Presentation on theme: "Acne Vulgaris Updates on Approach to Treatment Frank Morocco D. O"— Presentation transcript:
1 Acne Vulgaris Updates on Approach to Treatment Frank Morocco D. O Acne Vulgaris Updates on Approach to Treatment Frank Morocco D.O. December 8, 2012
2 Acne VulgarisMost common skin disease presenting to primary care physicans.Chronic disease for some patientsDon’t underestimate the social and psychological effect of acne on patientsAcne is not necessarily a rite of passage20% of
3 PathophysiologyFour primary pathogenic factors which interact in complex mannerSebum production by the sebaceous glandP. acnes follicular colonizationAlteration in the keratinization processRelease of inflammatory mediators into the skinOther factorsAndrogens, stress, occupational exposure, underlying metabolic abnormalitiesTreatment should target these pathogenic factorsThiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
4 Clinical Features Non-inflammatory Lesions Inflammatory Lesions Open comedones (blackheads)Closed comedones (whiteheads)Inflammatory LesionsPustules/papulesNodulesCystsHelp determine treatment modalities
7 Treatment Choice of treatment depends on Evaluate patient Type of acne SeverityAgeLocationPatient preferenceEvaluate patientCurrent medications, allergiesMenstrual historyTanning habits, hobbiesExpectations, myths, fearsScarringPregnancy
8 Treatment Approach should be multi-therapy, not monotherapy Topicals AntibioticsRetinoidsBenzoyl peroxideCombination therapiesOther therapiesOral therapyIsotretinoinAdjunctive therapyHormonal/anti-androgen therapyChemical peelsScar treatment
9 Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
10 Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne Moderate-Severe InflammatoryAcnePregnantAzelaic Acid (Cat B)Clindamycin Lotion (Cat B)Topical TherapiesRetinoidsAntibioticsSalacylic AcidBPO+/- WashesOral antibioticsTetracyclinesAdjunctive TherapiesSevere or ScarringIsotretinoinAdjunctive TherapiesOCPs, chemical peels,anti-androgensFailure of oralantibiotics
11 Treatment ApproachEarly, appropriate treatment is best to minimize potential for acne scarsCombination of a topical retinoid and antimicrobial agent remains the preferred approach for almost all patients with acneAttacks 3 of the 4 major pathogenic factors of acne: abnormal desquamation, P. acnes colonization, and inflammationRetinoids are anticomedogenic, comedolytic, and have some anti-inflammatory effectsBPO is antimicrobial with some keratolytic effects and antibiotics have anti-inflammatory and antimicrobial effectsThiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
12 Treatment ApproachTopical retinoids should be first-line agents in acne maintenance therapyAvoid contributing to antibiotic resistanceThiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
13 Benzoyl Peroxide Mechanism of action1 Advantages Formulations Bactericidal for P. acnesInhibits triglyceride hydrolysisDecreases inflammation of acne lesionsAdvantagesNo resistance demonstrated to date1When used in combination with a topical antibiotic can help to prevent resistance2Activity is enhanced when combined with other topicals (i.e. clindamycin)1,2FormulationsOTC & prescriptionWashes, gels, lotion, solution1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.2. Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J AmAcad Dermatol 2009;60:S1-50.
