Download Acne and Rosacea – handout version

Acne and Rosacea – handout
version
Dr Elizabeth Ogden
Associate Specialist in Dermatology
25.4.13
Acne
• Acne is the most common skin disease
• Affecting all races and ages
• Acne is most common in teenagers and young
adults
• An estimated 85% of all people between the ages
of 12 and 25 have acne outbreaks at some point
• Some people in their 30s, 40s and 50s continue
to get acne - 15% of women and 5% of men
Lesions
• If sebum breaks through to the surface, the
result is a whitehead.
• If the oil accumulates melanin pigment or
becomes oxidized, the oil changes from white
to black, and the result is a blackhead
• Blackheads are therefore not dirt and do not
reflect poor hygiene.
History
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When started
Sites involved
Current treatment
Previous treatments including over the counter
Medical history
Smoking
For women – period cycle, contraceptive history
Family history of acne
Other information – job, studying etc
Psychological impact
Examination
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Look at the face
Look at the neck
Look at the back
Look for blackheads and whiteheads
Look for papules and pustules
Look for nodules and cysts
Look for scarring
Look for signs of picking and scratching
Types of Lesions
• Whiteheads (comedones): These are pimples that stay
under the surface of the skin
• Blackheads: These pimples rise to the skin's surface and
look black
• Papules: These are small pink bumps that can be tender
• Pustules: These pimples are red at the bottom and have
pus on top
• Nodules: These are large, painful, solid pimples that are
deep in the skin
• Cysts: These deep, painful, pus-filled pimples can cause
scars
Types of Acne
1. Comedonal acne
2. Mild - moderate papulopustular acne
3. Severe papulopustular acne, moderate
nodular acne
4. Severe nodular acne, conglobate acne
Comedonal acne
• Non-inflamed lesions
• Open (blackheads) and
closed comedones
(whiteheads)
• Mid-facial distribution
• If very prominent early is indicative of poor
prognosis
Papulopustular acne
• Mixture of non-inflammatory and inflammatory lesions
• Papules and pustules
• May evolve into deep pustules or nodules in more
severe disease
• Inflammatory macules represent regressing lesions that
may persist for many weeks
Nodular/ conglobate acne
• Small nodules are defined as firm, inflamed lesions >
5 mm diameter, painful by palpation. Nodules are
defined as larger than 5 mm, large nodules are > 1
cm in size.
• They may extend deeply and over large areas,
frequently resulting in painful lesions, exudative
sinus tracts and tissue destruction. Conglobate acne
is a rare but severe form of acne found most
commonly in adult males with few or no systemic
symptoms.
Nodular/ conglobate acne
• Lesions usually occur on the trunk and upper limbs
and frequently extend to the buttocks. In contrast to
ordinary acne, facial lesions are less common. The
condition often presents in the second to third
decade of life and may persist into the sixth decade.
• Conglobate acne is characterized by multiple
grouped comedones amidst
• inflammatory papules, tender, suppurative nodules
which commonly coalesce to form sinus tracts.
Extensive and disfiguring scarring is frequently a
feature
Other Variants of Acne
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Acne fulminans
Gram-negative folliculitis
Rosacea fulminans
Vasculitic Acne
Mechanical acne
Oil/ tar acne
Chloracne
Acne in neonates and infants
Late onset and/or Persistent acne, sometimes
associated with genetic or iatrogenic endocrinopathies.
Late Onset Acne
• A recent US study has shown that late onset acne
in women is increasing
• 45% of women aged 21-30 had clinical acne
• 26 % aged 31-40 had clinical acne
• 12% of women aged 41-50 had clinical acne
• Another study has shown that Comedonal postadolescent acne (CPAA) is the most prevalent
form of acne in adult women
• Also CPAA was frequently of late-onset and
closely correlated with cigarette smoking.
Clinical Classifications
• 1. Comedonal acne
• 2. Mild - moderate papulopustular acne
• 3. Severe papulopustular acne, moderate
nodular acne
• 4. Severe nodular acne, conglobate acne
Psychological effects
• Acne can lead to profound psychological
effects on teenagers
• It is not proportional to the severity of the
Acne
• DLQI Questionnaires
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Prognostic factors of severe disease
that should influence treatment
choice
Family history
Course of inflammation
Persistent or late-onset disease
Hyperseborrhoea
Androgenic triggers
Truncal acne
Psychological sequelae.
