Acne Justin Walker October 2009. Classification Mild to moderate Plugged pores Plugged pores Sebum collection Sebum collection Moderate to severe.

AcneAcne

Justin WalkerJustin Walker

October 2009October 2009

ClassificationClassification

Mild to moderateMild to moderate Plugged poresPlugged pores Sebum collectionSebum collection

Moderate to severeModerate to severe Propionibacterium acnesPropionibacterium acnes Inflammation, pustulesInflammation, pustules Cysts, nodules, scarringCysts, nodules, scarring

Other causesOther causes PCOSPCOS Halogenated hydrocarbonsHalogenated hydrocarbons

DifferentialsDifferentials

DifferentialsDifferentials

RosaceaRosacea Older age groupOlder age group Absence of Absence of

comedones, nodules comedones, nodules and scarringand scarring

DifferentialsDifferentials

DifferentialsDifferentials

FolliculitisFolliculitis Infected hair follicle, Infected hair follicle,

responds to abx.responds to abx. NB demodex folliculitis NB demodex folliculitis

caused by mites, caused by mites, pityrosporum folliculitis pityrosporum folliculitis caused by yeasts.caused by yeasts.

DifferentialsDifferentials

DifferentialsDifferentials

Perioral dermatitisPerioral dermatitis Distribution!Distribution! Associated with Associated with

fluorinated steroids.fluorinated steroids.

What makes it worse?What makes it worse?

Progesterone only pillProgesterone only pill Hormone changes with periodsHormone changes with periods Make upMake up Picking and squeezingPicking and squeezing Humid environment/sweatingHumid environment/sweating Tight clothingTight clothing Drugs – phenytoin, steroid creamsDrugs – phenytoin, steroid creams Anabolic steroidsAnabolic steroids

MythsMyths

Poor hygienePoor hygiene DietDiet StressStress Water intakeWater intake SunshineSunshine Cannot be curedCannot be cured

Topical TreatmentsTopical Treatments

Benzoyl peroxideBenzoyl peroxide Available over the counterAvailable over the counter Good for comedones & infected lesionsGood for comedones & infected lesions 2.5-10% available, start low and increase as 2.5-10% available, start low and increase as

toleratedtolerated Wash skin beforehand, wash off after several Wash skin beforehand, wash off after several

hourshours Start od, bd if tolerated.Start od, bd if tolerated.

Topical TreatmentsTopical Treatments

Topical RetinoidsTopical Retinoids Adapalene, tretinoins and isotretinoinAdapalene, tretinoins and isotretinoin Unblock pores, reduce inflammationUnblock pores, reduce inflammation S/E: skin redness and peeling, sun sensitivity S/E: skin redness and peeling, sun sensitivity

– apply at night and wash off in morning.– apply at night and wash off in morning. Use lower strength if not tolerated.Use lower strength if not tolerated. Avoid in pregnancy – discuss contraception!Avoid in pregnancy – discuss contraception!

Topical TreatmentsTopical Treatments

Topical antibioticsTopical antibiotics Erythromycin and clindomycinErythromycin and clindomycin Good for inflammation but don’t unblock poresGood for inflammation but don’t unblock pores Local guidelines recommend topical for those Local guidelines recommend topical for those

who cannot tolerate oral.who cannot tolerate oral. Can use with short courses benzoyl peroxide/ Can use with short courses benzoyl peroxide/

azelaic acidazelaic acid Topical abx need to be used for 6 months.Topical abx need to be used for 6 months.

Topical TreatmentsTopical Treatments

Azelaic acidAzelaic acid Unblocks pores, some reduction of inflamed acneUnblocks pores, some reduction of inflamed acne Less effective than topical antibiotics or benzoyl Less effective than topical antibiotics or benzoyl

peroxideperoxide

Oral TreatmentsOral Treatments

AntibioticsAntibiotics Reduce inflammation, Reduce inflammation, Not good at unblocking pores – may need Not good at unblocking pores – may need

concommitant topical bp/aaconcommitant topical bp/aa Local guidelines: doxycycline, lymecycline, Local guidelines: doxycycline, lymecycline,

erythromycinerythromycin Use for 3 months and reviewUse for 3 months and review Tetracyclines: not for under 12s, not in pregnancy – Tetracyclines: not for under 12s, not in pregnancy –

discuss contraception. Women on cocp need discuss contraception. Women on cocp need additional precautioins for first 3 weeks.additional precautioins for first 3 weeks.

Oral TreatmentsOral Treatments

IsotretinoinIsotretinoin Suppresses sebum productionSuppresses sebum production Specialist initiationSpecialist initiation TeratogenicTeratogenic S/E dry skin/mucous membranes, S/E dry skin/mucous membranes,

nosebleeds, joint painsnosebleeds, joint pains Minimum course 16 weeks.Minimum course 16 weeks.

Oral TreatmentsOral Treatments

Co-cyprinidolCo-cyprinidol Cyproterone acetate with ethinylestradiol aka DianetteCyproterone acetate with ethinylestradiol aka Dianette Contains anti-androgenContains anti-androgen Same effectiveness as oral broad spectrumSame effectiveness as oral broad spectrum Useful if a woman also requires oral contraception, Useful if a woman also requires oral contraception,

although not licensed as a contraceptive.although not licensed as a contraceptive. Increased risk of venous thromboembolismIncreased risk of venous thromboembolism Use only in women with severe acne and hirsutismUse only in women with severe acne and hirsutism

When to Refer?When to Refer?

Immediate referralImmediate referral Acne fulminansAcne fulminans

Urgent referralUrgent referral Severe/Nodulocystic acne and may benefit from oral Severe/Nodulocystic acne and may benefit from oral

isotretinoinisotretinoin Severe psychological/social problemsSevere psychological/social problems

Routine referralRoutine referral At risk of or are developing scarring despite therapyAt risk of or are developing scarring despite therapy Moderate acne failing to respond (2 x 3 month Moderate acne failing to respond (2 x 3 month

courses abx)courses abx) Possible underlying endocrinological cause eg PCOSPossible underlying endocrinological cause eg PCOS

Acne fulminansAcne fulminans

Thank you!Thank you!