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Acne Vulgaris and Rosacea Dr. Lyn Guenther University of Western Ontario Objectives State the incidence of acne • Discuss the psychosocial impact of acne & scarring • Discuss the pathophysiology of acne • Differentiate acne vulgaris from rosacea • Elicit a history and perform a relevant examination • Give an approach to acne and rosacea treatment from mild to severe • Acne vulgaris Incidence: 95% • Scarring • - In 95% seeing a dermatologist for the first time - Increased with: Squeezing • Inflammatory lesions • Longer disease duration • Psychological Scarring • QOL studies: - Social, psychological & emotional deficits comparable to: • Asthma Epilepsy • Diabetes Mellitus • Back Pain • Arthritis • Pilosebaceous Unit Sebaceous Gland • Sebum • Follicle • Arrector Pili Muscle • 900 glands/cm2 on face, back, chest <100 glands/cm2 on rest of body Pathogenesis of Acne Abnormal Keratinization (genes) • Androgens cause increased sebum production • Propionibacterium acnes • Inflammation • Acne Vulgaris Pathophysiology Microcomedones Accumulation of Sebum Closed/Open Comedones(non-inflammatory acne) Proliferation of P. acnes Infiltration of neutrophils Ruptured comedones Papules, Pustules, Cysts (inflammatory acne) Acne vulgaris - History Age of onset • Family history of acne • Location and severity of lesions • Scarring • Psychosocial impact • Menses/Contraceptive use • Moisturizer and foundation • Medications & Drug Allergies • Current and Past treatment including response and A/E’s • Physical Examination: Scarring and Pigmentary Changes Scarring: depressed / ice pick / saucer / keloid Excoriations Hyper / hypo-pigmentation Lesion Morphology Non-inflammatory Comedonal Inflammatory Papules / pustules Nodules / cysts Acne Lesions Comedones Papules & Pustules Cysts Acne vulgaris - Why treat? Improve appearance • Minimize scarring • Eliminate discomfort of inflammatory lesions • Reduce psychological consequences • Acne vulgaris - Dispel myths • Acne is NOT caused by: - Chocolate - Fried or fatty food - Too much or too little sex - Dirt - Wrong kind of soap • Not contagious Acne vulgaris - Aggravating Factors Stress • Lack of sleep • Tight headbands/helmets • Grease-filled environments • Heavy makeup while exercising • Premenstrual in some • Acne vulgaris - Cleansing Wash BID • Lukewarm water • Mild cleanser • No abrasives • No scrubbing • Don’t squeeze • Acne vulgaris Moisturizers and Foundation Non-comedogenic • Non-acnegenic • Treatment Guidelines Non-scarring acne * Comedones: Retinoid * Tretinoin cream .01-.05% daily or * Tazarotene cream/gel or * Differin cream/gel * Papules/Pustules * Topical antibiotic B.I.D. * Benzoyl peroxide 5% daily * Antibiotic/benzoyl peroxide * Oral antibiotics * Hormonal agents for women desiring oral contraception ANTIBIOTIC Tetracyclines Tetracycline DOSE 500 mg B.I.D. Minocycline 100 mg/day Doxycycline 100 mg/day Erythromycin 500 mg B.I.D. Trimethoprim 100 - 200 mg/day NOTES *Avoid in pregnancy or children < 8 years *Take on empty stomach *G.I. irritation *May be taken with food *Dizziness may develop at higher dos es *Pigmentary changes *May be taken with food *Phototoxicity a potential problem *Safe in pregnancy and for children *May caus e G.I. Ups et *Useful in those resistant to other antibiotics Hormonal Therapies for Acne Diane-35® cyproterone acetate/ ethinyl estradiol Ortho -Tricyclen® norgestimate/ ethinyl estradiol Alesse® levonorgestral/ ethinyl estradiol Yasmin ® drospirenone-ethinyl estradiol Treatment Guidelines Severe or Scarring acne Isotretinoin: * 0.5mg/kg/day for the first 2-4 weeks * 1 mg/kg /day for the next 4-5 months to a total cumulative dose of 