Previous infantile acne may also correlate with
resurgence of acne at puberty
• Early age of onset with mid-facial comedones
• Early and more severe seborrhoea
• Earlier presentation relative to the menarche
The influence of the assessment of
scarring/ potential for scarring on disease
management
• Scarring usually follows deep seated
inflammatory lesions
• But can occur in more superficial inflamed
lesions in scar prone patients
• In dermatology clinics acne scarring is seen in
up to 90% of patients – (some very mild)
• The presence of scarring should support more
aggressive management and treatment early
in the disease process
Differential Diagnosis
• Seborrhoeic Dermatitis – look for scale in hair.
Rash on body, scale in ears and eyebrows
• Perioral Dermatitis – mostly women - papules
around mouth and use of topical steroids
• Rosacea – redness in the central face, fair skin
– no blackheads
• Contact or Irritant Dermatitis
Acne Scarring
Urgent referral if acne scarring or
Family History of Scarring Acne
Recommendations for comedonal
acne
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High strength of recommendation
None
Medium strength of recommendation
Topical retinoids
Low strength of recommendation
BPO
Azelaic acid
Negative Recommendations for
comedonal acne
• Topical antibiotics are not recommended
• Hormonal antiandrogens, systemic antibiotics and/
or systemic isotretinoin are not recommended
• Artificial ultraviolet (UV) radiation is not
recommended
Mild to moderate papulopustular acne
High strength of recommendation
• The fixed-dose combination adapalene and
BPO is strongly recommended
• The fixed-dose combination clindamycin and
BPO is strongly recommendedMedium
strength of recommendation
Medium strength of recommendation
• Azelaic acid, BPO, Topical retinoids
• For more widespread disease, a combination
of a systemic antibiotic with adapalene
Mild to moderate papulopustular
acne
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Low strength of recommendation
Blue light monotherapy
The fixed-dose combination of erythromycin and
tretinoin
The fixed-dose combination of isotretinoin and
erythromycin
Oral zinc can be considered
In case of more widespread disease, a combination of
a systemic antibiotic with either BPO or with
adapalene in fixed combination with BPO
Negative recommendations for
mild to moderate papulopustular acne
• Topical antibiotics as monotherapy are not
recommended.
• Treatment of mild to moderate papulopustular acne
with artificial UV radiation is not recommended.
• The fixed-dose combination of erythromycin and
zinc is not recommended.
Negative recommendations for
mild to moderate papulopustular acne
• Systemic therapy with anti-androgens,
antibiotics, and/ or isotretinoin is not
recommended.
Open recommendation
• Due to a lack of sufficient evidence, it is
currently not possible to make a
recommendation for or against treatment
with red light, IPL, Laser or PDT
Severe papulopustulo/moderate
nodular acne
High strength of recommendation
• Oral isotretinoin monotherapy is strongly
recommended for the treatment of severe
papulopustular acne.
Medium strength of recommendation
• Systemic antibiotics*can be recommended for
the treatment of severe papulopustular acne in
combination with adapalene, with the fixed
dose combination of adapalene/ BPO or in
combination with azelaic acid
• *Doxycycline or lymecycline limited to 3 months treatment
Severe papulopustular/ moderate
nodular acne
Low strength of recommendation
• Oral anti-androgens in combination with oral
antibiotics can be considered for the treatment of
severe papulopustular acne.
• Oral anti-androgens in combination with topical
treatment can be considered for the treatment of
severe papulopustular acne
• Systemic antibiotics in combination with BPO can
be considered for the treatment of severe
papulopustular/ moderate nodular acne.
Negative recommendation
Severe papulopustulo/moderate nodular
Acne
• Single or combined topical monotherapy is not
recommended.
• Oral antibiotics as monotherapy are not
recommended.
• Oral anti-androgens as monotherapy are not
recommended.
• Visible light as monotherapy is not
recommended.
