Download Pathogenesis of Acne Vulgaris

Adult Acne
Mary S. Stone MD
Department of Dermatology
Guidelines of care for the management of acne vulgaris.
J Amer Acad of Dermatol 74:945-973, 2016
Acneiform Disorders
Acne Vulgaris
 Acne Rosacea
 Perioral Dermatitis
 Topical Steroid Induced Acne
 Neonatal and Infantile Acne
 Drug Induced Acne

Pathogenesis of Acne
Vulgaris
Androgen related overproduction of
sebum
 Abnormal desquamation within the
sebaceous follicle
 Proliferation of Propionibacterium
acnes producing inflammation
 Genetic factors

Relationship between
sebaceous glands and acne
Acne occurs in the neonatal period
 Sebum is comedogenic
 Sebaceous gland activity is increased
in acne
 Inhibition of sebaceous gland function
improves acne

Adult Female Acne (>age25)
2x more than adult men seek care
 1/23 of all can office visits made by
females > 25 years old
 Distribution typically perioral or
mandibular
 May persist beyond menopause
 Premenstrual flares very common

Principles of Therapy
Correct defects in keratinization
 Decrease sebaceous gland activity
 Reduce the population of P. Acnes
and thereby its extracellular products
 Produce an anti-inflammatory effect

Correct Defect in
Keratinization

Topical
Retinoids (tretinoin, adapalene,
tazarotene)
 Alpha hydroxy acids
 Salicylic acid


Systemic

13 cis retinoid acid (Accutane)
Reduce P. Acnes Population

Topical
Benzoyl peroxide
 Azelaic acid
 Topical antibiotics


Systemic
Antibiotics
 Retinoids

Produce an Antiinflammatory Effect

Local
intralesional corticosteroids
 acne surgery
 Topical dapsone – may be more
effective in adult females


Systemic
Antibiotics Tetracycline, doxycycline,
minocycline
 corticosteroids

Dapsone 5% gel BID
Appears to act an anti-inflammatory
agent
 More effective in adult female acne
than in adolescents or men
 Can be oxidised by BPO casuing
orange-brown coloration (can be
washed off).

Decrease Sebaceous Gland
Activity

Hormonal Therapy

OCP’s
• FDA approved for acne: Ortho Tri-Cyclen,
Estrostep and Yaz
• Least androgenic progestins: desogestrel,
norgestimate
• Drospirenone has antiandrogenic
properties


Spironolactone
Oral Retinoids
Oral Contraceptives
As effective as oral antibiotics, but
slower (equal efficacy at 6 months,
antibiotics win at 3 months)
 Improve both inflammatory and noninflammatory acne
 Risks must be considered. Especially
useful in women who wish
contraseption or have other
indications such as menorrhagia

OCP’s

Only 4 FDA approved for acne:
Ethinyl estradiol/norgestimate (Ortho
TriCyclen)
 Ethinyl estradiol/norethindrone (Estro
step)
 Ethinyl estradiol/drospirenone (Yaz)
 Ethinyl
estradiol/drospirenone/levomefolate
(Beyaz)

Spironolactone
50-200 mg/day
 No need to check potassium in young
healthy women

Diet
AAD Guidelines: No specific dietary
changes recommended in manage of
acne
 Low glycemic index diets may
improve acne
 Limited evidence suggest that some
dairy, especially skim milk may
aggravate acne

13-cis retinoic acid
(Accutane)
Extremely effective agent in acne vulgaris
 Extremely potent teratogen
 Other side effects include:

Dryness of the skin
 Hyperlipidemia
 Boney spur formation
 Rarely depression
 Inflammatory bowel disease- debated, but
likely no relationship

13-cis-retinoid acid dosing
1mg/kg x 20 weeks
 120-150mg/kg total dosage
 Must be prescribed through the
ipledge program
 Some advocating higher dosing
220mg/kg to reduce recurrence

Drug-induced Acne
Anabolic steroids
 Corticosteroids
 Phenytoin
 Lithium
 INH
 EGFR inhibitors

Acne Rosacea Etiology

Vasomotor Liability
menopause
 alcohol and spicy foods

Disruption of epidermal barrier
 Triggering of innate immune system
 Demodex Mites

Rosacea: 4 types
Erythematous/telangiectatic
 Papulopustular
 Phymomatous
 Ocular


Unlike acne rosacea does not cause
comedones. Patient’s can have both.
Rosacea Treatment
Avoid triggers of flushing
 Topicals

Metronidazole cream/gel
 Sodium sulfacetamide
 Clindamycin lotion
 Azelaic acid
 Ivermectin (Soolantra)
 Brimonidine (Mirvaso)

Oral antibiotics- doxycycline
 13-cis retinoid acid

Brimonidine (Mirvaso)
Vasoconstrictive
 Selective α2-adrenergic receptor
agonist
 10-20% may have rebound erythema

Perioral Dermatitis
Primarily young women
 Discontinue topical steroids
 Topical metronidazole,
erythromycin, clindamycin,
pimecrolimus may help
 Low dose tetracyclines very
effective

Topical Steroids
Can induce either perioral dermatitis
or acne rosacea
 In general, no topical steroids stronger
than 1% hydrocortisone should be
used on the face
