1. DISORDER OF SKIN APPENDAGES

2. TOPICS INCLUDED Acne vulgaris Rosacea Miliaria Excessive hair loss
Excessive hair growth

3. DISORDER OF SENACEOUS GLANDS
Acne vulgaris

4. Sebaceous glands
Develop embryologically from hair germs, but a few free glands arise from the epidermis.
The glands themselves are multilobed
Contain cells full of lipid(sebum), which are secreted (holocrine secretion-when whole cell is secreted into the lumen)

5. Sebum is discharged into the upper part of the hair follicle.
It lubricates and waterproofs the
skin, and protects it from drying;
It is also mildly bactericidal and fungistatic.

6. ACTIVITY
Androgenic hormones, especially dihydrotestosterone, stimulate sebaceous gland activity.
Human sebaceous glands contain 5α-reductase, 3α- and 17α- hydroxysteroid dehydrogenase
Convert weaker androgens to dihydrotestosterone, which in turn binds to specific receptors in sebaceous glands, increasing sebum secretion.
So , not the levels of circulating androgens but an enhanced target organ sensitivity which is important.

7. Acne
Acne is a disorder of the pilosebaceous apparatus predominantly affecting the peripubertal popln andcharacterized by comedones, papules, pustules, cysts and scars.

8. Factors causing acne.

9. Prevalence Nearly all teenagers have some acne (acne vulgaris).
It affects the sexes equally, starting usually between the ages of 12 and 14 years, tending to be earlier in females.
The peak age for severity in females is 16–17 and in males 17–19 years.
Variants of acne are much less common.

10. Causes of Acne vulgaris
Many factors combine to cause acne characterized by chronic inflammation around pilosebaceous follicles

11. Sebum
Sebum excretion is elevated.

12. Hormonal changes
Androgens (from the testes, ovaries,adrenals and sebaceous glands themselves) are the main stimulants of sebum excretion,
In most of the cases the level of the androgens are within normal limit but there is enhanced end organ sensitivity (incred.activity of enzyme 5-alpha reductase)
Other hormones (e.g. thyroid hormones and growth hormone) have minor effects too.

13. Poral occlusion Occluded by keratinous plug induced by:
Both genetic and environmental factors (e.g. some cosmetics)
Reduced levels of linoleic acid in sebaceous gland secetions of acne patient
Results in vicious cycle of retentin of sebum to growth of microbs. Distention of follicle eventually ruptures releasing pro-inflammatory chemicals into dermis stimulating intense inflammation.The ductal epithelium also produces cytokines and an inflammatory cascade is triggered.

14. Bacterial Propionibacterium acnes
Acts as a source of antigenic stimulation,triggering a type IV inflammatory response.
Produce extracellular enzymes which attract inflammatoy cells.

15. Factors modifying Acne
Genetic predisposition(mode of inheritence not clear)
The condition is familial mostly with severe cystic acne
Identical twins
Cosmetics
Menstrual cycle
Psychological factors- anger, anxiety

16. Presentation Polymorphic eruption:
papules,pustule,comedones, nodules and cysts
Lesion heals with depressed or hypertrophic scarring and
Post-inflammatory hyperpigmentation can
follow.

17. Lesions are confined to the face, shoulders, upper chest and back.
Open comedones (blackheads), because of the plugging by keratin and sebum of the pilosebaceous orifice on the skin surface, or
Closed comedones (whiteheads), caused by plugging below the skin surface.
Associations :
Most have a background of greasy skin(seborrhea) with patulous follicular openings(pores)

18. Acne associated with virilization
May be caused by an androgen-secreting tumour of the adrenals, ovaries or testes or, rarely,
congenital adrenal hyperplasia
Acne accompanying the polycystic ovarian syndrome is caused by modestly raised circulating androgen levels

19. Variants of acne
Infantile acne may follow transplacental stimulation of a child’s sebaceous glands by maternal androgens.
May present at birth or may last for upto 3yrs
Its morphology is like that of common acne and it may be the forerunner of severe acne in adolescence.

20. Mechanical.
Excessive scrubbing, picking, or the rubbing of chin can rupture occluded follicles.
Papulopustular lesions in an odd distribution.
The patient played the violin (‘fiddler’s neck’)

21. Drug-induced
Lesions are monomorphic and esp. over back ,face may be involved
Suspicion should be raised when acne, dominated by papulopustules rather than comedones appear suddenly in a nonteenager
And coincides with the prescription of a drug known to cause acneiform lesions
Corticosteroids
Androgenic
Anabolic steroids
Gonadotrophins
Oral contraceptives
Lithium, iodides, bromides, antituberculosis and anticonvulsant therapy can all cause an acneiform rash.
Steroid-induced acne in a seriously ill patient.

