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Soutor 1e- Clinical Dermatology- Lecture 5- Acne, Rosacea and Related Disorders
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Soutor 1e- Clinical Dermatology- Lecture 5- Acne, Rosacea and Related Disorders
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Upload Date:
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Transcript:
Language: EN.
Segment:0 .
Segment:1 1. Acne, Rosacea and Related Disorders.
DR. HOLMES: I am Doctor Spencer Holmes, Clinical Professor in the Department of Dermatology at the University of Minnesota Medical School.
Segment:2 2. Learning Objectives.
DR. HOLMES: In this presentation, we will cover the common features of acne, rosacea, perioral dermatitis, folliculitis, and hidradenitis suppurativa.
Segment:3 3. Acne.
DR. HOLMES: Acne is a common disorder with a prevalence of up to 95% in adolescents. About 1/3 of patients with acne will have a moderate to severe case.
DR. HOLMES: Pathogenesis is complex, and includes the development of a microscopic plug in the follicular opening due to the hyperproliferation and adhesion of keratinocytes in the distal portion of the hair follicle. Also, androgenic hormones and the bacteria P. acnes plays a role. Genetics and emotional stress may also trigger or flare acne.
Segment:4 4. Acne.
DR. HOLMES: Acne usually presents at the onset of puberty with comedones on the central face.
DR. HOLMES: Inflammatory papules and/or pustules may develop in early to mid-teen years, and are usually confined to the face, but the neck and back may also be effected. Acne may last for years, but usually begins to improve in the late teens.
Segment:5 5. Presentations of Acne.
DR. HOLMES: Acne can present with several types of lesions, including open comedones or blackheads, with a central dark plug, and/or closed comedones, or whiteheads, with no visible keratin plug, as seen in Figure 1.
DR. HOLMES: Papular or pustular acne presents with inflamed two to five millimeter papules and/or pustules, as in Figure 2. These lesions are often the most bothersome cosmetically to the patient. Nodular acne presents as large, red, firm, or fluctuant nodules, which are often cyst-like, which may drain or form sinus tracks as seen in the jawline of the patient in Figure 3.
DR. HOLMES: These acne lesions may lead to elevated or depressed scars. The scars are not due to picking. They're the result of prolonged inflammation and individual susceptibility.
Segment:6 6. Acne.
DR. HOLMES: Patients normally have a mixture of acne lesions at one time, but often one type will predominate. Acne may be classified as mild, moderate, or severe, depending on the number and/or size of the lesions and the extent of the lesions.
DR. HOLMES: Resolving inflamed lesions may leave pink macules, or spots that may persist for many weeks, or areas of hyperpigmentation that may last for months. These are often misinterpreted as scars by the patient.
Segment:7 7. Rosacea.
DR. HOLMES: Rosacea is a common condition that occurs on the central face. Usually, it begins after age 30, and typically persists with intermittent or continual outbreaks.
DR. HOLMES: It is more common in women and fair-skinned people.
Segment:8 8. Rosacea Pathogenesis and Triggers.
DR. HOLMES: Several factors are involved in the pathogenesis of rosacea. Immune factors exist. Vascular abnormalities include labile vessels prone to dilatation. Up to 1/3 of patients have a family history of rosacea. Demodex folliculorum, a mite found in the facial pilosebaceous unit of most adults, is present in larger numbers in patients with rosacea.
DR. HOLMES: There are several triggers for redness of the face in rosacea patients, including sunlight exposure, exercise, temperature extremes, emotional stress, and certain foods and alcohol, especially wine. Rosacea papules can be triggered by the use of prescription topical steroids, which while initially decreasing redness, eventually cause a rebound of redness.
Segment:9 9. Subtypes of Rosacea.
DR. HOLMES: There are four subtypes or presentations of rosacea. Papulopustular rosacea is the most common presentation. It presents with erythematous papules and pustules on the central face, including the forehead, as seen in Figure 4. This may closely resemble acne, but no comedones are seen. Erythematotelangiectatic rosacea is a less common form of rosacea. There is a predominance of facial erythema, telangiectatic vessel presence, and sometimes episodic flushing, as seen in the woman in Figure 5.
Segment:10 10. Subtypes of Rosacea.
DR. HOLMES: Phymatous rosacea or rhinophyma is an uncommon presentation that mostly occurs in men. It presents with thick, pink, or skin-colored plaques with an irregular surface, typically on the nose. It may result in a bulbous nose as seen in this patient. Ocular rosacea may be an isolated finding or may be seen with other types of rosacea. It presents with conjunctivitis, blepharitis, and sometimes with recurrent chalazion.
