Download Acne - Continuity Lecture

ACNE
By Sapna Prabhakaran, MD
Objectives

Types

Diagnosis

Treatments
Types



Neonatal – may occur at birth, usu. occurs at 2-3 weeks of age, cause not
known but some believe it’s from maternal androgens and others propose
it’s an inflammatory response to resident yeast, s/s: inflammatory
erythematous papules and macules, rarely comedones, primarily in the
cheeks, rare on the trunk
tx: spontaneous resolves
Infantile - usually around 2-3 months of age, may represent persistance of
neonatal acne or a true acne variant, usually resolves by 6-12 months of
age
similar to neonatal acne but comedones maybe present
tx: topical 2.5% benzoyl peroxide or topical 2% erythromycin solution or
gel or topical retinoids such as adaplene
Acne vulgaris
Acne Vulgaris

Epidemiology of acne vulgaris
 Most
common skin disease that is treated by physicians
 Affects about 45 million individuals in the US, including
at least 85% of all teenagers and young adults
 Has the potential for significant negative impact on
quality of life
Pathophysiology



Result of a complex interaction between hormonal
changes and their effects on the pilosebaceous unit
- specialized structures consisting of a hair follicle
and sebaceous glands that are concentrated on the
face, chest and back
Onset at puberty because of increased androgen
production
Disordered function of the pilosebaceous unit with
abnormal follicular keratinization (tendency toward
increased follicular plugging)
Pathophysiology



Increased density of Propionibacterium acnes, a
normal resident of the skin
Increased sebum production, under the influence of
adrenal and gonadal androgens
Breakdown of sebum by P acnes results in
production of proinflammatory mediators, which
leads to the development of the characteristic
inflammatory lesions
Pathophysiology Factors

Factors that may exacerbate acne
 Trauma
– scrubbing the skin too vigorously or picking of
lesions
 Comedogenic cosmetics or other skin care products
 Tight fitting sports equipment
 Medications: corticosteroids and anabolic steroids,
antiepileptic drugs, lithium and certain contraceptives
 Hormonal dysregulation as in conditions like PCOS or
Cushing syndrome
NORMAL PILOSEBACEOUS UNIT
MICROCOMEDONE
WHITEHEAD (CLOSED)
BLACKHEAD(OPEN)
PAPULE
PUSTULE
CYST
Signs and Symptoms


Early on, acne lesions often appear on the forehead
and middle third of face (T-zone) and are obstructive;
inflammatory lesions tend to develop later and lesions
may occur on all areas of the face, neck, chest and
back
Comedones and inflammatory lesions
Open comedones – blackheads: dilated follicles
 Closed comedones – (whiteheads): white or skin colored
papules without surrounding erythema

Signs and Symptoms
Inflammatory lesions typically appear later in the course
of acne vulgaris and vary from 1-2mm micropapules to
nodules larger than 5mm
 Large (5-15mm) inflammatory nodules and cysts occur
in most severe cases and such nodulcystic presentations
are most likely lead to permanent scarring
 Mild, moderate and severe inflammatory acne can be
associated with disfiguring post-inflammatory
discoloration, which can be red, violaceous or greybrown hyperpigmentation
 Pigmentary lesions may persist for many months
Treatment



4-6 weeks or longer maybe required to observe a benefit
from treatment
Optimize skin care - use a facial cleanser that has salicylic
acid or benzoyl peroxide, if using prescription products, then
want to use a mild cleanser
Classify acne into mild moderate and severe to be able to
pick the appropriate treatment regimen
Treatment

Treatment strategies are based on severity of disease

Mild acne – (face: one fourth of the face is involved, few to
several papules or pustules, but no nodules or scarring)
Topical therapy are usually adequate as an initial intervention
and include a choice of topical retinoids, topical benzoyl
peroxide, and topical benzoyl/antibiotic combinations
 Retinoid pearls –

 apply to a dry face
 apply no more than a pea size amount for the entire face
 If the entire face needs to be covered - touch pea size aliquot to
each side of forehead, each cheek and chin and rub it in
 Apply to all areas and not as spot therapy
 Use a noncomedogenic moisturizer sparingly to counteract the
dryness assoc with retinoid therapy
Treatment
Treatment

Moderate acne ( face: about one half of the face to be involved;
there are several to many papules or pustules and a few to several
nodules; a few scars maybe present)




Benzoyl peroxide/topical antibiotics combination products, along with
topical retinoids, are an effective treatment strategy – one is applied in
the morning and one is applied in the evening
Another option is a topical antibiotic and a topical retinoid
If inflammatory lesions are present , use of oral antibiotics should be
added but still need to add benzoyl peroxide because has shown that
benzoyl peroxide decreases risk of developing antibiotic resistance
Female patients who have significant inflammatory acne, particularly
those who have premenstrual or menstrual flares, may benefit from
hormonal intervention such as oral contraceptive pills
Treatment

Severe acne (face: three fourths or more of the face
is involved; there are many papules and pustules, and
many nodules; scarring is present)
Nodulocystic acne or the presence of scarring warrant
prompt consideration for isotretinoin therapy( with referral
to a dermatologist)
 High dose oral antibiotics in combination with topical
therapy is an option while considering isoretinoin.