14 Retinoids Most important class of drugs used to treat acne Topical form of vitamin AMechanism of Action1Normalize follicular keratinizationAct on the microcomedoneProper instruction on application is essential to complianceGradual application with small amount of drug“Training for a marathon”1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
15 Retinoids “Least Irritating” (most tolerable) “Moderately Irritating” Adapalene gel (Differin® 0.1%, 0.3%)May be appropriate starting point for ethnic and/or sensitive skin“Moderately Irritating”Tretinoin (cream, gel)Tretinoin 0.01%, 0.05%, 0.025%Retin-A Micro® 0.1%, 0.04%Atralin™ Gel 0.05%Renova® 0.02%, 0.05%“Most Irritating” (least tolerable)Tazarotene (Tazorac®/Avage® 0.05%, 0.01%)Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
16 Topical Antibiotics Erythromycin Clindamycin phosphate 1% Azelaic acid Akne-mycin® 2% gel, Erygel ® 2% gel,Resistance of some P. acnes strainsUsage fallen out of favorClindamycin phosphate 1%Generic, Cleocin T® (lotion, gel, solution), Evoclin® foamAntibiotic-associated colitis very unlikelyWork best in combination with BPOGood choice for pregnant women (Pregnancy Category B)Azelaic acidFinacea™Bacteristatic/bactericidal against P. acnesWolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
17 Topical Antibiotics Sodium sulfacetamide/sulfur (10%/5%)1 Klaron® lotion, Plexion® line, Rosac® line, Clenia®Keratolytic effects, antibacterial for P. acnesUsed most commonly for rosaceaMetronidazole1Benefit for acne debatableMetronidazole lotion (generic), Metrogel 1%®Dapsone gel 5% (Aczone®)2Approved for moderate to severe acneBID dosingMay cause a temporary yellow or orange discoloration of skin and facial hair if used along with BPOLow risk of hemolytic anemia in G6PD deficient patients1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.2. Aczone® prescribing information. January 2009.
18 Combination Therapies Clindamycin/Benzoyl peroxideClindamycin phosphate 1%/benzoyl peroxide 5% (Benzaclin®Gel)Clindamycin phosphate 1%/benzoyl peroxide 5% (Duac®Gel)Clindamycin phosphate 1.2% /benzoyl peroxide 2.5% (Acanya™ Gel)Erythromycin/Benzoyl peroxideErythromycin 3%/benzoyl peroxide 5% (Benzamycin®)Retinoid/Benzoyl peroxideAdapalene 0.1%/benzoyl peroxide 2.5% (Epiduo™ Gel)Retinoid/ClindamycinTretinoin 0.025%/Clindamycin phosphate 1.2% (Ziana® Gel)Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
19 Oral Antibiotics Therapeutic role in acne Dosing Reduction of P. acnes Anti-inflammatory activityDosingStart high then taper down after control is achievedUse PRN during flaresDo not use as monotherapyWolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
21 How to Prevent Resistance Combine a topical retinoid plus an antimicrobialLimit the use of antibiotics to short periods and discontinue when there is no further improvement or the improvement is only slightCo-prescribe a BPO-containing product or use as washoutOral and topical antibiotics should not be used as monotherapyThiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.
22 Hormonal Therapy FDA-approved OCPs for acne Anti-androgens Ortho Tri-Cyclen®Estrostep®Yaz®Anti-androgensSpironolactoneDoses range between mgNot FDA-approved for acneMonitor side effects: menstrual irregularities, hyperkalemiaWolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
23 IsotretinoinApproved for the treatment of severe recalcitrant nodular acne in 1982Member of the Vitamin A familyEffects on acneNormalizes the keratinization processReduces sebocytes and secretionsReduces inflammationReduction in numbers of P. acnesWolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
24 Isotretinoin Pre-medication counseling Dosing 1-2 mg/kg/day Side EffectsContraceptionCompliance/duration of treatmentLaboratory monitoringiPledge registrationDosing 1-2 mg/kg/dayGoal mg/kg over course of treatmentWolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
33 Atopic Dermatitis “The itch that rashes” Hereditary skin manifestation; family history of eczema, asthma, and hay fever>50% of children with one atopic parents and 79% of children with both atopic parents develop allergic symptoms before 2yoDdx: seb derm, contact derm, scabies, and psoriasis
35 Atopic Dermatitis 3 Stages Infantile (2mos-2yrs): Risks: African and Asian races, males, greater gestational age at birth, Fam HX60% of atopic pts present 2mos-1yo. Disappear by 2yo.Usually begins as papular or exudative erythema and scaling of the cheeks, may extend to scalp, neck, forehead, wrists, extensor extremities. Plaques become lichenified.Become secondarily infected.Worsening after immunization or infection.Remission in summer (UV and humidity), relapse in winter (wool and dryness).Role of food allergy is contraversial; may be milk, eggs, peanuts, tree nuts, grains, fish, and soy. Some association with cow’s milk.
