Acne and Related Disorders Practice Questions

Q: 23 years old woman complains of recurrent acne over her face. History revealed that she had taken topical antibiotics for her acne without any significant improvement. Which one of the following tetracyclines is most preferred for her acne?

Doxycycline. ***Doxycycline*** - **Doxycycline** is a commonly preferred tetracycline for acne due to its **anti-inflammatory properties** and efficacy against *P. acnes* at sub-antimicrobial doses. - Its **longer half-life** allows for once-daily dosing, improving patient adherence compared to other tetracyclines. *Oxytetracycline* - While effective against *P. acnes*, **oxytetracycline** generally requires higher doses and more frequent administration, which can lead to poorer patient compliance. - It often causes **gastric irritation**, making it less favorable for long-term acne management. *Minocycline* - **Minocycline** is also effective for acne but is associated with a higher risk of **side effects** like dizziness, headache, and hyperpigmentation (e.g., skin, teeth). - Its potential for **drug-induced lupus-like syndrome** and **hepatotoxicity** makes it less preferred compared to doxycycline, especially for prolonged use. *Demeclocycline* - **Demeclocycline** is primarily used as an **ADH antagonist** for treating syndrome of inappropriate antidiuretic hormone (SIADH) and is not a first-line treatment for acne. - It has a higher incidence of **photosensitivity** and overall greater renal toxicity compared to other tetracyclines, making it unsuitable for acne.

Q: An 18-year-old man has facial and upper back lesions that have waxed and waned for the past 6 years. On physical examination, there are 0.3- to 0.9-cm comedones, erythematous papules, nodules, and pustules most numerous on the lower face and posterior upper trunk. Other family members have been affected by this condition at a similar age. The lesions worsen during a 5-day cruise to the Adriatic. Which of the following organisms is most likely to play a key role in the pathogenesis of these lesions?

Propionibacterium acnes. ***Propionibacterium acnes*** (now *Cutibacterium acnes*) - The presence of **comedones, papules, nodules, and pustules** on the face and upper back in an 18-year-old is classic for **acne vulgaris**. - **_P. acnes_** is a commensal bacterium that proliferates in clogged hair follicles, contributing to inflammation and lesion formation in acne due to its lipolytic activity and immune-activating properties. *Herpes simplex virus type 1* - **HSV-1** typically causes **oral herpes (cold sores)** or **genital herpes**, characterized by painful vesicles and ulcers. - The described lesions (comedones, papules, nodules, pustules) are not characteristic of HSV-1 infection. *Group A β-hemolytic streptococcus* - **Group A Strep** causes infections like **pharyngitis (strep throat)**, **impetigo**, or **cellulitis**, which are typically acute and rapidly spreading. - Its presence is not associated with chronic, polymorphic lesions characteristic of acne. *Mycobacterium leprae* - **_M. leprae_** is the causative agent of **leprosy**, presenting with skin lesions, nerve damage, and other systemic effects. - The skin lesions of leprosy are typically macules, papules, or nodules with sensory loss, not the comedones and pustules seen in acne.

Q: A patient presented with oily skin and acne formation primarily on the face. Multiple enlarged glands were noted on examination. What is the etiopathogenesis of the disease process?

Sebaceous gland hypertrophy. ***Sebaceous gland hypertrophy*** - **Oily skin (seborrhea)** and **acne formation** are directly linked to increased activity and size of the sebaceous glands. - Hypertrophied sebaceous glands produce excessive **sebum**, which clogs pores and creates a favorable environment for **Cutibacterium acnes** (formerly *Propionibacterium acnes*), leading to acne. *Septal deviation of nose* - **Septal deviation** is a structural abnormality within the nose, primarily affecting breathing and potentially leading to snoring or nosebleeds. - It has no direct etiopathogenic link to **acne** or **oily skin**. *Mucous gland hypertrophy* - **Mucous gland hypertrophy** typically occurs in conditions like chronic bronchitis, leading to increased mucus production in the respiratory tract. - It is unrelated to **skin oiliness** or **acne vulgaris**. *Sweat gland hypertrophy* - **Sweat gland hypertrophy** would primarily result in excessive sweating (**hyperhidrosis**). - While sweat glands contribute to skin moisture, their hypertrophy does not directly cause the **oily appearance** or **acne breakouts** described.

