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Acne

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Acne

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  1. Acne Preeti Matkins MD, FSAHM Director, Adolescent Medicine Levine Children’s Hospital 11/2011 Adapted from Kristin M. Rager, MD, MPH 2009

  2. Acne • Estimated that • 85% of teens are affected • Up to 50% of adults • Can cause significant damage to mood, self-esteem, social interaction • If you fix acne, your patients will really like you!

  3. Tell me what you are using right now for your skin…

  4. You can help me fix this???? Not this fast Not this slow

  5. Disorder of Pilosebaceous Follicle

  6. COMEDONES INFLAMMATORY PAPULES, PUSTULES, NODULES

  7. Propionibacterium Acnes • Normal skin flora, but proliferates in sebum • Releases chemotactic factors which attract neutrophils • Hydolyzes lipids into free fatty acids • Ruptures follicular epithelium causing inflammation

  8. Acne Progression About 8 weeks

  9. Types of Lesions

  10. Noninflammatory Acne -Open Comedones They are black because of exposure to air

  11. Noninflammatory Acne – Closed Comedones The top is “on” (sebum accumulation)

  12. Inflammatory Lesions

  13. Acne Severity

  14. Acne Severity MILD MODERATE SEVERE

  15. Best just to describe what you see in your note… Quantify (rare, numerous, extensive), type and location of lesions, scarring, postinflammatory pigment changes

  16. Not just on the face!

  17. Describe inflammatory Open comedomes Closed comedomes

  18. Describe

  19. Describe

  20. Describe

  21. Treatment • Many options • Engage patient in deciding which one he/she wants • Depends on • Type of lesions • Severity (scarring/cystic) • Dry or Oily skin • Skin sensitivity • In women, presence of hyperandrogenism

  22. Treatment - Mechanisms of Action

  23. TOPICAL Adapalene Azelaic Acid Benzoyl Peroxide Antibiotics Tazarotene Tretinoin ORAL Isotretinoin Antibiotics Contraceptives Current Acne Treatments

  24. Comedones only (mild or no inflammation) Topical retinoids are the treatment of choice* • Tretinoin • Adapalene • Tazarotene *2008 Acne Treatment Guidelines Am Academy of Dermatology

  25. Topical Retinoids • Increase turnover of epithelieal cells inhibit keratinization and comedome formation • Resolve mature comedones • Anti-inflammatory properties with macrophage that inhibit cytokine inflammatory response • Likely to promote remission of acne secondary to prevention of new lesion formation • Likely to enhance penetration of other topical drugs

  26. Topical Retinoids • Should be applied to entire affected areaQHS (can use QOHS if irritation)* • Can combine with antibiotics and/or benzoyl peroxide when inflammatory lesions are present • Sides of peeling, dry skin, burning, stinging, erythema, pruritis • No matter the pigmentation-Must use sunscreen! *tretinoin is light sensitive

  27. Topical RetinoidsSide Effects • Dry skin • Erythema • Irritation • Can be managed by changing : • Base • Dosing (qohs) Or change medication

  28. Topical Tretinoin (Retin-A, Retin-A Micro) • 0.025% and 0.01% gel (alcohol base) • cost for 45g $113-165 • 0.025%, 0.05%, 0.1% Cream (alcohol base) • cost for 45g $171-208 • Retin-A Micro (0.04%, 0.1% gel) • Less irritating than tretinoin regular • Don’t have to wait 20 minutes after washing face • cost for 45g 0.1% $241 All cost from epocrates.com 11/20/11

  29. Adapalene (Differin) • Equal efficacy to tretinoin/better tolerated • Tretinoin may have results faster • Selective binding to retinoid receptors • Less sensitive to light breakdown • 0.1% cream and gel • 0.3% cream • cost for 45g $250-300

  30. Tazarotene (Tazorac) • Initially approved for psoriasis • Prodrug effects retinoic acid receptors • Decrease inflammatory markers • Perhaps better efficacy than Tretinoin or Adapalence, but worse irritation • 0.05% or 0.1% gel or cream • cost for 30g $210-250

  31. Salicylic acid Nonprescription solutions, cleansers, soaps Azeleic acid May help with postinflammatory hyperpigmentation Safe in pregnancy Useful for patients who are unable to tolerate the topical retinoids Other Comedolytic Topical Agents

  32. Inflammatory AcneMild to Moderate • Benzoyl peroxide (BP) or a combination of BP plus a topical antibiotic is treatment of choice • Combination therapy is more effective than monotherapy for patients with acne that has progressed from predominantly comedonal to increasingly inflammatory lesions • Do not use BP in colitis, IBD • Combo therapy reduces antibiotic resistance

