Download ACNE EVALUATION AND TREATMENT

ADOLESCENT ACNE:
EVALUATION AND
MANAGEMENT
BETSY PFEFFER MD
ASSOCIATE PROFESSOR PEDIATRICS
MORGAN STANLEY CHILDREN’S HOSPITAL
OF NEW YORK PRESBYTERIAN
ACNE:WHY DO WE CARE
 Affects
>80% of adolescents (M>F)
>40% of adults over 25
One of the top ten most prevalent
diseases globally
ACNE:WHY DO WE CARE
 Associated with:
Disfigurement
Pain, soreness
Loss of confidence & embarrassment
Depression, anxiety
 Severity of acne and psychological
impairment do not necessarily
correspond
ACNE:WHY DO WE CARE
• Effects on quality of life
• Comparable to those suffering from
chronic diseases like asthma, seizures and
diabetes
• Body dysmorphic disorder
• 14% of patients with acne
PATHOPHYSIOLOGY
• Typically begins at puberty
• Genetics plays a role in severe acne
• Disorder of the pilosebaceous unit
(face, neck, chest, shoulders, back)
• Obstruction of the sebaceous follicle
• The primary pathologic event in acne
• Gives rises to the microcomedo, the
precursor of all acne lesions
PATHOPHYSIOLOGY
• Acne arises from the interaction of 4 factors:
• Increased androgen production leads to
increased sebum
• Abnormal keratinization and desquamation
obstructs the pilosebaceous duct
• Propionibacterium acnes proliferates in
excess sebum and breaks down sebum into
free fatty acids
• Proinflammatory mediators are activated
and result in inflammatory acne
EXTRINSIC INFLUENCES
• Friction and manipulation
• Can worsen acne and increase
inflammation and scarring
• Occlusive products
• Close fitting sports equipment
EXTRINSIC INFLUENCES
• Smoking
• Studies have suggested that severe acne
increases with smoking
• Evidence supporting this is controversial
• Medications:
• Steroids
• Antiepileptics
• Progestin only contraceptives
DIET
• Diet
• Diary, correlation between consumption
and acne (no randomized controlled
studies)
• High glycemic diet
• Randomized controlled trials show that a low
glycemic diet might improve acne
• Chocolate
• Well-recognized belief that chocolate causes or
exacerbates acne; limited evidence backing up
such a claim
STRESS & MENSES
• Stress
• Acne among university students has been
associated with exam stress
• Hormones
• 70% of females report mild premestrual
facial acne
• Acne is also common in girls who have
polycystic ovary syndrome
CLINICAL FEATURES
 Mild acne
 Comedomes-non-inflammatory
 Closed (whiteheads)
 Flesh colored papules 1-3mm in size
 Open (blackheads)
 Contents of the comedome oxidizes upon
expose to the light (tyrosine is oxidized to
melanin)
 Moderate acne
 Comedomes/Inflammatory Papules/Pustules
 Severe acne
 Papules/Pustules/Nodulocystic lesions
CLOSED COMODOME
OPEN COMODOME
PAPULAR ACNE
PUSTULAR ACNE
NODULOCYSTIC ACNE
CONSEQUENCES OF ACNE
• Postinflammatory changes
• Risk of scarring
• Mild acne low risk
• Moderate acne medium risk
• Severe acne high risk of:
•
•
•
•
•
Punctate depressions (ice-pick scars)
Depressed scars (thumbprint scars)
Atrophic scars
Hypertrophic papular scars
Keloids
ICE PICK SCAR
THUMBPRINT SCARS
ATROPHIC SCARS
HYPERTROPHIC SCARS
KELOIDS
RARE FORMS OF SEVERE ACNE
• Acne fulminans
• Severe acne in young males in
association with fever, arthritis
• Acne conglobata
• Comedomes, pustules, foul smelling cysts,
sinus tracts, atrophic and keloid scarring
• Treat with high dose steroids and
isotretinoin
ACNE FULMINANS
ACNE CONGLOBATA
DIFFERENTIAL DIAGNOSIS
• Keratosis pilaris
• Perioral dermatitis
• Angiofibromas
• Pseudofolliculitis barbae
• Acne keloidalis nuchae
• Folliculitis
• Hidradentis suppurativa
KERATOSIS PILARIS
• Small perifollicular papules on the
extensor surfaces of the arms and legs,
cheeks and buttocks
• May be seasonal
• May improve w/ keratolytic moisturizers
containing ammonium lactate or urea
KERATOSIS PILARIS
PERIORAL DERMATITIS
• Idiopathic
• Sensation of stinging and burning.