120-150 mg/kg * 80% have long-term drug free remission * 20% require a second course * patients unable to take isotretinoin should be given topical therapy combined with systemic antibiotics or hormonal agents Isotretinoin Sebaceous follicles Decreases sebum production within 2 weeks • Corrects follicular hyperkeratinization • Decreases growth of P. acnes • Decreases inflammation • Pre-Accutane On Accutane Isotretinoin Contraindication: Absolute: Pregnancy (see Pregnancy Prevention Program™) • Relative: • History of pre-morbid depression • History of hypertriglyceridemia/ hypercholesterolemia • Pre-existing liver disease Accutane use and pregnancy • Isotretinoin is a potent teratogen - >25% risk of fetal malformation. Reported pregnancy rate on Accutane<1% • - Average age: 26 years. • Reasons for these pregnancies: - abstinence unsuccessful - use of ineffective method of contraception - contraceptive used inconsistently - unexpected sexual activity - failure of contraceptive method Pregnancy Prevention Program™ Two negative pregnancy tests required before starting Accutane • - Initial visit & day 2-3 of next period • Two effective forms of birth control - one primary and one secondary • Begin therapy on 2nd or 3rd day of next menses Pregnancy Prevention Program™ • One month prescription only • Monthly pregnancy testing • Monthly contraceptive counseling • Initial Consent form • Patient Information booklet Effective Forms of Contraception Primary • Tubal ligation • Partner’s vasectomy • Birth control pills • Injectable/implanted hormones • IUD Secondary • Diaphragms with spermicide • Latex condoms with spermicide • Cervical caps with spermicide Isotretinoin Adverse Events Cheilitis 96% • Dermatitis 55% • Dry nose 51% • Eye irritation 11% • Joint pain 13% • Depression rare • Elevated TG (25%) & cholesterol (7%) • Elevated liver enzymes (15%) • Isotretinoin and Psychiatric Events Depression Isotretinoin Use Suicide/attempt 10-13 per 1-1.7 per 100,000 patients 100,000 patients (1982-2000) 20 per 20,000 per USA General 100,000 patients 100,000 patients Pop’n (CDC 1980-92) Isotretinoin Mucutaneous adverse events: • Chapstick • Lubricants Lab monitoring: • CBC, liver function and fasting lipids • Pregnancy test Case studies Case 1 Washes with apricot scrub • Has tried numerous other cleansers • Has stopped eating chocolate • No other treatment • • Case 2 Won’t socialize • Regular menses • Not sexually active • No prior treatment • Case 3 Oily skin • Seborrheic dermatitis • Plucks facial hair • Irregular menses • Proactive-No help • Case 4 Acne lesions hurt • Tetracycline 500 mg BID for 6 months, then • Minocycline 100 mg BID for 8 months • Differin gel x14 months • Rosacea ~10% of Canadians affected • Women: Men=2:1, but men more prone to rhinophyma • Celtic descent • - Uncommon in Africans & Asians • Onset usually after age 30 - Peak: 4th to 7th decade - Rarely in children Konshik PC et al. Dermatol Clin 1992;10(3):533-47 Rosacea Pathophysiology Genetic • Abnormalities of cutaneous vasculature • - Dysregulation of thermal mechanisms • Dermal matrix degeneration - Poor connective tissue support for cutaneous vessels • Infectious organisms - Demodex - Helicobacter pylori Excess of canthelicidins and protease stratum corneum tryptic enzyme (STCE) in facial skin • Yamaski K et al. Nat Med 2007;13:975-80 Rosacea Pathophysiology • Murine model: - Injection of cathelicidins found in rosacea or addition of SCTE → skin inflammation - Deletion of the serine protease inhibitor gene Spink5 → protease activity → skin inflammation - TCN + Minocycline indirectly inhibit serine proteases and work even in the face of bacterial resistance Hypothesis: Increase in local