WHERE DRUGS ACT
BENZOYL PEROXIDE





Antibacterial and mild comedolytic
Ubiquitous treatment for inflammatory and noninflammatory acne
Formulations: 2.5, 5, and 10% gels, lotions and creams
Risks: irritation, contact dermatitis, and bleaching of
clothes
Pearl: start low, brief application during initial days of
treatment: 15-30 minutes/day
RETINOIDS





Normalizes follicular keratinization
Resolves matures comedones
Prevents new lesions
Enhances penetration of other drugs
Basically reverse the ‘stickiness” of the skin cells, allowing
them to slough normally
TRETINOIN (RETIN-A)





Comedolytic
Best topical treatment for comedones
Risks: irritation, photosusceptability, hyperpigmentation
Formulations: 0.01, 0.025, 0.05, 1% gel, cream
Pearl: bedtime use, brief application during initial phase
of treatment
TOPICAL ANTIBIOTIC




Clindamycin
Antibacterial
Risks: irritation, rare report of pseudomembranous colitis
Formulation: gel,lotion and newer foam (Cleocin)
SYSTEMIC ANTIBIOTICS

Tretracycline
Antibacterial
 500mg BID
 Inhibits chemotaxis of neutrophils (anti-inflammatory
effect
 Photosensitivity, GI irritation, vaginal candidiasis,
teratogenic; possible reduced effect of OCPs
 Take ½ hr before, or 2hrs after meal

TRIAZ





Benzoyl peroxide, glycolic acid, zinc
Anti-microbial, anti-comedonal
3, 6 and 9%
Less irritation
Also successful in pseudofolliculitis barbae
BENZACLIN




BP 5%-clindamycin combination
Maybe used in lieu of oral antibiotics in mild papular,
pustular acne
Benzamycin (erythromycin/BP combination)
Duac (clinda/BP)
ZIANA




Clindamycin/tretinion combo
Antibacterial/comedolytic
Risks: irritation, GI effects of clinda
Expensive
ADAPELENE (DIFFERIN)



Synthetic napthalene retinoid derivitive
Anti-comedones, some anti-inflammatory
Risks: irritation 10-40%; photosusceptible,
hyperpigmentation
RETIN A-MICRO


Different formulation of Retin-A
Anti-comedonal with less irritation
TAZAROTENE (TAZORAC)





Retinoid derivitive
Anti-comedonal, anti-inflammatory, antiproliferative
Also used in psoriasis
Irritation 10-30%;
Start brief contact, 2-5 minutes BID
AZELAIC ACID (AZELEX)





Dicarboxylic acid
Antimicrobial, anti-keratinization
Decrease hyperpigmentation
20% Cream BID dosing
Useful in pts that prone to hyperpigmenation

ORAL AGENTS
MINOCIN (MINOCYCLINE)

Special acne indication


50mg BID dosing
Risks: gray-blue discoloration of skin; hepatitis;
lupus like illness
DOXYCYCLINE




Low dose formulation
Periostat 20mg BID
Likely anti-inflammatory effect
More expensive than regular hight dose doxy
BACTRIM



DS BID used 2-3 months
Moderate severe cases
Consider prior to using accutane
ZITHROMAX

Pavone-Italy:


Schachner, Miami:


500mg qd x 3 days, then 7 days off, for 3 cycles
Z-pak x 5days, then 1 month off
Elewski, Miami:

Z-pak during menstrual flares
ISOTRETINOIN (ACCUTANE)


Most effective agent for severe inflammatory acne or
nodularcystic acne
Only drug that affects all pathogenic factors




Anti-comedonal, anti-bacterial, anti-inflammatory, decrease
sebum production;
Teratogenic, anemia, thrombocytopenia, hepatitis,
ocular/vaginal dryness, arthralgia, pseudotumor cerebri,
depression
Can have granulomatous reaction initially (can use
prednisone)
Dermatology/national registry
ORAL CONTRACEPTIVES
Increases sex hormone
binding globulin
Decreases free
testosterone
Decrease
inflammatory acne
OCP




Ortho-tri-cyclen, Yaz, Yasmin
Risks: nausea, vaginal bleeding
Consider using in mod-severe inflammatory acne
Trial prior to Accutane
Prognosis




Acne vulgaris is often self limited and resolves by late teenage
or early adult years
Treatment is warranted during periods of disease activity to
alleviate disfigurement, enhance well being and prevent
scarring.
Referral to dermatology is recommended after failure to
respond topical and/or oral therapies after 2-3 months of
appropriate use
Severe acne with presence of nodules, cysts and/or scarring
Treatment
Conclusion

Thanks for your time !!!