Q: The treatment of choice in nodulocystic acne is

Isotretinoin. ***Isotretinoin*** - **Isotretinoin** is the most effective treatment for **severe nodulocystic acne** due to its ability to reduce sebum production, normalize follicular keratinization, decrease *Propionibacterium acnes*, and exert anti-inflammatory effects. - It is often considered in cases that are **resistant to conventional therapies** like topical agents and systemic antibiotics. *Benzoyl peroxide* - **Benzoyl peroxide** is an effective topical agent for **mild to moderate inflammatory acne** by killing *P. acnes* and reducing inflammation. - It does not have sufficient potency to treat **severe nodulocystic acne**, which involves deep-seated inflammatory lesions. *Oestrogens* - **Oestrogens** (often in oral contraceptives) can be used to treat acne in women by reducing androgen effects on sebaceous glands. - While helpful for hormonal acne, they are not the **primary treatment of choice** or sufficiently potent for **severe nodulocystic acne**. *Systemic steroids* - **Systemic steroids** are powerful anti-inflammatory agents that can be used for **short-term control** of severe inflammatory acne flares or acne fulminans. - They are not a **long-term treatment of choice** for nodulocystic acne due to their significant side effect profile and the need for a more definitive solution to prevent recurrence.

Q: All trans retinoic acid is used topically for -

Acne vulgaris. ***Acne vulgaris*** - **All-trans retinoic acid (tretinoin)** is a topical retinoid that is highly effective in treating **acne vulgaris** by normalizing follicular keratinization, reducing sebum production, and possessing anti-inflammatory properties. - It helps in preventing the formation of new **comedones** and promoting the clearance of existing lesions. *Lupus vulgaris* - **Lupus vulgaris** is a cutaneous form of **tuberculosis**, typically treated with multidrug antitubercular therapy. - Retinoic acid is **not a primary treatment** for this condition. *Alopecia areata* - **Alopecia areata** is an autoimmune hair loss condition, often treated with **topical or intralesional corticosteroids**, or immunomodulators. - Topical retinoic acid is **not indicated** for its treatment. *Androgenic alopecia* - **Androgenic alopecia (male or female pattern baldness)** is primarily treated with **topical minoxidil** or **oral finasteride**. - While retinoids can stimulate hair growth, they are **not a first-line treatment** for androgenic alopecia and are sometimes used as an adjuvant to minoxidil.

Q: Which of the following is a primary causative factor for acne?

Androgen. ***Androgen*** - **Androgens** significantly stimulate the **sebaceous glands** to produce more sebum, which is a primary factor in the development of **acne**. - Increased sebum production, combined with follicular hyperkeratinization, creates an environment conducive to the growth of **Cutibacterium acnes** and subsequent inflammation. - Androgens are considered one of the **four primary pathogenic pillars** of acne vulgaris. *Cutibacterium acnes* - **Cutibacterium acnes** (formerly *Propionibacterium acnes*) is a commensal bacterium that proliferates in the sebum-rich, anaerobic environment of clogged follicles. - While it contributes to **inflammation** and is essential in acne pathogenesis, bacterial colonization is **secondary to** the initial processes of increased sebum production and follicular obstruction driven by androgens. - Antibacterial therapy helps manage acne but doesn't address the primary hormonal trigger. *Keratin* - **Keratin** is a protein that plays a role in the formation of acne via **follicular hyperkeratinization**, leading to clogged pores. - However, the increased production of keratinized cells is often secondary to androgenic stimulation and inflammatory processes, making it a contributing factor rather than the sole primary cause. *Diet alone* - While certain **dietary factors** (e.g., high glycemic index foods, dairy) are implicated in exacerbating acne for some individuals, diet is generally considered a **modulatory factor** rather than a primary causative one. - Acne is a complex multifactorial condition, and diet alone rarely accounts for its primary onset without other hormonal or genetic influences.

Q: A 40-year-old man with severe hidradenitis suppurativa on adalimumab develops new pustules and nodules despite compliance. Current weight is 120 kg. Most appropriate next step is:

Increase adalimumab frequency. ***Increase adalimumab frequency*** - For patients on **adalimumab** with an inadequate response, increasing the frequency of administration (e.g., weekly instead of every other week) is a common and effective strategy, especially in highly symptomatic patients. - Given the patient's **high weight (120 kg)**, there's a possibility of suboptimal drug levels, and increasing the frequency can help achieve therapeutic concentrations and improve disease control. *Add intralesional steroids* - **Intralesional steroids** are useful for treating individual, inflamed **hidradenitis suppurativa (HS)** lesions, particularly for acute pain and inflammation. - They are not appropriate for managing widespread, severe disease progression or breakthrough symptoms despite systemic therapy, as they do not address the underlying systemic inflammation. *Switch to another TNF inhibitor* - While switching biologics is an option for non-responders, it is typically considered after optimizing the existing therapy, such as increasing the **frequency** or **dosage** of the current drug, especially when dealing with a potential suboptimal drug level due to high body weight. - In this case, there's still room to intensify the current **adalimumab** regimen before considering a full class switch. *Add oral antibiotics* - **Oral antibiotics** are often used in **hidradenitis suppurativa (HS)** for their anti-inflammatory and immunomodulatory properties and to treat secondary infections. - However, they are generally not the primary solution for breakthrough disease in a patient already on a TNF inhibitor like **adalimumab**, especially when the main issue might be insufficient systemic disease control from the biologic.