  33. Benzoyl Peroxide • Antibacterial and comedolytic • Anti-inflammatory • Apply to entire affected area • Start QD, can advance to BID • Most will experience mild erythema and scaling with treatment, but that this will decrease in 1-2 weeks • 2% develop contact allergy

  34. Benzoyl Peroxide • 5, 6.5, 8.5, 10% cream • 2.5, 4.5, 5, 6.5, 8.5, 10% gel cost generic $10-25 • 5, 10% lotion • 2.5, 4, 4.5, 5, 6.5, 8, 8.5, 10% wash cost 60g $110 • Lotions and creams are less irritating than gels • Wash great for those who don’t want “creams” • Can cause bleaching of the hair and clothing

  35. Topical and Oral Antibiotics

  36. Antibiotics • Eliminate P. acnes from the sebaceous follicles and thereby suppress inflammation • Should not be used as monotherapy • Generally well-tolerated • Topical or oral • Topical sufficient with mild to moderate inflammatory acne • Offer oral to those with acne on non-face

  37. Topical Antibiotics • When used BID are as effective as oral • Erythromycin or Clindamycin • Significantly more effective when combined with BP • Benzamycin (BP 5%/3% erythro gel) cost generic 46.6 g $58-100 • Benzaclin (BP 5%/1% clinda gel) • Duac, Acanya • cost 50 g $110-149; (generic $5-25 online patient reports)

  38. BP + Topical Antibx Benza-Clin Duac Acanya Benza-mycin Retinoids+ Topical Antibx Retinoids + Clinda Veltin Ziana cost 60 g $452 Retinoid + BP Epi-Duo cost 45g $260 • 2 Topicals? • Combo vs Monotherapy may reduce inflammation • and # comedomes more quickly • Addresses: Direct cornefication, P acnes, Inflammation What are the Combo Meds?

  39. Oral antibiotics • May produce more rapid clinical improvement than topical, but may induce vaginal candidiasis, or cause GI distress, give rise to resistance to P. acnes • Daily over 3 to 6 months, with subsequent tapering and discontinuation as acne improves • Topical retinoids and/or BP may help maintain improvement once antibiotics are discontinued

  40. Oral antibiotics • Tetracycline- start at 500 bid • empty stomach b/c absorption is inhibited by food, dairy products, antacids, and iron • Doxycycline-start at 50 or 100 bid • less expensive and as effective as minocycline, photosensitivity, can take whenever with food *No recommendation for Azithromycin due to resistance

  41. Oral antibiotics • Minocycline -start at 50 or 100 bid • Expensive, vertigo, pseudotumor cerebri, tooth discoloration, and a lupus-like syndrome • Erythromycin -start at 500 bid • Less effective, higher rates of resistance, GI sides

  42. Oral Antibiotics plus topical retinoids • Clearing of acne is faster and greater • Add topical retinoids early—at the onset of therapy—for greatest and fastest results • Antibiotic should be discontinued when inflammatory lesions resolve adequately • Maintain success by continuing topical retinoid after antibiotic discontinued

  43. Hormonal Therapy

  44. Hormonal Therapy • Great if also in need of contraception • Use early in females with moderate to severe acne • Increases SHBG, therefore decreasing circulating androgens • Works even if not hyperandrogenic • Ortho tri-cyclen is only OCP to seek acne as an indication (but no better than any other)

  45. Hormonal Therapy – 2004 Cochrane Review • “The three oral contraceptives evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few differences were found in acne effectiveness between oral contraceptive types“

  46. Oral Isotretinoin

  47. Oral Isotretinoin • Targets all pathophysiolgic factors • May achieve dramatic results even in severe disease • Common side effects: dry skin, eyes, nose, lips • Education vital –major teratogenicity!! • Refer to Derm if you think a patient needs • Must be an FDA registered prescriber

  48. Other therapies • Light therapy • Tea Tree Oil • Antibacterial? • Descicant? • Sodium Sulfacedamide • Grapefruit • cleansers (antbacterial?) • Seed extract often used for rosacea • Dapsone • Many combo agents are OTC strength packaged as a “system”

  49. What is Proactiv? • “Renewing cleanser” 2.5% benzoyl peroxide • “Revitalizing toner” no active ingredient but does contain witch hazel • “Repairing lotion” 2.5% benzoyl peroxide • Use all bid • $39.95 for 2 m supply