ACNE By Sapna Prabhakaran, MD
Dec 26, 2015
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 presenttx: topical 2.5% benzoyl peroxide or topical 2% erythromycin solution or gel or topical retinoids such as adaplene
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
Acne Vulgaris
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)
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 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
Pathophysiology Factors
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
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
Signs and Symptoms
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
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.
Treatment
WHERE DRUGS ACT
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
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,
anti-proliferative 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: 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
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
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 !!!