antimicrobial peptide expression may change the normal skin microflora in rosacea Yamaski K et al. Nat Med 2007;13:975-80 Rosacea affects QOL • Recent Canadian Survey (n=1271): - Social life affected in 36% • 16% of all respondents declined a social invitation due to rosacea symptoms Lower self esteem • Affects professional interactions • Rosacea: Skin changes • Symmetric over convexities of central face - nose, cheeks, chin, central forehead Occ. on neck, scalp, chest • Very rarely on back and limbs • Rosacea: Skin changes • Primary features: - Flushing: Usually lasts > 10 minutes • Sparing of periocular skin • Often assoc. with burning, stinging • - Persistent Erythema - Telangiectasia - Papules, pustules (follicular and nonfollicular) ……..NO COMEDONES Rosacea: Skin changes • Secondary features: - Burning or stinging - Lowered threshold for irritation from topical substances - Plaques - Dry appearance - Edema (e.g. periorbital, glabellar, malar) • Acute, chronic recurrent, chronic persistent • Pitting or non-pitting - Ocular - Peripheral location (neck, chest, scalp, ears, back) Subtypes of Rosacea 1. 2. 3. 4. Erythematotelangiectatic Papulopustular Phymatous Ocular Phymatous Variant Men • Erythematous, irregularly swollen, bulbous, dilated pores, telangiectasia • - Rhinophyma (nose) - Metophyma (forehead) - Gnathophyma (chin) - Blepharophyma (eyelids) - Otophyma (ears) Aloi F et al. JAAD 2000;42:468-72 Rosacea-Ocular • 50% of patients • 6th-7th decade (later than skin) • Women=Men • Onset with skin:2 - 53% skin first - 20% eyes first - 27% together • Strong correlation with flushing3 1. Barankin B, Guenther L. Can Fam Physician. 2002;48:721-4. 2. Borrie P. Br J Ophthalmol 1953:65:458. 3. Wilkin JK. Int J Dermatol 1983;22:393-400. Rosacea-Ocular Dry, gritty eyes, itching, burning, tearing, blurry vision, photophobia • Blepharitis (93%), conjunctival hyperemia (86%), conjunctivitis, keratitis, superficial punctate keratopathy (41%), keratoconjunctivitis sicca (up to 40%) corneal vascularization ulceration and perforation, iritis (20%), chalazion (22%) • ~ 60% of patients with chalasion have rosacea • Barankin B, Guenther L. Can Fam Physician. 2002;48:721-4. Rosacea Triggers • Food: - Hot food - Spicy food - Tomatoes - Chocolate - Yogurt, sour cream,cheese Alcohol • Hot and cold temperatures • Wind • Exercise • Stress • Rosacea Triggers • Drugs:1 - Corticosteroids - Amiodarone • Rosacea + multiple chalazia2 - Epidermal growth factor receptor inhibitors - High dose vitamin B6 and B12 1. 2. Crawford GH et al. JAAD 2004;51:327-41 Reifler DM et al. Am J Ophthalmol 1987;103:594-5 Rosacea Treatment Avoid triggers • Flushing: • - Clonidine 0.05 mg OD→BID - Green moisturizers • Telangiectasia - Vascular lasers (e.g. pulsed dye, KTP, 532 and 810 light-emitting diode (LED), Alexandrite, Nd-TAG, IPL alone or with PDT) Rosacea Treatment: Topical Mild cleansers • Sunscreen: titanium dioxide & zinc oxide well tolerated • Topical • - Metronidazole - Azelaic acid 15% (Finacea) - Sodium sulfacetamide 10%/sulfur 5% - Clindamycin - Dapsone - Pimecrolimus/Tacrolimus - +/- BP, VAA (phymatous rosacea; may irritate) • Eye: - Warm soaks, dilute baby shampoo - Topical steroids (ophthalmologist) - Artificial tears: Rosacea Treatment: Oral • Oral antibiotics (skin + eye) - Tetracyclines: Tetracycline • Minocycline • Doxycycline • - Others: Erythromycin • Clarithromycin • Azithrmycin • Metronidazole • Dapsone • Isotretinoin (skin including phymas + eye) • Rosacea Treatment: Rhynophyma Medical: Isotretinoin • Surgical: • - Ablative lasers - Shave excision - Cryosurgery - Electrosurgical loops to shave off excessive tissue, then fine tune with dermabrasion www.rosaceainfo.com