Itching is rare
• May occur after use of topical steroids
• Treatment:
• Discontinue steroid use
• Topical benzoyl peroxide
• Topical and/or oral antibiotics
PERIORAL DERMATITIS
ANGIOFIBROMAS
• Tuberous sclerosis
• Rubbery papules/plaques
• Flesh colored to brownish
• Seen on nasolabial folds
• Begin in childhood
• Treat with pulsed dye laser therapy or
carbon dioxide laser resufacing
ANGIOFIBROMAS
SHAVING
• Pseudofolliculitis barbae
• Beard hair, when shaved closely, causes
inflammation, papules and nodules
• Acne keloidalis nuchae
• Papules and nodules on the nape of the
neck
• Avoid close shaves, use depilatories,
topical retinoids, benzoyl peroxide
PSEUDOFOLLICULITIS BARBAE
ACNE KELOIDALIS NUCHAE
FOLLICULITIS
• Papules/pustules on the face, back
buttocks
• Typically staph aureus
• Treatment
• Anti-bacterial wash like benzoyl peroxide
(Clearisil, Proactiv), chlorhexidine (Hibiclens), or
Phisoderm twice a day
• Topical antibiotics
• Best results may be achieved with combination
therapy using topical products and antibacterial
washes
FOLLICULITIS
HIDRADENITIS SUPPURATIVA
• Disease of the follicle
• Deep tender nodules in the groin,
axilla, buttocks
• Difficult to treat
• May respond to Accutane
HIDRADENITIS SUPPURATIVA
ACNE TREATMENT
 Basic skin care
No scrubbing or picking
Cleanse with a gentle soap, may contain
salicylic acid, glycolic acid or benzoyl
peroxide
If moisturize use noncomedogenic agent
ACNE TREATMENT
• Acne treatments work by preventing new
lesions
• Response may not appear for many weeks
• Mild comedomal acne
• Topical retinoids
• Mild papulopustular acne
• Topical retinoids
• Antibacterial
• Benzoyl peroxide, topical antibiotics or azelaic
acid
ACNE TREATMENT
• Moderate acne
• Systemic drugs
• Oral antibiotics, hormonal therapy, oral retinoids
• Systemic therapy should be considered in
diseases with tendency for
physical/psychological scarring, postinflammatory hyperpigmentation,
widespread disease
• Sever acne
• Isoretinoin
TOPICAL RETINOIDS
 Tretinoin (Retin A), Adapalene (Differin),
Tazarotene (Tazorac)
 Excellent choice for comedomal and
inflamatory acne, targets the microcomedo
 Improves follicular desquamation
 Retinoids are the most effective comedolytic
agents
 Eliminate mature comedones and inhibit the
formation of new ones
 Use at night over entire face, may increase
concentration over time
 Results in six to eight weeks
TOPICAL RETINOIDS
• Anti-inflammatory action (Adapalene best)
• Degraded by prolonged exposure to the
sun and when used with benzoyl peroxide
• AdapaleneMost photostable so does not have to
be used at night
• Enhances the penetration of other topical
agents
• Adapalene
• Can be used in combination with benzoyl
peroxide
TOPICAL RETINOIDS
• Adverse affects
• Irritant potential (Tretinoin most irritating,
Adapalene least)
• Sun sensitivity
• Pustular eruption after 3-4 weeks
• Potential hyper/hypopigmentation in black
and Asian patients
• Contraindicated in pregnancy
TOPICAL ANTIBIOTICS
• Erythromycin and Clindamycin
• Decrease P.acnes and percentage of free
fatty acids
• Slow to act
• Resistance often develops over time
• Best used in combination with topical
retinoids/benzoyl peroxide
• Rare cases of pseudomembranous colitis
w/topical clindamycin
BENZOYL PEROXIDE
• Bacteriocidal effect on P.acnes & no
evidence of resistance
• Mild comedolytic action
• Helps decrease the presence of antibiotic
resistent P. acnes when combined with a
topical antibiotic
• Adverse effects
• Irritation, will decrease in most cases
• Bleaches clothing and hair
• Allergic contact dermatitis
TOPICAL DAPSONE
• Not first line therapy
• A synthetic sulfone
• Anti-inflammatory and antimicrobial
properties
• Used for mild/moderate acne
• More effective in reducing
inflammatory lesions compared to
non-inflammatory lesions
AZELAIC ACID
• Not first line therapy
• Dicarboxylic acid
• Bacteriostatic against P.acnes and normalizes
keratinization
• Most effective when used with other agents
• Side affects uncommon
• Use in caution in teens w/dark complexions
due to potential risk of hypopigmentation
OVER THE COUNTER PRODUCTS
• Alpha hydroxy acid (glycolic acid and lactic
acid)
• Remove dead skin
• Reduce inflammation
• May stimulate growth of new smoother skin
• Salacytic Acid
• Salacytic acid comedolytic properties that are