36 Atopic Dermatitis 3 Stages Childhood (2-10yrs): Lichenified, indurated plaques on the antecubital and popliteal fossae, flexor wrists, eyelids, face, and around the neck.Itching → scratching → secondary changes → itchIf >50% BSA, associated with growth retardation
37 Atopic Dermatitis Adult: Pruritus with heat or stress Localized, erythematous, scaly, papular, exudative, or lichenified plaques. Prurigo-like paps are common.Hyperpitmentation in dark skin with hypopitmentated healed excoriated lesionsOften antecubital and popliteal fossae, neck, forehead, and eyes.Older adults: chronic hand dermatitis (women after first child), worse with frequent wet exposure. r/o contact allergy.Usually improves with time, uncommon after middle lifeNew-onset in adulthood: HIV can be a trigger
38 Modified Criteria for Children with Atopic Dermatitis Essential FeaturesPruritusEczemaTypical Morphology and age-specific patternChronic or relapsing historyImportant FeaturesEarly age at onsetAtopyPersonal and/or family historyIgE reactivityXerosisAssociated FeaturesAtypical vascular responses (e.g. facial pallor, white dermatographism)Keratosis pilaris/ichthyosis/hyperlinear palmsOrbital/periorbital changesOther regional findings (e.g. perioral changes;periauricular lesions)Perifollicular accentuation/lichenification/prurigo lesions
39 Features Associated with Atopy Dennie-Morgan fold: linear transverse fold just below the lower eyelidProminent nasal crease“Normal” skin is subclinically inflamed, dry, scalyPityriasis alba: hypopigmentation with sclight scale on cheeks, upper arms, trunk in young children. Responsive to emollients and topical steroidsKeratosis pilaris: horny follicular lesions of outer aspects of upper arms, legs, cheeks, and buttocks; refractory to treatmentDirty neck appearance due to hyperkeratosis and hyperpigmentation
40 Features Associated with Atopy Perioral, perinasal, and periorbital pallorWhite dermatographismIncreased susceptibility of cataractsIncreased susceptibility of infection;Patients heavily colonized with Staph. Treatment of lesional skin reduces colonization even w/o ABXChronic suppressive ABX therapy may stabilize disease: Cephs, Bactrim, clinda, doxyEczema herpeticum: generalized herpes simplex, sudden vesicular, pustular, crusted or eroded lesions. Become secondarily infected.Eczema vaccinatum: widespread vaccinia infxnExtensive flat wart or molluscum; poor tolerance to Tx
42 Atopy: Pathogenesis Immunologic defects are the main component Th2 activation with IL-4, 5, 10, and 13. Elevated IgE and eosinophilia; impaired antiviral activity.Defects in barrier function with increased transepidermal water loss, correlating with disease severity. Increased TEWL in winter and in stress.Environmental factors: increased with increased hygeine and higher socioeconomic status. May have allergens to dust mites, grass pollens
43 Management of Atopy Infants and children: Avoid hot baths, alkaline soaps, vigorous rubbing and scrubbing.Short, once-a-day, tepid baths followed by a barrier cream using soak and smear; ointment bases are preferred.Immediate change of wet or soiled diapers.Nighttime sedating antihistamines for itchDietary restriction for a specific known antigen
44 Management of Atopy Adults Avoid temperature extremes Hydrate dry skin especially in winterAvoid overbathing and hot waterAvoid woolBiofeedback techniques for emotional stress
45 Topicals for Atopy Topical corticosteroids are the mainstay 1-2.5% hydrocortisone in infants. Monitor growth in infants and young children.Mid-potency (TAC) in older children and adults except on the face1-2x a day is enough to saturate receptors; more provides only emollient effectOcclusion increases penetration and receptor saturationMust be strong enough to control pruritus and remove inflammationRegular emollients: petrolatum, hydrophilic creams with ceremidesAnti-Staph therapy for acute flaresTopical calcineurin inhibitors
