1. By Sapna Prabhakaran, MD
Acne
By Sapna Prabhakaran, MD

2. Objectives
Types
Diagnosis
Treatments

3. 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 present
tx: topical 2.5% benzoyl peroxide or topical 2% erythromycin solution or gel or topical retinoids such as adaplene
Acne vulgaris

4. 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

5. 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)

6. Pathophysiology
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

7. Pathophysiology Factors
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

8. NORMAL PILOSEBACEOUS UNIT

9. MICROCOMEDONE

10. WHITEHEAD (CLOSED)

11. BLACKHEAD(OPEN)

12. PAPULE

13. PUSTULE

14. CYST

15. 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

16. Signs and Symptoms
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

17. Treatment
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

18. Treatment Treatment strategies are based on severity of disease
Mild acne – (face: one fourth of the face is involved, few to several papules or pustules, but no nodules or scarring)
Topical therapy are usually adequate as an initial intervention and include a choice of topical retinoids, topical benzoyl peroxide, and topical benzoyl/antibiotic combinations
Retinoid pearls –
apply to a dry face
apply no more than a pea size amount for the entire face
If the entire face needs to be covered - touch pea size aliquot to each side of forehead, each cheek and chin and rub it in
Apply to all areas and not as spot therapy
Use a noncomedogenic moisturizer sparingly to counteract the dryness assoc with retinoid therapy

19. Treatment

20. 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

21. 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.

22. WHERE DRUGS ACT

23. 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: minutes/day

24. 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

25. 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

26. TOPICAL ANTIBIOTIC Clindamycin Antibacterial
Risks: irritation, rare report of pseudomembranous colitis
Formulation: gel,lotion and newer foam (Cleocin)

27. 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

28. TRIAZ Benzoyl peroxide, glycolic acid, zinc
Anti-microbial, anti-comedonal
3, 6 and 9%
Less irritation
Also successful in pseudofolliculitis barbae

29. BENZACLIN BP 5%-clindamycin combination
Maybe used in lieu of oral antibiotics in mild papular, pustular acne
Benzamycin (erythromycin/BP combination)
Duac (clinda/BP)

30. ZIANA Clindamycin/tretinion combo Antibacterial/comedolytic
Risks: irritation, GI effects of clinda
Expensive

31. ADAPELENE (DIFFERIN) Synthetic napthalene retinoid derivitive
Anti-comedones, some anti-inflammatory
Risks: irritation 10-40%; photosusceptible, hyperpigmentation

32. RETIN A-MICRO Different formulation of Retin-A
Anti-comedonal with less irritation

33. TAZAROTENE (TAZORAC) Retinoid derivitive
Anti-comedonal, anti-inflammatory, anti- proliferative
Also used in psoriasis
Irritation 10-30%;
Start brief contact, 2-5 minutes BID

34. AZELAIC ACID (AZELEX) Dicarboxylic acid
Antimicrobial, anti-keratinization
Decrease hyperpigmentation
20% Cream BID dosing
Useful in pts that prone to hyperpigmenation

35. ORAL AGENTS

36. MINOCIN (MINOCYCLINE)
Special acne indication
50mg BID dosing
Risks: gray-blue discoloration of skin; hepatitis; lupus like illness

37. DOXYCYCLINE Low dose formulation Periostat 20mg BID
Likely anti-inflammatory effect
More expensive than regular hight dose doxy

38. BACTRIM DS BID used 2-3 months Moderate severe cases
Consider prior to using accutane

39. ZITHROMAX Pavone-Italy: Schachner, Miami: Elewski, Miami:
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

40. 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

41. ORAL CONTRACEPTIVES Increases sex hormone binding globulin
Decreases free testosterone
Decrease inflammatory acne

42. OCP Ortho-tri-cyclen, Yaz, Yasmin Risks: nausea, vaginal bleeding
Consider using in mod-severe inflammatory acne
Trial prior to Accutane

43. 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

44. Treatment

49. Conclusion
Thanks for your time !!!