Heals with scarringHeals with scarring Treatment; oral isotretinoin Treatment; oral isotretinoin

for 5 months for 5 months

Acne FulminansAcne Fulminans Rare form of extremely Rare form of extremely

severe cystic acnesevere cystic acne Teenage boys, chest and Teenage boys, chest and

backback Rapid degeneration of Rapid degeneration of

nodules leaving ulcerationnodules leaving ulceration Fever, leukocytosis, Fever, leukocytosis,

arthralgias, myalgias are arthralgias, myalgias are commoncommon

Lytic changes can be seen Lytic changes can be seen on x-rayon x-ray

Tx; oral steroids, ABX, and Tx; oral steroids, ABX, and isotretinoinisotretinoin

This febrile 26-year-old white male was hospitalized prior to the availability of isotretinoin and treated with prednisone dapsone and Vleminckx's compresses.

SAPHO SyndromeSAPHO Syndrome

SSynovitis, ynovitis, AAcne, cne, PPustulosis, ustulosis, HHyperostosis, and yperostosis, and OOsteomyelitissteomyelitis

Acne fulminans, acne conglobata, Acne fulminans, acne conglobata, pustular psoriasis, and palmoplantar pustular psoriasis, and palmoplantar pustulosispustulosis

Chest wall is most site of Chest wall is most site of musculoskeletal complaintsmusculoskeletal complaints

Tropical AcneTropical Acne

Nodular, cystic, and pustular lesions Nodular, cystic, and pustular lesions on back, buttocks, and thighson back, buttocks, and thighs

Face is sparedFace is spared Young adult military stationed in Young adult military stationed in

tropicstropics

Premenstrual AcnePremenstrual Acne

Papulopustular lesions week priorPapulopustular lesions week prior Estrogen-dominant contraceptive Estrogen-dominant contraceptive

pills will diminishpills will diminish

Preadolescent AcnePreadolescent Acne

NeonatalNeonatal InfantileInfantile ChildhoodChildhood

Neonatal AcneNeonatal Acne

First four weeks of First four weeks of life life

Develops a few Develops a few days after birthdays after birth

Facial papules or Facial papules or pustules pustules

Infantile AcneInfantile Acne

Cases that persist beyond 4 weeks or Cases 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 acne drug-induced acne

Acne VenenataAcne Venenata

Contact with acnegenic chemicals Contact with acnegenic chemicals can produce comedonescan produce comedones

Chlorinated hydrocarbons, cutting Chlorinated hydrocarbons, cutting oils, petroleum oil, coal taroils, petroleum oil, coal tar

Radiation therapyRadiation therapy

Acne CosmeticaAcne Cosmetica

Closed comedones Closed comedones and papulopustules on and papulopustules on the chin and cheeksthe chin and cheeks

May take months to May take months to clear after stopping clear after stopping cosmetic productcosmetic product

Pomade Acne; blacks, Pomade Acne; blacks, males, due to greases males, due to greases or oils applied to hair or oils applied to hair

Pomade acne in a 22-year-old Hispanic female who routinely used baby oil on her face.

Acne DetergicansAcne Detergicans

Patients wash face with comedogenic Patients wash face with comedogenic soapssoaps

Closed comedonesClosed comedones TX; wash only once or twice a day TX; wash only once or twice a day

with non-comedogenic soap with non-comedogenic soap

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 sparse Comedones and pustules are sparse

or absentor absent Tx; retinoic acid, abx don’t help Tx; retinoic acid, abx don’t help

Excoriated AcneExcoriated Acne

Aka; picker’s acneAka; picker’s acne Girls, minute or trivial primary lesions Girls, minute or trivial primary lesions

are made worse by squeezingare made worse by squeezing Crusts, scarring, and atrophyCrusts, scarring, and atrophy TX; eliminate magnifying mirror, r/o TX; eliminate magnifying mirror, r/o

depression depression

Acneiform EruptionsAcneiform Eruptions Originate from skin Originate from skin

exposure to various exposure to various industrial chemicalsindustrial chemicals

Papules and pustules Papules and pustules not confined to usual not confined to usual sites of acne vulgarissites of acne vulgaris

Chlorinated Chlorinated hydrocarbons, oils, hydrocarbons, oils, coal tarcoal tar

Oral meds; iodides, Oral meds; iodides, bromides, lithium, bromides, lithium, steroids (steroid acne)steroids (steroid acne)

Oil acne on the thigh. A 42-year-old machinist whose pants were often damp from contact with insoluble cutting oils had experienced intermittent and recurrent follicular eruptions for 8 months.

