25/11/2016 1 Deepani Rathnayake MBBS, MD, FACD Acne Affects >80% of adolescents >40% of adults Associated with Disfigurement Loss of confidence Depression Affects quality of life Chronic disease with recurrent relapses Pathogenesis i) increased sebum production, presents as seborrhea (ii) hypercornification of the pilosebaceous duct, Initially microcomedones, later open and closed comedones (iii) colonization of the duct with Propinebacterium acnes, (iv) inflammation‐ leading to papules pustules, nodules and cyst
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25/11/2016
1
Deepani Rathnayake
MBBS, MD, FACD
Acne
Affects >80% of adolescents
>40% of adults
Associated with Disfigurement
Loss of confidence
Depression
Affects quality of life
Chronic disease with recurrent relapses
Pathogenesis
i) increased sebum production, presents as seborrhea
(ii) hypercornification of the pilosebaceous duct, Initially microcomedones, later open and closed comedones
(iii) colonization of the duct with Propinebacteriumacnes,
(iv) inflammation‐ leading to papules pustules, nodules and cyst
25/11/2016
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Contributing factors
?Stress
?Diet
Glycemic load,
Occupation( exposure to coal tar, Oil, halogenated hydrocarbons)
Bactericidal, comedolytic and anti inflammatory action
Bactericidal against both sensitive and resistant P acnes ( release free oxygen radicals)
Adverse effects Irritation
Bleaches clothing and hair
( Benzoyl peroxide wash , use white towel, pillow cases)
Azeleic acid ( 15% gel, 20% cream, 20% lotion)
Antibacterial
Improve post inflammatory hyperpigmentation
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If topical Rx not effective, in moderate to severe acne
oral antibiotics
oral isotretinoin
hormonal
Oral antibiotics
Doxycycline
Minocycline
Erythromycin
Azithromycin
Doxycycline
50mg ‐100mg daily
Effect evident after 6‐8 weeks
prescribe for 3 months initially
Side effects – photosensitivity, thrush, gastrointestinal discomfort
Better combine with Benzoyl peroxide +_ topical retinoids
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Minocyline 50‐100mg daily
Prescribe for 3 months initially
Side effects
Less photosensitivity compared to Doxycycline
Drug hypersensitivity syndrome
Autoimmune reaction
Dizziness and headaches
Blue pigmentation of skin ,nails after prolong use
Erythromycin
250‐500mg daily
If planning pregnancy
In Children
Combination with Roaccutane
Duration of antibiotics Effect after 6‐8 weeks
Try for 3 months
Reduce dose and maintain
If relapse‐ need Roaccutane or Hormonal treatment
Unlikely to cure acne
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Antibiotic resistance To Propionibacterium acnes – can reduce efficacy of RX
Can be transferred to close contacts
To reduce
Adding Benzoyl peroxide with antibiotics ( effective for resistant P. acnes)
Avoid antibiotics as monotherapy
Isotretinoin
Most effective treatment , cure acne
Reduces sebum production
Normalizes follicular keratinization
Decreases inflammation
Indications Severe acne
Mild to moderate acne , with evidence of scarring
Relapse after antibiotics, hormonal treatments
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Case 121 year old female with acne in the chin and jaw line for 2 yrs, Also has irregular periods
1. What is the clinical diagnosis?.
2. What are the important factors you would check in the history and examination.?
3. What investigations would you do.?
4. How would you treat this patient.?
1. Hormonal acne
2. History‐ Irregular periods, premenstrual flair
examination‐ acne more in the jaw line, chin,
Seborrhoea, Hirsutism, FPHL,
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3.Initial tests should be done in 2nd half of the cycle, stop the pill for at least 4 weeks, Total testosterone, ( very high levels suspect ovarian tumour) Follicle‐stimulating hormone (FSH) and luteinizing hormone
(LH). (LH/FSH ratio can be elevated in PCOD) Serum dehydroepiandrosterone sulphate (DHEAS) (adrenal
source) (DHEAS greater than 21.7 µmol/L may have an adrenal tumor)
Serum insulin levels‐ high levels indicate insulin resistance and later risk of DM
Anti – Mullerian Hormone(AMH) – for PCODcan be done any day of the cycle, even while on the pill
Levels‐PCOD‐ Over 4ng/mlNormal‐ 1.5‐4 ng/mlLow‐ 0.5‐1 ng/ml
Rx Spironolactone
Cyproterone acetate
Contraceptive pills
containing ethinylestrodiol (oestrogen) and an antiandrogenic progesterone
cyproterone acetate (Diane™‐35, Estelle™ 35 and Ginet‐84™)