Q: A 25-year-old woman with severe nodulocystic acne develops acute-onset fever, arthralgia, and osteolytic lesions while on isotretinoin. Most appropriate next step is:

Stop isotretinoin, start antibiotics. ***Stop isotretinoin, start antibiotics*** - The combination of **fever**, **arthralgia**, and **osteolytic lesions** in the context of isotretinoin use suggests the development of **isotretinoin-induced SAPHO syndrome** (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis). Although rare, it can mimic infection, and given the patient's acute symptoms and systemic involvement, stopping the potential offending agent (isotretinoin) and empirically treating with antibiotics for possible osteomyelitis is the safest initial step [1]. - While SAPHO syndrome is an autoimmune condition, initially ruling out and treating potential infection, especially with osteolytic lesions, is crucial before solely focusing on immunosuppression [2]. *Continue isotretinoin and add NSAIDs* - Continuing isotretinoin is inappropriate as it could be the **trigger** for the patient's systemic symptoms and osteolytic lesions. - While NSAIDs can alleviate arthralgia, they would not address the **underlying systemic inflammation** or potential infection suggested by the osteolytic lesions and fever. *Decrease isotretinoin dose* - Simply decreasing the dose might not be sufficient to halt the progression of an isotretinoin-induced inflammatory or autoimmune response like **SAPHO syndrome**. - The severity of symptoms with **fever** and **osteolytic lesions** warrants complete cessation of the suspected causative agent. *Add oral steroids* - While oral steroids might be considered for the inflammatory component of **SAPHO syndrome**, adding them without stopping the suspected trigger (isotretinoin) is not optimal. - Furthermore, if there's an underlying infection leading to the osteolytic lesions, steroids could worsen the clinical picture by **immunosuppression**.

Q: A 25-year-old male presents with scattered papules and pustules on the face, with comedones. Previous treatment with topical clindamycin showed minimal improvement. Which treatment would be most appropriate?

Topical tretinoin. ***Topical tretinoin*** - This patient presents with **comedonal and inflammatory acne** (papules and pustules with comedones) that has shown **minimal response to topical clindamycin**, a topical antibiotic. - **Topical retinoids** like tretinoin are considered **first-line therapy for comedonal acne** and are effective in treating both comedones and inflammatory lesions by normalizing follicular keratinization and reducing inflammation. They are often combined with antimicrobials for inflammatory acne. *Oral isotretinoin* - **Oral isotretinoin** is reserved for **severe, nodulocystic acne** or **moderate acne unresponsive to other therapies** due to its significant side effect profile and teratogenicity. - The patient's presentation with scattered papules and pustules suggests moderate, not severe, acne, and prior treatments have not yet included topical retinoids or oral antibiotics. *Topical benzoyl peroxide* - **Topical benzoyl peroxide** is an effective antimicrobial and comedolytic agent, often used in conjunction with topical retinoids or antibiotics for inflammatory acne. - While it could be added to the regimen, **topical tretinoin** is more specifically indicated for the comedonal component and overall improvement of acne pathology. The question asks for the **most appropriate single treatment** given current resistance concerns. *Oral minocycline* - **Oral minocycline**, an oral antibiotic, is typically used for **moderate to severe inflammatory acne**, often when topical treatments alone are insufficient or when there's a significant inflammatory component. - Given the patient's prior use of **topical clindamycin with minimal improvement**, introducing an oral antibiotic might be a consideration, but addressing the **comedonal aspect** with a topical retinoid and cycling antibiotics (if needed) is a more structured approach. Oral antibiotics are generally considered after failure of topical combination therapy.

Q: A 30-year-old man presents with multiple painful, suppurative nodules in his axillae and groin, and he has a history of smoking. What is the most likely diagnosis?

