Updated: 9/11/2018

Acne Vulgaris

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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
 

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Questions (3)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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
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(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

5%

(1/19)

2

Hyperlipidemia

37%

(7/19)

3

Fatigue

0%

(0/19)

4

Xerophthalmia

32%

(6/19)

5

Alopecia

16%

(3/19)

M1

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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:
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

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PREFERRED RESPONSE 2
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