1. Acne Dr. Jerald E. Hurdle Kennebec Medical Consultants

2. Learning Objectives  To manage the patient with acne vulgaris,  To review the clinical presentation and management of Acne Rosacea, and  To recognize acneiform rashes & folliculitis.

3. Case Study 1 28 yr old ♀ Always had dandruff Using over the counter cream for facial rash

4. Attends Primary Care PCP prescribes 2.5% HC Cream Initially improves then returns PCP stops HC and rash gets much worse Pt demands referral to dermatology

5. Diagnosis: peri-oral dermatitis

6. Acne Vulgaris Common Puberty onwards Disease of pilosebaceous unit Gets better with time Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo (whitehead); (D) papule; (E) pustule.

7. Acne Vulgaris: pathogenesis 4 factors Presence of hormones (androgens) Sebaceous gland activity (due to #1) P. acnes (bacteria) in the hair follicle (it lives on the oil and breaks it down to free fatty acids which cause inflammation) Plugging of the hair follicle (abnormal keratinization of the upper portion)

8. Acne Vulgaris: classification By severity By type of lesions By distribution Mild Moderate Severe

9. Acne Vulgaris: classification By severity By type of lesions By distribution Papules & Pustules Nodules & Cysts Open Comedones Closed Comedones

10. Acne Vulgaris: classification By severity By type of lesions By distribution

11. Acne Vulgaris: Rx Patient Education Diet Cleanliness Cosmetics Picking UV light

12. Acne Vulgaris: Rx Patient Education Treatment Response & Time Course Prognosis excellent All treatments take up to 3 months to see improvement No one ever becomes zit free for the rest of their life

13. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics

14. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Gel, wash or cream 5-10% 1-2 x daily Side effects: redness, dryness & bleaching

15. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Tretinoin (Retin-A) 0.025- 0.1% 1 x Daily @ night Adapalene (Differin) 0.1% gel or cream 1-2 x daily SEs: dryness, redness & sun sensitivity

16. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Tretinoin (Retin-A) 0.025- 0.1% 1 x Daily @ night Adapalene (Differin) 0.1% gel or cream 1-2 x daily SEs: dryness, redness & sun sensitivity

17. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics

18. Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Clindamycin 1% Gel, lotion & solution 2x Daily Erythromycin 2% gel or sol, 2x daily

19. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone

20. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach

21. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset

22. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset Minocycline 50-100mg 1-2x daily Hyperpigmentation

23. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset Minocycline 50-100mg 1-2x daily Hyperpigmentation Doxycycline 50-100mg 1-2x daily Photosensitivity

24. Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone

25. Acne Vulgaris: Rx Severe Disease

27. Isotretinoin Refer to Dermatology Women of childbearing potential need adequate contraception Check LFTS & fasting lipids I-Pledge process bureaucratic: warn patient Likely to require 6 months of Rx Dry skin, cracked lips : inevitable side effects Acne Vulgaris: Rx Severe Disease

28. Photography Useful for treatment monitoring

30. Acne Variants: acne excoriee Predominantly in young women Comedones & papules excoriated +++ Often underlying psych component (anxiety, OCD or personality disorder)

31. Acne Variants: peri-oral dermatitis Commoner in women Eczematous patches and papules around mouth Occasionally around eyes Exacerbated by topical steroids Treat as acne vulgaris & stop steroids

32. Case 2 33-year-old female complains of red cheeks Homeless, chronic alcoholic

33. Case 2: Physical Exam Red Cheeks Papules and pustules on the central face and nose NO Comedones

34. Case 2: Diagnosis? A. Systemic Lupus Erythematosus B. Bacterial Folliculitis with cellulitis C. Acne Rosacea D. Pellagra from nutritional deficiency

35. Case 2: Diagnosis? A. Systemic Lupus Erythematosus (no pustules) B. Bacterial Folliculitis with cellulitis (acute and systemic symptoms) C. Acne Rosacea D. Pellagra from nutritional deficiency (scale, diarrhea, but no pustules)

36. Case 2: Acne Rosacea Chronic inflammatory condition of the “flush” areas of the face (nose, cheeks > brow, chin) F > M Middle age (30-50) Affected persons blush easily

37. Case 2: Question 2 Which of the following might trigger this patient’s rosacea? A. Alcohol B. Heat/Hot Beverages C. Sunlight D. Hot, spicy foods E. All of the above

38. Case 2: Question 2 Which of the following might trigger this patient’s rosacea? A. Alcohol B. Heat/Hot Beverages C. Sunlight D. Hot, spicy foods E. All of the above

39. Acne Rosacea: triggers Alcohol Sunlight Hot Beverages (heat) Hot, Spicy food If it makes you flush it can flare rosacea Rosacea is NOT related to androgens!!

40. Acne Rosacea: clinical features Erythema and Telangiectasias Papules and Pustules (NO COMEDONES!) Rhinophyma (W.C. Fields nose) Ocular Rosacea (keratitis, blepharitis, conjunctivitis)

41. Acne Rosacea

46. Acne Rosacea Treatment Medical treatment only effective for the papular and pustular component Topical Antibiotics (metronidazole) Topical Sulfur Oral Antibiotics (tetracyclines) Therapy is suppressive and may be required lifelong

47. Acne Rosacea: Surgical Treatment Laser therapy can help the telangiectasias and the rhinophyma, once the papulopustular component is controlled.

48. Steroid Rosacea Topical Steroids may exacerbate or induce an acneiform eruption resembling rosacea Treatment: Stop the topical steroids; give oral tetracyclines. Never treat central facial papular eruptions with topical steroids. It may be rosacea which will flare severely when the topical steroids are stopped

49. Case 3

50. Acneiform Eruptions: Drugs Systemic/topical steroids Anabolic steroids Lithium Phenytoin (Dilantin ® ) Epidermal growth factor receptor inhibitors

51. Acneiform Eruptions: Acne Keloidalis Nuchae & Pseudofolliculitis Barbae Predominantly affects men of African descent Due to ingrowing hairs Avoid shaving Treat as acne

52. Folliculitis Confined to hair follicles No comedones Lesions tend to monomorphic Often itchy Common causes Staph, Pityriasporum If HIV positive, consider eosinophilic folliculitis

53. Learning Objectives  To manage the patient with acne vulgaris,  To review the clinical presentation and management of Acne Rosacea, and  To recognize acneiform rashes & folliculitis.