What’s New (and What’s Not) in Acne and Rosacea Adam O. Goldstein, MD Assistant Professor Department of Family Medicine University of North Carolina at Chapel Hill

Objectives 1. Know differential diagnosis acne/rosacea 2. Increased knowledge treatment strategies 3. Increased familiarity new products 4. Learn 2 new patient education tips GOAL: Improved therapeutic outcomes

Acne Most common dermatologic disease Onset usually adolescence but anytime More frequent and severe in males 70% women premenstrual flares

Acne Quiz (T/F) 1. Certain foods make acne worse Dirty skin makes acne worse Acne worsens with sexual activity Acne improves within 24 hours of tx Sweating may make acne worse Humidity may exacerbate acne Acne may worsen during menstruation Stress may make acne worse...

Art of acne treatment: Negotiating long-term treatment Increasing compliance by using fewer medications Contracting with adolescents Thorough explanation of natural history of disease Patience with acne’s emotional toil Combining different mechanisms

Art of acne treatment: “Quality of Life” scale Feeling self-conscious 2. Decrease in socialization 3. Difficulties in relationships (partner, friends, family) 4. Feeling like an outcast 5. People making fun of you 6. Feeling rejected (romance, friends)

Common pitfalls in acne treatment Using more than two medications Insufficient patient education or unrealistic expectations Frustration all around

Acne: Etiology Combination hormonal (androgen), bacterial (Proprionibacterium acnes) and follicular (hyperkeratosis)causing debris and occlusion Bacteria multiply and inflammatory response Comedones: “Blackheads” and “Whiteheads” Blackheads = open comedones Whiteheads = closed comedones

Acne: Morphology Comedones Papules Pustules Nodules Cysts

Acne: Differential Diagnosis Rosacea: No comedones, erythema striking, central face Hidradenitis:Axilla & inguinal, nodules & cysts, scarring Keratosis Pilaris:Upper arms & trunks, follicular- based papules Perioral Derm.: Papulovesicles & erythema, perioral, topical steroid use Senile Comed.: Face & neck, comedones and cysts in damaged skin Topical steroids:Lesions same stage, no comedones

Rosacea

Hidradenitis

Keratosis Pilaris

Perioral Dermatitis

Senile Comedones

Topical Steroids

Acne Keloidalis

Acne: Treatment Treatment goal is to prevent new lesions/scarring Treatment will not improve outcomes for 4-6 weeks (Acne exacerbated by iodides, bromides, hydantoin, chlorinated hydrocarbons, occluding topical preparations, vigorous washing, and mechanical occlusion)

Acne and Iodides

Acne and Dilantin

Acne and Topical Steroids

Mechanical occlusion

Mild acne: Apply one agent thinly to entire face If two agents selected, use at separate times Apply after washing with water or mild soap Choices: – Benzoyl peroxide Topical antibiotics – TretinoinBirth Control Pills – Azelaic acid Salicylic acid Use for 6-8 weeks before judging if effective

Mild acne Benzoyl peroxide($) – Antibacterial, drying and peeling actions – Rx: % gel/cream/wash – OTC: % gel/lotion/cream – Usually start with 2.5-5%, thin layer QD-BID

Mild acne Benzoyl peroxide – Water based preps are milder and less drying – Alcohol/acetone preps useful in oily skin – Washes and soaps are good for acne on the chest, back and shoulders (5-10%) – Benzamycin gel grm- benzoyl peroxide and erythromycin- must be kept refrigerated

Mild acne: Benzoyl peroxide Side Effects – Occasional hypersensitivity reactions (1-5%) – Oxidating agent: will bleach clothes and hair

Mild acne Topical antibiotics (all Px) ($$) – Erythromycin 2%- pledgettes, pads, gel (oily skin), solution, ointment (dry skin) – Clindamycin 1%- solution, gel, lotion (e.g. Cleocin T) – Meclocycline- cream; useful in patient with very dry skin (e.g. Meclan)

Mild acne: Topical antibiotics Sodium sulfacetamide 10%, Sulfur 5%, Sodium thiosulfate 10% – Numerous keratolytic/astringent agents – Useful if lotion preparation preferred and other topical antibiotics not working or tolerated – Sulfacet R- tinted (can cover redness) – Novacet- untinted Bacterial resistance may develop after 6-12 months of use

Mild acne: Topical Retinoids Especially good for comedonal or papular acne Modulates keratinization Use pea size amount to entire face Apply 3x week for 2 weeks, then nightly Increases photosensitivity Flare reaction frequent Web Sites: monos/retin-a.htm

Topical Retinoids Retin A (Renova) ($$$) Vehicles:0.025%, 0.05%, 0.1% cream; 0.01%, 0.025% gel Start with 0.025% strength Apply at bedtime 30 minutes after washing Avita Vehicles: 0.025% cream/gel Slow release polymer may be less irritating Retin A Micro Vehicle: 0.1% gel; Thick and yellow Slow release may be less irritating

Retinoid-Like Adapalene (Differin) ($$$) – Vehicles: 0.1% gel, solution – May apply right after washing at bedtime Tazarotene (Tazorac) – Vehicles: 0.05, 0.1% gel – Irritating initially – May be useful with oily skin – Short contact therapy