Hidradenitis suppurativa. ***Hidradenitis suppurativa*** - This condition is characterized by **chronic inflammation** of the **apocrine glands**, presenting as painful, deep-seated nodules, abscesses, and sinus tracts in intertriginous areas like the **axillae and groin**. - **Smoking** is a significant risk factor, and the recurring nature of the lesions fits this diagnosis perfectly. *Furunculosis* - **Furunculosis** involves single or multiple painful, pus-filled lesions (boils) caused by bacterial infection of hair follicles, typically **Staphylococcus aureus**. - While furuncles can occur in the axillae and groin, they generally don't present as widespread, chronic, or deeply interconnected **nodules and sinus tracts** characteristic of the patient's presentation. *Lymphogranuloma venereum* - **Lymphogranuloma venereum (LGV)** is a sexually transmitted infection caused by specific serovars of **Chlamydia trachomatis**. - It primarily causes **genital ulcers**, **inguinal lymphadenopathy** (buboes), and proctitis, but does not present with the diffuse, suppurative nodules in the axillae seen in this case. *Erythrasma* - **Erythrasma** is a superficial skin infection caused by **Corynebacterium minutissimum**, characterized by well-demarcated, reddish-brown patches with fine scales, often in intertriginous areas. - It typically causes **asymptomatic or mildly itchy patches** and does not involve painful, suppurative nodules or abscesses.

Question 1

23 years old woman complains of recurrent acne over her face. History revealed that she had taken topical antibiotics for her acne without any significant improvement. Which one of the following tetracyclines is most preferred for her acne?

Accepted Answer

Doxycycline

Answer

Oxytetracycline

Answer

Minocycline

Answer

Demeclocycline

Question 2

An 18-year-old man has facial and upper back lesions that have waxed and waned for the past 6 years. On physical examination, there are 0.3- to 0.9-cm comedones, erythematous papules, nodules, and pustules most numerous on the lower face and posterior upper trunk. Other family members have been affected by this condition at a similar age. The lesions worsen during a 5-day cruise to the Adriatic. Which of the following organisms is most likely to play a key role in the pathogenesis of these lesions?

Accepted Answer

Propionibacterium acnes

Answer

Herpes simplex virus type 1

Answer

Group A β-hemolytic streptococcus

Answer

Mycobacterium leprae

Question 3

A patient presented with oily skin and acne formation primarily on the face. Multiple enlarged glands were noted on examination. What is the etiopathogenesis of the disease process?

Accepted Answer

Sebaceous gland hypertrophy

Answer

Septal deviation of nose

Answer

Mucous gland hypertrophy

Answer

Sweat gland hypertrophy

Question 4

The treatment of choice in nodulocystic acne is

Accepted Answer

Isotretinoin

Answer

Benzoyl peroxide

Answer

Oestrogens

Answer

Systemic steroids

Question 5

All trans retinoic acid is used topically for -

Accepted Answer

Acne vulgaris

Answer

Lupus vulgaris

Answer

Alopecia areata

Answer

Androgenic alopecia

Question 6

Which of the following is a primary causative factor for acne?

Accepted Answer

Androgen

Answer

Cutibacterium acnes

Answer

Keratin

Answer

Diet alone

Question 7

A 40-year-old man with severe hidradenitis suppurativa on adalimumab develops new pustules and nodules despite compliance. Current weight is 120 kg. Most appropriate next step is:

Accepted Answer

Increase adalimumab frequency

Answer

Add intralesional steroids

Answer

Switch to another TNF inhibitor

Answer

Add oral antibiotics

Question 8

A 25-year-old woman with severe nodulocystic acne develops acute-onset fever, arthralgia, and osteolytic lesions while on isotretinoin. Most appropriate next step is:

Accepted Answer

Stop isotretinoin, start antibiotics

Answer

Continue isotretinoin and add NSAIDs

Answer

Decrease isotretinoin dose

Answer

Add oral steroids

Question 9

A 25-year-old male presents with scattered papules and pustules on the face, with comedones. Previous treatment with topical clindamycin showed minimal improvement. Which treatment would be most appropriate?

Accepted Answer

Topical tretinoin

Answer

Oral isotretinoin

Answer

Topical benzoyl peroxide

Answer

Oral minocycline

Question 10

A 30-year-old man presents with multiple painful, suppurative nodules in his axillae and groin, and he has a history of smoking. What is the most likely diagnosis?

Accepted Answer

Hidradenitis suppurativa

Answer

Furunculosis

Answer

Lymphogranuloma venereum

Answer

Erythrasma

Acne and Related Disorders — MCQs

Acne and Related Disorders — MCQs

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