Acne

1. Acne By Sapna Prabhakaran, MD

2. Objectives • Types • Diagnosis • Treatments

3. 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

4. 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

5. 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)

6. 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

7. 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

8. NORMAL PILOSEBACEOUS UNIT

9. MICROCOMEDONE

10. WHITEHEAD (CLOSED)

11. BLACKHEAD(OPEN)

12. PAPULE

13. PUSTULE

14. CYST

15. 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

16. 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 grey-brown hyperpigmentation • Pigmentary lesions may persist for many months

17. 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

18. 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

19. Treatment

20. 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

21. 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.

22. WHERE DRUGS ACT

23. BENZOYL PEROXIDE • Antibacterial and mild comedolytic • Ubiquitous treatment for inflammatory and non-inflammatory 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

24. 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

25. 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

26. TOPICAL ANTIBIOTIC • Clindamycin • Antibacterial • Risks: irritation, rare report of pseudomembranous colitis • Formulation: gel,lotion and newer foam (Cleocin)

27. 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

28. TRIAZ • Benzoyl peroxide, glycolic acid, zinc • Anti-microbial, anti-comedonal • 3, 6 and 9% • Less irritation • Also successful in pseudofolliculitis barbae

29. BENZACLIN • BP 5%-clindamycin combination • Maybe used in lieu of oral antibiotics in mild papular, pustular acne • Benzamycin (erythromycin/BP combination) • Duac (clinda/BP)

30. ZIANA • Clindamycin/tretinion combo • Antibacterial/comedolytic • Risks: irritation, GI effects of clinda • Expensive

31. ADAPELENE (DIFFERIN) • Synthetic napthalene retinoid derivitive • Anti-comedones, some anti-inflammatory • Risks: irritation 10-40%; photosusceptible, hyperpigmentation

32. RETIN A-MICRO • Different formulation of Retin-A • Anti-comedonal with less irritation

33. TAZAROTENE (TAZORAC) • Retinoid derivitive • Anti-comedonal, anti-inflammatory, anti-proliferative • Also used in psoriasis • Irritation 10-30%; • Start brief contact, 2-5 minutes BID

34. AZELAIC ACID (AZELEX) • Dicarboxylic acid • Antimicrobial, anti-keratinization • Decrease hyperpigmentation • 20% Cream BID dosing • Useful in pts that prone to hyperpigmenation

35. ORAL AGENTS

36. MINOCIN (MINOCYCLINE) • Special acne indication • 50mg BID dosing • Risks: gray-blue discoloration of skin; hepatitis; lupus like illness

37. DOXYCYCLINE • Low dose formulation • Periostat 20mg BID • Likely anti-inflammatory effect • More expensive than regular hight dose doxy

38. BACTRIM • DS BID used 2-3 months • Moderate severe cases • Consider prior to using accutane

39. ZITHROMAX • Pavone-Italy: • 500mg qd x 3 days, then 7 days off, for 3 cycles • Schachner, Miami: • Z-pak x 5days, then 1 month off • Elewski, Miami: • Z-pak during menstrual flares

40. 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

41. ORAL CONTRACEPTIVES

42. OCP • Ortho-tri-cyclen, Yaz, Yasmin • Risks: nausea, vaginal bleeding • Consider using in mod-severe inflammatory acne • Trial prior to Accutane

43. 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

44. Treatment

49. Conclusion • Thanks for your time !!!