Snapshot A 25-year-old woman presents to her dermatologist’s office for acne. She reports that she had severe acne when she went through puberty. However, this resolved before she graduated from high school. In the past year, as she prepared applications for medical school, she reports that she is getting acne every month around the time of her menstruation. She also reports having worse acne when her stress levels coincide with her menstruation, though this is just speculation. On physical exam, she has no active lesions, but marked post-inflammatory hyperpigmentation consistent with the resolution of previous acne lesions. She is started on oral contraceptives for management of her acne, along with a topical retinoid. Introduction Clinical definition common chronic skin condition characterized by inflammatory and non-inflammatory lesions Epidemiology incidence very common demographics up to 85% of teenagers but can affect adults as well more severe around puberty location face, back, neck, chest, and upper arms risk factors menstrual cycle emotional stress occlusion of skin with greasy products excessive sweating pregnancy milk consumption Etiology multifactorial androgen production medications steroids Pathogenesis blockage or outlet obstruction of pilosebaceous unit, forming comedones from ↑ sebum production abnormal desquamation of keratinocytes and its accumulation colonization of bacteria Propionibacterium acnes inflammatory lesions result from leakage of sebum from comedones into dermis secretion of proinflammatory cells by Propionibacterium acnes ↑ androgen production also play a role in acne formation Associated conditions polycystic ovary syndrome Cushing syndrome congenital adrenal hyperplasia Prognosis in many cases, acne will resolve in adulthood however, hormonal acne may persist Presentation Symptoms nodular or cystic acne may be painful Physical exam inflammatory lesions erythematous papules, pustules, cysts, or nodules non-inflammatory lesions are comedones, which are dilated hair follicles filled with keratin, sebum, and bacteria open comedones are known as blackheads closed comedones are known as whiteheads scarring pitting and puckered indentation in skin Studies Making the diagnosis most cases are clinically diagnosed Differential Hidradenitis suppurativa Rosacea Folliculitis Treatment Management approach multiple factors go into the decision to treat acne, including severity of acne, type of acne, presence or potential for permanent scarring, concern for side effects, and adherence to therapy Medical benzoyl peroxide topical or wash indication for mild comedonal acne antibiotics topical indications for mild non-comedonal acne used in conjunction with benzoyl peroxide or topical retinoid drugs clindamycin erythromycin systemic indications for mild to moderate non-comedal acne should not be used long-term or as monotherapy drugs tetracycline minocycline doxycycline retinoids topical indications for mild to moderate acne, especially with comedones and inflammatory acne often first-line when combined with an antimicrobial agent (topical or systemic) drugs adapalene tazarotene tretinoin systemic indications for moderate to severe acne, especially cystic acne for patients with existing or potential for permanent scarring contraindicated in pregnancy drugs isotretinoin adverse effects include teratogenicity, hypertriglyceridemia, idiopathic intracranial hypertension, hepatotoxicity, cheilitis, and photosensitivity hormonal therapy indications for severe acne or acne refractory to other therapy for acne that seem to correspond with menstrual cycle drugs oral contraceptives spironolactone Complications Permanent acne scarring and cosmetic disfigurement
QUESTIONS 1 of 3 1 2 3 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.MK.4666) A 17-year-old male is diagnosed with acne vulgaris during a visit to a dermatologist. He is prescribed a therapy that is a derivative of vitamin A. He has no other significant past medical history. Which of the following is the major side-effect of this therapy? Review Topic QID: 107097 1 Hyperglycemia 6% (1/17) 2 Hyperlipidemia 41% (7/17) 3 Fatigue 0% (0/17) 4 Xerophthalmia 24% (4/17) 5 Alopecia 18% (3/17) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.MK.9) A 16-year old girl presents to your clinic with skin findings similar to that seen in Figure A. You are considering treatment with Isotretinoin. What test must this patient have prior to starting isotretinoin? Review Topic QID: 103802 FIGURES: A 1 Complete blood count 0% (0/20) 2 Pregnancy test 75% (15/20) 3 Chest x-ray 0% (0/20) 4 Basic metabolic panel 0% (0/20) 5 No testing needed 20% (4/20) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2
Login to View Community Videos Login to View Community Videos Acne Vulgaris Chris Robinson Dermatology - Acne Vulgaris 2/14/2015 77 views