22. Acne due to cosmetics
Cosmetics esp. oil based or other topical preparations may induce comedone formation or precipitate inflammation around hair follicles.

23. Conglobates (gathered into balls) is the name given to a severe form of acne with all of the above features as well as abscesses or cysts with intercommunicating sinuses that contain thick serosanguinous fluid or pus.
On resolution, it leaves deeply pitted or hypertrophic
scars, sometimes joined by keloidal bridges.
Hyperpigmentation is usually transient, it can persist, particularly in those with an already dark skin.

24. Fulminans Acne fulminans
It is a rare variant in which conglobate acne with ulcerated and crusted lesion and is accompanied by
Fever, arthralgia,myalsia and a high erythrocyte sedimentation rate (ESR).

25. chloracne
Exogenous Tars, chlorinated hydrocarbons, oils and oily cosmetics can cause or exacerbate acne.
Suspicion should be raised if the distribution is odd(forearm, legs)or unusal age(mid age male) or if comedones predominate

26. Excoriated This is most common in young girls.
Obsessional picking otherwise mild acne
Results in excoriations on face while primary lesions not visible

27. Late onset This too occurs mainly in women Is limited to the chin.
Nodular and cystic lesions are predominant.
It is stubborn and persistent.

28. Tropical
This occurs mainly on the trunk and may
be conglobate.

29. Acne after facial massage
Acne following (3-6 wks later) in abt 30% of patients
Nodules with few comedones
Along mandibular region

30. Course
Acne vulgaris clears by the age of 23–25 years in 90% of patients,
Some (5% of women and 1% of men) still need treatment in their thirties or even forties.

31. Investigations None are usually necessary.
Cultures are occasionally needed to exclude a pyogenic infection, an anaerobic infection or Gram-negative folliculitis.

32. Any acne, including infantile acne, that is associated with virilization needs investigation to
Exclude an androgen-secreting tumour of the adrenals, ovaries or testes
To rule out congenital adrenal hyperplasia

33. Differential diagnosis
Rosacea affects older individuals
Pyogenic folliculitis
Hidradenitis suppurativa is associated with acne conglobata, but attacks the axillae and groin.
Pseudofolliculitis barbae, caused by ingrowing hairs, occurs on the necks of men with curly facial hair and clears up if shaving is stopped.

34. Treatment General measures
Acne frequently has marked psychological effects.
Even those with mild acne need sympathy, optimistic approach is essential, and regular encouragement is worthwhile.
Local hygiene, diet, stress

35. Local treatment 1 Regular gentle cleansing with mild soap and water
Benzoyl peroxide.
This antibacterial agent plus decreases inflammation
applied only at night initially, but can be used twice daily if this does not cause too much dryness and irritation.
Retinoic Acid(RA)/tretinoin
The vitamin A (retinol) analogues (tretinoin, isotretinoin, adapalene,(recently introducedand less irritent) ,tazarotene)normalize follicular keratinization, and reduce sebum production and reduce inflammation,decrease p.acne
They are especially effective against comedones.
Patients should be warned about skin irritation (start with small amounts) and photosensitivity.

36. The weakest preparation should be used first, and applied overnight on alternate nights.
Sometimes, after a week or two, it will have to be stopped temporarily because of irritation.
The combination of benzoyl peroxide in the morning and tretinoin at night has many advocates.
Isotretinoin 0.05%, 0.025%, 0.1%
Other agents
Azelaic acid :reduce post acne hyperpigmentation
Alpha hydroxy acids eg. Glycolic acid

37. Topical antibiotics
Topical clindamycin, erythromycin and sulfacetamide
Cosmetic camouflage- Cover-ups help some patients, especially females, whose scarring is unsightly. They also obscure post-inflammatory pigmentation.

38. Systemic treatment Antibiotics
tetracycline includes:doxycycline and minocycline mostly used and less frequently erythromycin and azithromycin
Used in mod. to severe acne and in those who are having psy. problem
Tetracycline-1gm,doxycycline- 100mg,minocycline-100mg, erythromycin- 1gm, azithromycin-250mg daily for long periods of time up to 6 mths or even longer.
It should be taken on an empty stomach, 1 h before meals or 4 h after food

39. Oral antibiotics should be combined with topical agents because then it is possible to withdraw the antibiotic and maintain in topical therapy.
Side effects:
GI disturbance
Vaginal candidiasis
Resistance
Grayish pigmentation in case of minocycline
To be avoided in pregnancy.

