Title: GZ / The Grenz Zone Season 2 / 18 & 19 Acne
Tags: GZ DermnetNZ

The 4 main contributing factors for acne include:
abnormal keratinization
excess sebum production
Propionibacterium acnes overgrowth
Inflammation
Back Extra: keratinocytes proliferate too quickly and are more cohesive
sebum production is under hormonal control. Androgen receptor bind DHT and produces more sebum
P. acnes thrives in oily environment

Q: Oral contraceptives are given to female patients with acne because OCPs inhibit [...] production via negative feedback to decrease sebum production. OCPs also [...] sex hormone binding globulin which reduces free androgens in serum
A: androgen; increase

Q: P. acnes induces inflammation in acne by activating [specific receptor], which are receptors on the surface of keratinocytes and macrophages
A: toll-like receptor 2
Back Extra: This causes the release of inflammatory mediators IL-1, IL-8, IL-12, and TNF-alpha

Medications that trigger acne can be remembered by "A PIMPLE":
A anabolic steroids
P prednisone
I iodides
M marijuana
P progresterone-only contraceptives
L lithium
E {{EGFR inhibitors}}
Back Extra: other triggers include: Hormonal or menstrual flares, stress, cosmetic products, mechanical factors (e.g. sports gear), and diet
High glycemic index increases insulin causing an increase in androgens

Q: Open comedones are referred to as [white or black heads]
A: blackheads
Back Extra: turns black due to air oxidizing oils and debris

Q: Closed comedones are commonly referred to as [black or white]
A: whiteheads
Back Extra: white or fleshy pumps that have no obvious follicular opening

Q: 3 acne variants are:
[...]
[...]
[...]
A: acne excoriee; acne congloblata; acne fulminans
Back Extra: Acne excoriee: young acne patient w/ anxiety or OCD that picks at their lesions
Acne conglobata: nodulocystic acne WITHOUT systemtic changes
Acne fulminans: nodulocystic acne WITH systemic changes (fevers, joint pain, and even osteolytic bone lesions)

Q: [...] syndrome includes synovitis, acne conglobata, pustulosis, hyperostosis, and osteitis
A: SAPHO
Back Extra: pustulosis includes pustular psoriasis
Hyperostosis = excessive growth of bone
Get x-ray of SC joint

Q: When using a topical antibiotic in the treatment of acne, make sure to combine it with [...] in order to decrease antibiotic resistance
A: benzoyl peroxide
Back Extra: Remember the ABCDE's for topical antibiotics:
Azelaic acid
Benzoyl Peroxide
Clindamycin
Dapsone (Aczone)
Erythromycin
Sulfacetamide

Q: 3 common prescription topical retinoids used in the treatment of acne are [...], [...], and [...]
A: tretinoin; adapalene; tazarotene
Back Extra: Tretinoin: is inactivated by UV light so use at night. DO NOT combine with BPO because it is oxidized/inactivated by it
Adapalene: light stable and is OFTEN combined with BPO (e.g. Epiduo)
Tazarotene: pregnancy category X, strongest topical retinoid

Q: 2 treatment options for a female patient with acne flares on her jawline during menses that does not want to take antibiotics are [...] and [...]
A: OCPs; spironolactone
Back Extra: Make sure to screen patient to see if risk outweights benefits of getting on the pill (e.g. female >35 who smokes, cardio risk factors, breast cancer, severe cirrhosis, etc.)

Q: The ONLY treatment that works on all 4 components of acne is [...]
A: isotretinoin
Back Extra: Daily use for around 6 months. May shrink sebaceous glands up to 90%

Q: Side effects of isotretinoin include [most common side effect], birth defects (craniofacial and cardiac), depression, IBD, myalgias, arthralgias, slow healing, and paronychia
A: dryness
Back Extra: Must be enrolled in iPledge: 2 forms of contraceptives and NO donating blood. Monthly pregnancy tests
Check fasting lipid panel and LFTs
DO NOT combine with tetracycline: can cause pseudotumor cerebri

Q: Side effects of minocycline include [most common tetracycline side effect], teeth discoloration, [...], and vertigo
A: GI effects; blue-gray hyperpigmentation
Back Extra: DO NOT combine with isotretinoin. Can cause pseudotumor cerebri

Q: Mild acne is usually treated with [2 answers]
A: benzoyl peroxide and/or topical retinoid

Q: Moderate acne is usually treated with [3 answers]
A: topical retinoid, BPO, and topical antibiotic
Back Extra: Can also consider oral antibiotic or OCP/Spironolactone for female patients

Q: Severe acne can either be treated with [...] or a combination of topical BPO, topical antibiotic, topical retinoid, and oral antibiotics
A: isotretinoin

Q: [type of acne] is common and presents from birth to 1 month
A: Neonatal Acne
Back Extra: usually self-resolves

Q: [...] is more comedonal and persistent than neonatal acne and presents from 1 month - 1 year
A: Infantile acne

Q: [...] is from 1-6 years, while [...] is from 7-11 years. Both of these types of acne must be assessed for signs of androgen excess
A: Mid-Childhood acne; prepubertal acne
Back Extra: Androgen excess signs: pubic hair, testicle or clitoral enlargement, breast development, increased muscle mass, etc.
If there is any signs of precocious puberty, an endocrine referral is needed

Q: Regardless of acne severity, some basic skin care recommendations include counseling on washing their face [how many times daily], use of a daily facial moisturizer with >SPF 30, and refraining from picking
A: 2x daily
Back Extra: - Recommend the use of gentle cleanser, benzoyl peroxide, salicyclic acid, and sulfur-based washes for the face
- Daily facial moisturizers aids in the prevention of PIH (post-inflammatory hyperpigmentation)
- Picking at lesions can lead to permanent scarring

For topical antibiotic treatments in acne, remember your ABCDE's:
A: Azelaic acid
B: benzoyl peroxide
C: clindamycin
D: dapsone (Aczone)
E: erythromycin
S: sulfacetamide

Q: What is the mechanism of action of spironolactone?
[2 answers]
A: Aldosterone antagonist and 5-alpha reductase inhibitor
Back Extra: 5-alpha reductase converts testosterone to DHT. Black box warning for personal or FHx of breast cancer
Side effects of spironolactone: menstrual irregularities, breast tenderness, gynecomastia, urinary frequency, orthostatic hypotension

Q: What are the 3 types/affected areas of minocycline hyperpigmentation? (3 S's)
Type 1: [...]
Type 2: [...]
Type 3: [...]
A: scars; shins; sun-exposed areas

Q: What are the 3 FDA approved OCPs for acne include:
[...]
A: Ortho Tri-Cyclen, Yaz, Estrostep
Back Extra: Ortho Tri-Cyclen combines norgestimate with ethinyl estradiol
Yaz combines drospirenone with ethinyl estradiol
Estrostep combines norethindrone with ethinyl estradiol