Retinoids-Comparisons Adapalene 0.1% gel vs. Tretinoin 0.025% gel, meta- analysis of 5 RCT’s (BMJ, 139S 1998) –equivalent efficacy reducing total lesions –Adapalene with significant difference in reduction of inflammatory and total lesions at week 1 –Adapalene with greater local tolerability Adapalene 0.1% gel vs. Tretinoin 0.05% gel, Split-face clinical and bio-instrumental comparison (Dermatology. 198(2):218-22, 1999) –Tretinoin with better comedolysis and clinical improvement than adapalene –Erythema transiently more pronounced with tretinoin

Salicylic acid: 2% OTC ($) Keratolytic Many preparations Useful in combo with tretinoin or topical antibiotics

20% Azelaic acid (Px) Mechanism unknown ($$) Useful for patients intolerant to tretinoin or benzoyl peroxide Avoid on broken skin Use qd-bid, usually in combination with other topicals

Acne and Birth Control Pills Lowers hormonal factors exacerbating acne Use pill with low androgenic potential Know side effects and contraindications Acne often improves during pregnancy

Moderate acne

Mild treatment + Add oral antibiotics –Tetracycline- 500 mg bid or doxycycline mg/day –Erythromycin- 500 mg bid –Minocycline mg/day –Trimethoprim/Sulfamethoxazole 1 DS qd-bid Comedo removal

Minocycline has fewer GI side effects, but it is more expensive

Severe acne Moderate regimen X 3 months Isotretinoin for severe nodulocystic acne Steroid injections – TAC acetonide 10 mg/ml diluted to 3 mg/ml – Inject 0.1 ml into fresh cyst Prednisone rarely Consultation

Isotretinoin (Accutane) mg/kg/day weeks 80% success rate Indications wider than previous thought Improvement continues after treatment stops Very teratogenic: (2 forms birth control for one month beforehand) Laboratory monitoring: ( HCG before & monthly, CBC, LFT, TG, LDH, TG’s, Cholesterol, Q 2 weeks, then monthly) Use moisturizers, lip balms and artificial tears Monthly costs $

Acne: Myths NO relation to junk foods NO relation to “hygiene” NO relation to masturbation or other sexual activity NO way to make acne go away overnight

Acne: Truths YES acne may worsen premenstrual YES sweating may worsen acne YES humid environments may worsen acne YES stress can exacerbate acne

Acne: Patient Education 6-8 week response Avoid scrubbing Keep regimen simple Compliance is key to FTIP; Have patient bring medications to office

Acne: Patient Education Use water-based makeup “Oil-free” moisturizers Web Sites: Useful general information for clinicians Comprehensive site Patient support group

Acne Rosacea “Rosy” dilatation of the central face: – eyes, nose, chin, cheek, forehead Diverse spectrum of disease- (papules, pustules, nodules, cysts) Rhinophyma -hyperplasia of the nose in middle aged men

Acne Rosacea Look for periodic facial flushing after temperature increase, spicy food ingestion or alcohol Absence of comedones Disease is chronic: Treatment goal is control

Acne Rosacea: Differential Diagnosis Acne Vulgaris: comedones, younger patient, lack of flushing, less erythema Seb. dermatitis: no acneiform lesions Lupus: no papules and pustules Carcinoid: flushing is transient

Acne Rosacea: Treatment Topical – Antibiotics, Benzoyl peroxide, Tretinoin Oral antibiotics Isotretinoin for severe, recalcitrant cases Referral for surgery, dermabrasion, laser Potent topical steroids often worsen disease

Acne Rosacea: Topical Therapy Preferred topical antibiotic: – Metronidazole 0.1% cream (Noritate): qday 0.75% cream or gel: bid – Alternatives: Sodium sulfacetamide 10%/sulfur 5% lotion Clindamycin 1% lotion, gel or solution Erythromycin 2% solution

Acne Rosacea: Topical Therapy Benzoyl peroxide at 2.5% & up to 10% if tolerated Tretinoin 0.025%, 0.05% 0.1% cream – Start with lowest dose – May be used in combination with other products

Acne Rosacea: Oral antibiotics Useful for nodular lesions Doxycycline mg/day or tetracycline mg/day Minocycline mg at bedtime Treat until improvement occurs, then taper for control

Acne Rosacea: Patient Education Control vs cure Avoid excessive sunlight, alcohol, temperature extremes and precipitating foods Flares may require higher “pulse” treatment Good web sites: – National Rosacea Society –Patient education brochure –

On the Horizon…. New retinoids Combination products: retinoids and topical antibiotics Glycolic acid, salicylic acid peels Hormonal treatments Antibiotic alternatives

Cases 14, Sports PE & whiteheads- incidental 16, with comedones and mild inflammation 16, before the prom 20, with sensitive skin, papular lesions and skin irritation 21, moderate acne on 0.1% Retina cream and 5% Benz. Peroxide, wanting referral to dermatologist 22, with extensive cystic acne for 5 years

Conclusion Be confident Use 1-2 agents if at all possible Define expectations Think about acne rosacea in adults