Gram Negative FolliculitisGram Negative Folliculitis

Occurs in patients treated with Occurs in patients treated with antibiotics for acne over a long-termantibiotics for acne over a long-term

Enterobactor, Klebsiella, Proteus Enterobactor, Klebsiella, Proteus Anterior nares colonizedAnterior nares colonized Tx; isotretinoin, AugmentinTx; isotretinoin, Augmentin

Gram-negative folliculitis of the face in a 17-year-old white male who had had acne for 2 years. The patient had been treated successfully with tetracycline and topical medications, but over the preceding 3 months he had gradually developed more pustules. Gram-negative folliculitis was suspected, and the patient was treated successfully with oral cephalexin in place of the tetracycline. (Culture yielded Escherichia coli.)

Acne KeloidalisAcne Keloidalis

Folliculitis of the deep levels of the hair Folliculitis 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 Asian Occurs at nuchal area in blacks or Asian menmen

Not associated with acne vulgarisNot associated with acne vulgaris Hypertrophic connective tissue becomes Hypertrophic connective tissue becomes

sclerotic, free hairs trapped in the dermis sclerotic, free hairs trapped in the dermis contribute to inflammation contribute to inflammation

Tx; intralesional Kenalog, surgeryTx; intralesional Kenalog, surgery

Hidradenitis SuppurativaHidradenitis Suppurativa

Disease of the apocrine gland Disease of the apocrine gland Axillae, groin, buttocks, also areolaAxillae, groin, buttocks, also areola Obesity and genetic tendency to Obesity and genetic tendency to

acneacne Tender red nodules become fluctuant Tender red nodules become fluctuant

and painfuland painful Rupture, suppuration, formation of Rupture, suppuration, formation of

sinus tracts sinus tracts


Most frequently axillae of young women Most frequently axillae of young women Men usually affected in the groin and Men usually affected in the groin and

perianal areaperianal area Follicular keratinization with plugging of Follicular keratinization with plugging of

the apocrine duct; dilation and the apocrine duct; dilation and inflammationinflammation

DDx; Furuncles are unilateral, and not DDx; Furuncles are unilateral, and not associated with comedones, Bartholin associated with comedones, Bartholin cyst, scrofuloderma, actinomycosis, cyst, scrofuloderma, actinomycosis, granuloma inguinale granuloma inguinale


Oral antibiotics, Oral antibiotics, culture S. aureus, culture S. aureus, gram-negativesgram-negatives

Intralesional Intralesional steroids, surgerysteroids, surgery

Isotretinoin helpful Isotretinoin helpful in some casesin some cases

PDTPDT

Hidradenitis suppurativa in a 62-year-old white male who had a 20-year history of abscesses and draining sinuses in his axillae, groin and intergluteal cleft. Severity and frequency of flare-ups had gradually decreased over the preceding 5 years, but serosanguineous drainage from sinuses and occasional new pustules continued to emerge.

Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens

Aka; Aka; Dissecting cellulitis of the scalp Dissecting cellulitis of the scalp Uncommon suppurative disease Uncommon suppurative disease Nodules suppurate and undermine to Nodules suppurate and undermine to

form sinusesform sinuses Scarring and alopeciaScarring and alopecia Adult black men most common, Adult black men most common,

vertex and occiput vertex and occiput

Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens

Tx; intralesional steroids, Tx; intralesional steroids, isotretinoin, oral abx, surgical isotretinoin, oral abx, surgical incision and drainageincision and drainage

Acne vs. RosaceaAcne vs. Rosacea

acneacne rosacearosacea

RosaceaRosacea

Chronic inflammatory eruption of the Chronic inflammatory eruption of the flush areas of the faceflush areas of the face

Erythema, papules, pustules, Erythema, papules, pustules, telangiectasia, hypertrophy of the telangiectasia, hypertrophy of the sebaceous glandssebaceous glands