46 Systemics for AtopyAntihistamines for sedation: hydroxyzine, diphenhydramine, or clopheniramine.The nonsedating antihistamines do not relieve pruritusShort courses of anti-Staph ABX, topical mupirocin for nasal carriageSystemic steroids only for acute exacerbations, in short courses of 3 weeks or lessCyclosporin is usefule but expensive; symptoms recur on stopping medsImmunosuppressives and antiproliferatives (Immuran, Cellcept, MTX) can be effective for unresponsive dzPhototherapy: PUVA, UVA, narrow-band UVB, or Goeckerman with tar may be helpful
47 Atopy: Treating the Acute Flare Treat triggers and the precipitant of the flareShort course of systemic steroids3-4 days of home hospitalization:Bedrest and isolation of stressors with large doses of antihistamine at bedtimeDaily tub soaks followed by topical steroid ointment under wet pajamas and a sauna suit
48 EczemaBroad range of conditions beginning as spongiotic progressing to lichenifiedAcute: red edematous plaque with small grouped vesiclesSubacute: erythematous plaques with scale or crustingChronic: dry scale and lichenification
49 Regional EczemasEar: external canal most frequently affected. Earlobe = nickel allergy.Gentle lavage to remove scale and cerumen. Topical steroids if not infected.Eyelid: may be related to volitle chemicals, or transfer of allergen from hands.Allergic contact affects upper lids, atopic affects bothBreast/Nipple: Painful fissuring can occur, esp in nursing mothers. If >3 mos BX to r/o Paget’s
50 Hand Eczema Most commonly in atopic patients Complete H&P and patch testing to distinguish from atopic/allergic/irritant/psoriasisAllergens: glyceryl monothioglycolate, ammonium persulfate, isothiazolinones, formaldehyde, paraben, Compositae plants, nickel, dyes (p-phenylenediamine)
51 Hand Eczema Acute Vesiculobullous Hand Most commonly in atopic patientsAcute Vesiculobullous HandEczema (Pompholyx, Dyshidrosis):idiopathic, patients have hyperhydrosis. Severe sudden pruritic vesicular outbreak, can coalesce to bullae. “Tapioca pudding”. Spontaneously resolve over weeks.Chronic Vesiculobullous: hyperkeratotis, scaling, fissuredHyperkeratotic Hand Dermatitis: hyperkeratotic, fissure-prone erythematous areas of middle or proximal palm and volar fingers. R/o psoriasis.
52 Treatments for Hand Eczema Vinyl gloves during wet work, or rubber if there is no allergy. White cotton gloves under vinyl may be effective.Protective clothing during gardening/hobbies/chemical exposureGlycerin and dimethicone barrier productsMoisturizing protective cream/ointments after hand washing and at night. White petrolatum restores barrier function.
53 Treatments for Hand Eczema Systemic steroids results in dramatic improvement but relapse is commonTopical calcineurin inhibitors, tar soaks, phototherapy, PUVA can be effectiveOral MTX, azathioprine, cellcept may be helpfulSuperpotent and potent topical steroids are first-line pharmacotherapy and efficacy is enhanced by occlusion. Use should not exceed 2-3 weeks, then tapered to weekend-only with weaker topicals on weekdays
54 Diaper DermatitisIrritant: erythematous dermatitis limited to exposed surfaces, folds are unaffected. Can become ulcerated (Jacquet erosive diaper dermatitis) papular, or nodular (granuloma gluteale infantum)Skin wetness encourages frictional irritation and bacterial/Candidal growthProtection of skin with superabsorbant gel diapers, frequent changing, Zn oxide paste, mixture of Nystatin ointment and 1% hydrocortisone ointment after each diaper change