• Artificial UV radiation sources is not
recommended
Treatment nodular/ conglobate acne
High strength of Recommendation
• Oral isotretinoin is strongly recommended as a
monotherapy for the treatment of conglobate
acne
Treatment nodular/conglobate acne
Medium strength of recommendation
• Systemic antibiotics can be recommended in
combination with azelaic acid
Low strength of recommendation
• Oral anti-androgens in combination with oral
antibiotics
• Systemic antibiotics in combination with
adapalene, BPO or the adapalene-BPO
Negative Recommendations Treatment
nodular/ conglobate acne
• Topical monotherapy is not recommended
• Oral antibiotics are not recommended as monotherapy
• Oral anti-androgens are not recommended as
monotherapy
• Artificial UV radiation sources are not recommended
• Visible light as monotherapy is not recommended
Summary of therapeutic
recommendations
Comedonal
Acne
High strength of
recommendation
Medium strength of
recommendation
Topical
Retinoid
Mild-to-moderate
papulopustular acne
Severe
papulopustular/
moderate nodular
acne
Severe nodular/
Conglobate acne
Adapalene + BPO
or
BPO + Clindamycin
Isotretinoin
Isotretinoin
Azelaic acid
or BPO
or
Topical retinoid
or
systemic antibiotic +
Adapalene
Systemic
antibiotics +
adapalene
or
Systemic
antibiotics
+ azelaic acid
or
Systemic
antibiotics +
adapalene + BPO
Systemic
antibiotics
+ azelaic acid
Summary of therapeutic
recommendations
Comedonal
Acne
Alternatives
for females
Mild-to-moderate
papulopustular acne
Severe
papulopustular/
moderate nodular
acne
Hormonal
antiandrogens +
topical
treatment
Or hormonal
antiandrogens +
systemic
antibiotics
Severe nodular/
Conglobate acne
Hormonal
antiandrogens +
systemic
antibiotics
Factors which make Acne worse
• Cosmetic agents and hair pomades
• Medications -steroids, lithium, some antiepileptics and
iodides.
• Polycystic Ovary Disease, Congenital Adrenal
Hyperplasia – causing androgen increase/ sensitivity
• Pregnancy may cause a flare-up.
• Mechanical occlusion with headbands, shoulder pads,
back packs, or under-wire bras can be aggravating
factors
• Excessive sunlight may either improve or flare acne
Food
• Parents often tell teens to avoid pizza, chocolate,
greasy, fried foods, and junk food.
• While these foods may not be good for overall
health, they don't cause acne or make it worse
• BUT there is concern about excessive intake of milk
especially skimmed milk
• Good advice about diet may help acne - eating
more low glycaemic index foods and more foods
rich in omega 3 - whole grains, fresh fruits and
vegetables, fish, olive oil and garlic
Late Onset Acne
• A recent US study has shown that late onset acne
in women is increasing
• 45% of women aged 21-30 had clinical acne
• 26 % aged 31-40 had clinical acne
• 12% of women aged 41-50 had clinical acne
• Another study has shown that Comedonal postadolescent acne (CPAA) is the most prevalent
form of acne in adult women
• Also CPAA was frequently of late-onset and
closely correlated with cigarette smoking.
Combined Oral Contraceptives
• Recent US survey showed that combined oral
contraceptives were used infrequently for
women with acne - 3.3% on initial consultation
• Non enzyme inducing antibiotics – NO
ADDITIONAL CONTRACEPTIVE
PRECAUTIONS NEEDED NOW
• Any COC can make acne better but cocyprindiol and drospirenone are the two best
progestogens (least androgenic)
Acne – When to Refer
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Most patients with acne can be managed in primary care.
However, referral to a specialist service is advised if they:
✪✪✪have a very severe variant such as fulminating acne with
systemic symptoms (acne fulminans)
✪✪have severe acne or painful, deep nodules or cysts
(nodulocystic acne) and could benefit from oral isotretinoin
✪✪have severe social or psychological problems, including a
morbid fear of deformity (dysmorphophobia)
✪are at risk of, or are developing, scarring despite primary care
therapies
✪have moderate acne that has failed to respond to treatment
which should generally include several courses of both topical
and systemic treatment over a period of at least 6 months.
Failure is probably best based upon a subjective assessment by
the patient
✪are suspected of having an underlying endocrinological cause
for the acne such as polycystic ovary syndrome that needs
assessment
Rosacea
• Thought to be a disease of the fair skinned –
but not exclusively so
• Typically starts 30s to 60s – develops gradually
• Incidence in Swedish study 10%
• Higher incidence in the fairer skinned
Causes
• It is felt to be caused by a combination of
factors – vascular, environmental and
inflammatory
• The skin's innate immune response appears to
be important - antimicrobial peptides such as
cathelicidins promote an inflammatory
reaction.
• Hair follicle mites Dermodex are sometimes
found in greater numbers within rosacea
papules but their role is unclear.