Usually mid-faceUsually mid-face Women ages 30-50Women ages 30-50

RosaceaRosacea

Ocular RosaceaOcular Rosacea

Blepharitis, conjunctivitisBlepharitis, conjunctivitis Keratitis, iritis, episcleritisKeratitis, iritis, episcleritis C/O gritty, stinging sensationC/O gritty, stinging sensation

Ocular rosacea occurs in Ocular rosacea occurs in about 58% of rosacea patientsabout 58% of rosacea patients

Chronically inflamed eyelid Chronically inflamed eyelid margins may be confused with margins may be confused with

seborrheic dermatitisseborrheic dermatitis

Granulomatous RosaceaGranulomatous Rosacea

Midface, perioral, Midface, perioral, lateral mandible lateral mandible areasareas

Noncaseating Noncaseating granulomasgranulomas

Rosacea granuloma in a 62-year-old white male who had had a rapidly enlarging asymptomatic papule on the left side of his nose for 8 weeks. Biopsy findings were consistent with a rosacea granuloma.

Rosacea EtiologyRosacea Etiology

Vasomotor liabilityVasomotor liability Hot liquids, ETOH, steroids (oral and Hot liquids, ETOH, steroids (oral and

topical) ie: perioral dermatitistopical) ie: perioral dermatitis Demodex folliculorumDemodex folliculorum not causative not causative

Differential Diagnosis RosaceaDifferential Diagnosis Rosacea

Acne VulgarisAcne Vulgaris Lupus Lupus

erythematosuserythematosus Bromoderma, Bromoderma,

ioderma ioderma Papular syphilidPapular syphilid

Iodine-induced acne in a 17-year-old adolescent boy. The patient had been prescribed suppressive doses of Lugol's solution for hyperthyroidism and developed acne on his forehead.

Inflammatory rosaceaInflammatory rosacea

Papules and Papules and pustules are pustules are characteristiccharacteristic

Rosacea TreatmentRosacea Treatment

Long-term oral tetracycline is Long-term oral tetracycline is suppressive, required for ocular suppressive, required for ocular rosacearosacea

Topical metronidazoleTopical metronidazole Sunscreens, avoidance of flushing Sunscreens, avoidance of flushing

triggerstriggers Flash lamped pumped dye laser for Flash lamped pumped dye laser for

telangiectasiastelangiectasias

RosaceaRosaceaRhinophymaRhinophyma

RhinophymaRhinophyma

Men over 40Men over 40 Pilosebaceous Pilosebaceous

gland hyperplasia gland hyperplasia with fibrosis, with fibrosis, inflammation, and inflammation, and telangiectasia telangiectasia

Treatment is Treatment is surgerysurgery

Severe rhinophyma in a 65-year-old individual whose increasing lobular nasal enlargement had progressed without treatment for over 30 years.

Pyoderma FacialePyoderma Faciale

Postadolescent girls, reddish cyanotic Postadolescent girls, reddish cyanotic erythema with abscesses and cystserythema with abscesses and cysts

Distinguished from acne by absence Distinguished from acne by absence of comedones, rapid onset, fulminant of comedones, rapid onset, fulminant course and absence of acne on the course and absence of acne on the back and chest back and chest

Tx; oral steroids followed by Tx; oral steroids followed by isotretinoinisotretinoin

Perioral DermatitisPerioral Dermatitis

Papulosquamous Papulosquamous eruptioneruption

Clear zone around Clear zone around vermillion bordervermillion border

Women 23-35yrsWomen 23-35yrs Etiology; ?topical Etiology; ?topical

steroids, fluorinated steroids, fluorinated toothpastetoothpaste

Tx; d/c topical Tx; d/c topical steroids, oral TCN if steroids, oral TCN if pustules pustules

A 40-year-old woman who had papular acneiform eruption about her mouth and chin for 8 to 10 years. It had been treated intermittently by another physician with betamethasone valerate cream. The eruption gradually improved over a 5-month period with the use of tetracycline and non-fluorinated topical steroids in gradually decreasing potency.

acne andrews’ chapter 13 ben adams, d.o. 1-31-06

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