less potent than retinoids
• Promotes exfoliation
• Few well designed trials of its efficacy exist
OVER THE COUNTER PRODUCTS
• Sulfur, sodium sulfacetamide, and
resorcinol are active ingredients in several
OTC products
• Sulfur has mild antibacterial and
keratolytic properties
• Sulfur has an odor
• Often combined with sodium sulfacetamide
to mask the scent
SYSTEMIC ANTIBIOTICS
• Decreases P.acnes and reduces amount of
free fatty acids
• Preferred agents:
• Minocyclin most effective, Doxycycline,
Tetracyclin least effective
• High rates of resistance to Erythromycin
• Discontinue or taper within 1-2 months after
new inflammatory lesions have stopped
emerging (can take several months)
HORMONAL CONTROL
• Oral contraceptive pills in females
• Increases production of sex hormone binding
globulin leading to a decrease of circulating
androgens
• Decreases ovarian androgen production
• Orthotri-cyclen, Estrostep, Yaz FDA approved
for the treatment of acne
• Oral antiandrogens (spironolactone) can be
useful
• Oral corticosteroids, short course for patients
with severe inflammatory disease
ISOTRETINOIN
• Systemic retinoid used for
nodulocystic acne
• Reduces sebum production
• Normalizes follicular keratinization
• Decreases inflammation
• Most effective treatment with
remission in 60% after single course
(15-24 weeks)
ISOTRETINOIN
• Baseline CBC, LFT’s, lipids (repeat in 1-2
months)
• Pregnancy test (repeat monthly)
• Post pubertal females must be on
contraception and have two
sequential negative pregnancy tests
before starting
ADVERSE EFFECTS ISOTRETINOIN
 Teratogenic and retinoid embryopathy can
occur with a single exposure during
gestation
 Drying/chapping of skin and mucous
membranes
 Myalgias/Arthralgias
 Photosensativity
 GI effect: transaminitis, lipid abnormalities,
pancreatitis, IBD (?)
 Hematologic: leukopenia, elevated platlets
and ESR
ADVERSE EFFECTS ISOTRETINOIN
 Renal
 Protienuria, Hematuria
 Neurologic
 Pseudotumor Cerebri
 Mood disorders
 Depression, suicidal ideations and suicides
 No causal relationships have been
established
MISCELLANEOUS THERAPY
• Comedome removal
• May be helpful if comedomes are resistent to
other treatments
• Chemical peels
• Little evidence supporting efficacy
• Intralesional steroids
• Used for large inflammatory nodules/cysts
• Can be associated with local atrophy
• Topical tree oil
• One clinical trial documented effectiveness
ACNE SCARS
• Facial scarring from acne affects up to
20% of teenagers
• Treatment
• Subcision
• Punch excision
• Laser resurfacing
• Demabrasion
• Chemical peels
• Fractionated laser treatments
MANAGING ADOLESCENTS
• Remember adolescents are impatient
• Empower the patient to take control of
their care
• Can improve adherence
• Give reasonable expectations
• Treatment takes time
• Acne may worsen initially
• Irritation may occur but tends to improve
RESOURCES
1. Current concepts in acne management.
Yan AC - Adolesc Med Clin - 01-OCT-2006; 17(3): 613-37
2. Guidelines of care for acne vulgaris management.
Strauss JS - J Am Acad Dermatol - 01-APR-2007; 56(4): 651-63
3. High school dietary dairy intake and teenage acne.
Adebamowo CA - J Am Acad Dermatol - 01-FEB-2005; 52(2): 207-14
4 Acne : Clinical Review Purdy,S-BMJ-04-NOV-2006;333:949-953.
5. Acne vulgaris, Hywel C et a Lancet 2012
6. Guidelines of care for acne vulgaris management
Work Group : John S. Strauss,et al J AM ACAD DERMATOL APRIL 2007
7 The relationship of diet and acne
A review Dermato-Endocrinology 1:5, 262-267; September/October 2009
8. Nutrition and acne F. William Danby, MD⁎ Clinics in Dermatology (2010)
9. The epidemiology of acne vulgaris in late adolescence The Dove Press
Lynn DD et al Published 19 January 2016 Volume 2016
10. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental
Indian and African American women. Perkins AC et al. J Eur Acad DermatolVenereol 2011
11. Guidelines for Treating Acne ANDREAS. D. KATSAMBAS, MD Mild Comedonal Acne
Clinics in Dermatology Y 2004
12. Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne
Lawrence F. Eichenfield, MD et al, PEDIATRICS Volume 131, Supplement 3, May 2013
13. Epidemiology of acne vulgaris K. Bhate et al, British Association of Dermatologists 2013
14. Guidelines for Treating Acne ANDREAS. D. KATSAMBAS, MD, Clinics in Dermatology, 2004