Causes
• No good evidence Helicobacter pylori plays a
role
• Rosacea may be aggravated by facial creams
or oils, and especially by topical steroids
• Sun damage is an important factor in rosacea
- hence the distribution
Signs
• Early signs - easy blushing and flushing
• Often are stingers – burning and stinging from
cosmetics and medications
• Patients with rosacea also have defective
barrier function
Signs
• Redness – affecting the nose, the cheeks and
chin – this is the most important sign – will be
worse when hot, when eating and with
alcohol.
• Scattered pustules and papules in the same
areas
• Neck, back and chest spared
Differential Diagnosis
• Seborrhoeic Dermatitis - look for scaling on
scalp, naso labial creases, eyebrows and ears
• Keratosis Pilaris – look at upper arms and
thighs
• Acne – look for blackheads. Check chest and
back
• Lupus Erythematosus – follicular plugging,
look in the ears
4 main subtypes
• Erythematotelangiectatic (vascular)
• Inflammatory (papulopustular)
• Phymatous (sebaceous)
• Ocular
Ocular Rosacea
• Between 20% to 50% of rosacea sufferers can
have ocular involvement
• No correlation exists between the severity of
ocular disease and the severity of facial
rosacea
• Symptoms vary from minor irritation, dryness,
and blurry vision to potentially severe ocular
surface disruption and inflammatory keratitis
• Blepharitis and conjunctivitis are commonest
Ocular Rosacea
• Other ocular findings include lid margin,
conjunctival telangiectasias, eyelid thickening,
eyelid crusts and scales, chalazia, hordeolum,
punctate epithelial erosions, corneal infiltrates,
corneal ulcers, corneal scars, and vascularization.
• Sight-threatening disease is rare with rosacea;
however, keratitis can result in sterile corneal
ulceration and eventual perforation if not treated
aggressively
Other rarer facial problems that can be
confused with Rosacea
• Tuberous Sclerosis
• Birt-Hogg-Dube syndrome
• Sebaceous Hyperplasia
• Acne excoriée
Advice to Rosacea Sufferers
• Where possible, reduce factors causing facial
flushing.
• Avoid oil-based facial creams. Use water-based
make-up
• Never apply a topical steroid to the rosacea.
• Protect the skin from the sun using light oil-free
facial sunscreens
• Keep the face cool: minimize exposure to hot or
spicy foods, alcohol, hot showers and baths and
warm rooms
• Green based make up can help disguise the
redness
Treatment – Topical Treatment
• Metronidazole cream or gel can be used
intermittently or long term on its own for mild
cases and in combination with oral antibiotics
for more severe cases.
• Azelaic acid cream or lotion is also effective,
applied twice daily to affected areas. Can be
used in pregnancy
Treatment – oral treatment
• 6-12 weeks of lymecycline, doxycycline or
minocycline reduce inflammation, the
redness, papules, pustules and eye symptoms.
Low doses can be used – there is 40mg low
dose doxcycycline
• Further courses are often needed from time to
time as the antibiotics don't cure the disorder.
• Sometimes co-trimoxazole or metronidazole
are prescribed for resistant cases.
Other Treatments
• Isotretinoin - but not always successful (different to
acne)
• Medications to reduce flushing such as clonidine (an
alpha 2 receptor agonist) may reduce the vascular
dilatation . Does have side effects.
• Anti-inflammatory agents Oral non-steroidal antiinflammatory agents such as diclofenac may reduce
the discomfort and redness
• Tacrolimus ointment and pimecrolimus cream are
reported to help some patients with rosacea.
Treatment of Ocular Rosacea
• Lid hygiene - Hot compresses, Mild, non irritating
cleaning solutions, such as dilute baby shampoo or
commercially preparations. Light pressure applied to the
eyelids can aid in gland expression.
• Artificial tears - used often and ointment at night.
• Antibiotics -Tetracyclines (eg, tetracycline, doxycycline,
minocycline) for antibiotic effect, and, once the disease
has come under control, the dose may be tapered to a
lower, suppressive dose and maintained indefinitely. The
40mg low dose doxcycycline is useful for maintenance.
Telangiectic Rosacea
• The papular part of the rosacea is relatively
easy to help but the persistent redness
doesn’t go away easily with topicals especially
if of long standing
• Vascular laser - persistent telangiectasia can
be successfully improved with vascular laser
or intense pulsed light treatment
Treatment
• IPL treatment to reduce redness
• Protect from the Sun
• Green based foundation
• Make up to help redness