Segment:11 11. Perioral Dermatitis.
DR. HOLMES: Perioral dermatitis primarily occurs in women ages 20 to 45, although it sometimes can occur in pre-adolescent boys and girls. It is commonly misdiagnosed as a contact dermatitis or as a dryness problem, and is therefore treated with topical steroids, which only exacerbate the problem.
Segment:12 12. Perioral Dermatitis: Pathogenesis and Triggers.
DR. HOLMES: The exact cause of perioral dermatitis is unknown. Triggers for perioral dermatitis include topical and inhaled steroids, oral contraceptives, menstruation, pregnancy, certain skincare products, fluorinated toothpaste, and emotional stress.
DR. HOLMES: Most patients will have tried numerous topical products without success.
Segment:13 13. Perioral Dermatitis.
DR. HOLMES: Perioral dermatitis, as seen in this patient, typically presents with subtle perioral erythema, with or without scale. Tiny papules and pustules may also be superimposed on this erythema. Often, there is a several millimeter band of normal skin along the edge of the lips.
DR. HOLMES: The nasolabial folds and skin around the lateral canthal areas or periorbital areas may also be seen.
Segment:14 14. Folliculitis.
DR. HOLMES: Folliculitis is a very common disorder of the hair follicle that can be seen at any age in hair-bearing sites. It may be asymptomatic or tender and itchy. It is a common incidental finding on physical examination. Diabetic and immunocompromised patients may be more susceptible.
Segment:15 15. Causes of Folliculitis.
DR. HOLMES: There are several causes for folliculitis. Bacteria, including Staphylococcus aureus, and less frequently, species of Streptococcus and Pseudomonas, usually acquired in hot tubs and whirlpools, and other gram-negative organisms can also be implicated. Fungi, including Pityrosporum species and candida can also cause folliculitis. Mechanical folliculitis can be caused by the hair being pulled tightly back, called traction folliculitis.
DR. HOLMES: Also, hair removal methods such as shaving, waxing, and plucking can be a cause. Folliculitis can also be caused by chronic friction from tight clothing or ingrown hairs in the neck and beard, causing a problem known as pseudofolliculitis.
Segment:16 16. Folliculitis.
DR. HOLMES: Folliculitis usually presents with small, one to three millimeter perifollicular pustules and/or papules in any hair-bearing area as seen in Figure 8.
DR. HOLMES: In this case, the folliculitis was caused by shaving of the legs with a blade. It usually occurs on the trunk, buttocks, thighs, face, and scalp. Pseudofolliculitis is initiated by the ingrowing of hairs into the skin with subsequent development of papules and pustules. This typically occurs in African-Americans, as seen in the patient in Figure 9.
DR. HOLMES: These lesions may be itchy.
Segment:17 17. Hidradenitis Suppurativa.
DR. HOLMES: Hidradenitis suppurativa is a chronic inflammatory follicular disorder in the apocrine gland-bearing areas of the axillary, inguinal, and inframammary regions. It is more common in females. The onset of disease is in the early twenties with a gradual decrease in activity in the fifties.
Segment:18 18. Pathogenesis.
DR. HOLMES: The pathogenesis of hidradenitis is similar to that of acne. The apocrine sweat gland empties into the hair follicle.
DR. HOLMES: Follicular keratin plugs form, and may lead to rupture of the hair follicle with follicular content extruded into the dermis. This triggers the formation of inflammatory nodules and abscesses. Lesions may coalesce and sinus tracks may form. Risk factors include obesity, cigarette smoking, and a family history of hidradenitis suppurativa. It is often misdiagnosed early as a primary infection or boils.
Segment:19 19. Hidradenitis Suppurativa.
DR. HOLMES: Hidradenitis suppurativa presents with a gradual onset of persistent or recurrent painful boil-like lesions in the axillae and inguinal areas, as seen in the patient in Figure 10. The buttocks, inner thighs, perineal, and perianal area may also be involved. Single or grouped comedones may be seen as in Figure 11. Yellow, sometimes odoriferous drainage may be expressed from cysts and sinus tracks.
DR. HOLMES: With repeated flares, multiple sinus tracts and purple or hyperpigmented scars may form.
Segment:20 20. Summary.
DR. HOLMES: In summary, the diseases of the pilosebaceous unit are common and will affect most people at some point in their lives. These diseases rarely cause serious systemic problems, but they can cause significant psychosocial distress. Many of these diseases last years or become chronic, requiring long-term therapy.