General Dermatology

– Severe form of nodulocystic acne in young males (13–16 years old)

– Presents with sudden-onset suppurative nodular acne with ulceration, eschars and systemic symptoms (may include myalgias, arthralgias, fever, ↑ ESR, ↑ WBCs, ± sterile osteolytic bone lesions typically over clavicle or sternum)

– Treat with low-dose accutane and prednisone or prednisone alone initially, followed by isotretinoin (to prevent flare and formation of granulation tissue)

Acne conglobata
(Figures 3.1A, 3.2A)

– Acute-onset nodulocystic acne without systemic manifestations

– Part of the follicular occlusion triad (dissecting cellulitis of scalp, pilonidal cyst and hidradenitis suppurativa)

Acne excoriée
(Figure 3.1B)

– Mainly seen in young women with emotional or psychological disorders (such as obsessivecompulsive disorder) who repeatedly pick at lesions

– Presents as mild acne with several excoriations, crusted erosions and sometimes ulcerations with subsequent scarring

– Antidepressants may be warranted

Acne with underlying
endocrinologic abnormality
(Figure 3.1C)

– If acne with accompanying hirsutism ± irregular menses, check lab work for hormonal abnormality (check LH, FSH, DHEA-S, free and total testosterone)

– Source of androgens

Ovarian androgens: testosterone
Adrenal androgens: DHEA-S, 17-hydroxyprogesterone

Polycystic ovarian syndrome (PCOS):

– Seen in 5–10% of women of reproductive age

– Androgen excess causing hirsutism, irregular menses, ± polycystic ovaries, obesity, insulin resistance, ↑ LH/FSH ratio, ↓ fertility, ↑ testosterone

– Acne lesions typically nodular and involve lower ½ of face (especially jawline)

– Treatment: oral contraceptive pill (resulting in ↑ SHBG, ↓ free testosterone), spironolactone (off-label, blocks androgen receptor)

Late congenital adrenal hyperplasia:

– ↑ DHEA-S or 17-hydroxyprogesterone due to partial deficiency of adrenal enzymes (commonly 21-hydroxylase or 11-hydroxylase)

– Due to exposure to insoluble cutting oils or chlorinated aromatic hydrocarbons (such as chlorinated dioxins and dibenzofurans)

– Chloracne (form of industrial acne): presents with comedones, pustules and cysts over malar cheeks, retroauricular region, and scrotum

– Due to repeated obstruction of the pilosebaceous unit through friction/pressure

Neonatal acne (Cephalic
neonatal pustulosis)

– Begins around 2 weeks of age and often resolves by third month of age

– Presents with erythematous small papules on cheeks

– Typically begins around 3–6 months of age, resolves within 1–2 years

Drug-induced acne
(Acneiform eruption)

– Due to corticosteroid, phenytoin, lithium, isoniazid, iodides, epidermal growth factor receptor inhibitors (EGFRI: cetuximab, erlotinib, gefitinib), anabolic steroids

– Presents with abrupt-onset monomorphic-appearing papules and pustules; comedones typically not seen

Pyogenic Arthritis (sterile), Pyoderma gangrenosum, Acne

– Inherited (AD), CD2 binding protein 1 (CD2BP1) mutation; CD2BP1 is a pyrininteracting protein, which is part of inflammatory pathway associated with familial Mediterranean fever, Muckle-Wells syndrome, and familial cold urticaria

– Skin changes typically present near or at puberty

Hyper Androgenism, Insulin Resistance, Acanthosis Nigricans

SAPHO
(Chronic recurrent multifocalosteomyelitis)

Synovitis, Acne (conglobata), Pustulosis (palmoplantar), Hyperostosis, Osteitis

– Inflammatory bone changes (commonly involving sternoclavicular joint, spine {spondyloarthropathy} and long bones); peripheral arthritis also common

– 1 st line treatment: bisphosphonates suggested in many case reports and series; other treatments include mainstay therapies for psoriatic arthritis (methotrexate, anti-TNF a agents, etc.)