40. Hormonal Antiandrogenics only for females
Cyproterone acetate, a combined antiandrogen– oestrogen treatment
Combined oral contraceptives
Spironolactone
Isotretinoin- for severe intractable acne
Severe acne,conglobata
Relapses
Side effects:dryness of skin, eye,nose bleed,initial aggravation of inflammation , myalsia, altered night vision and hair loss, avoided in pregnancy,
Careful monitoring with blood pictures and pregnancy test before and after starting rx

41. Acne scar treatment
Dermabrasion This helps to smooth out facial scars.
Lasers Skin resurfacing with CO2 and erbium lasers is rapidly replacing dermabrasion and chemical peeling
Dermal fillers Bovine collagen or hyaluronic acid fillers can be injected into depressed scars to improve their appearance.
Cryotherapy
Intralesional corticosterois

42. ROSACEA

43. definition
Rosacea is a chronic skin disorder characterized by erythema and telangiectasia and punctuated by acute episodic eruption of papules, pustules and swelling.

44. Rosacea affects the face of
adults, usually women.
Although its peak incidence is in the thirties and forties, it can also be seen in the young or old.
It may coexist with acne.

45. cause
Rosacea is often seen in those who flush easily in response to warmth, spicy food, alcohol or embarrassment.
Hereditary component
Fair-skinned
Psychological abnormalities
chemicals, high dosages of isotretinoin, benzoyl peroxide and tretinoin.
A pathogenic role for the follicular mite dermodex folliculorum as well as for microaerophilic gm negetive bacterium. Helicobacter pylori is suspected but has not been confirmed.

46. sites The cheeks, nose, centre of
forehead and chin are most commonly affected
The periorbital and perioral areas are usually spared
Lymphoedema, below the eyes and on the forehead, is seen in few cases
Intermittent flushing is followed by a fixed erythema and telangiectases.
Discrete domed inflamed papules, papulopustules and, rarely, plaques or nodules develop
No comedones or seborrhoea

47. Usually symmetrical
Exacerbations and remissions

48. types 1. Papulopustular rosacea Inflammatory lesions are predominant
Some permanent redness with red papules with some pus filled pustules (typically last 1- 4 days); this subtype can be easily confused with acne.

49. Types.. 2. Erythematotelangiectatic rosacea
Vascular features predominate
Permanent redness / erythema with a tendency to flush and blush easily.
Small blood vessels are usually visible near the surface of the skin k/a telangiectases, sometimes associated with burning or itching sensations.

50. Types…
3. Phymatous type
This subtype is most commonly associated with rhinophyma, an enlargement of the nose.
Symptoms include thickening of skin, irregular surface, nodularities, and enlargement of nose.
Phymatous rosacea can also affect chin (gnatophyma), forehead (metophyma), eyelids (blepharophyma), and ears (otophyma).
Small blood vessels may be visible near the surface of the skin (telangiectases). .

51. types
4. Ocular type
Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning

52. Complications Rhinophyma Blepharitis Conjunctivitis Keratitis
lymphedema

53. Rhinophyma
Hyperplasia of the sebaceous glands and connective tissue of the nose
Common in males

54. Differential diagnosis
Acne
Seborrhoeic eczema
Perioral dermatitis
Systemic lupus erythematosus
Photodermatitis
Menopausal symptoms
Superior venacaval obstruction

55. Differentiating rosacea from acne
Absence of comedones
Comedones are present
Affects the central face, no trunk involvement
Diffusely over face, trunk involvement is present
Appears after adolescence
Usually teenagers
Erythema and telangiectases
Telangiectases are not seen

56. Treatment Topical agents
Topical metronidazole (0.75% metronidazole gel)
Retinoic acids
Corticosteroids not to be used
Systemic therapy:
Antibiotics- tetracyclines-start with 1 gm a day reduce dose to 250mg daily over a period of 2-3 ,months ,as the lesions respond
Erythromycin second choice
Metronidazole
Isotretinoin 1mg/kg body weight daily for 3- 6mths

57. Various techniques can be used to improve the appearance of disfiguring rhinophymas
Surgical excision
Cryotherapy
Electrocautery
Argon or CO2 laser ablation.