ACNE Definition Inflammation of sebaceous follicles Follicle sebaceous gland follicular canal hair

ACNE Classification comedonal acne mild inflammatory acne moderate inflammatory acne severe inflammatory (nodulocystic)

ACNE Pathogenesis Pubertal changes increased sebaceous production of sebum abnormal sloughing of follicular wall lining closed comedone (whitehead) open comedone (blackhead)

ACNE Pathogenesis Accumulation of Propionobacterium acnes (normal skin flora) metabolization of sebum release of free fatty acids attraction of neutrophils  rupture of follicular wall extrusion into the dermis inflammatory lesions papules, pustules nodules, cysts

Acne lesions at a glance

ACNE Lesions Inflammatory and comedonal acne

ACNE Lesions Open comedones are evident on the chin

ACNE Lesions inflammatory and comedonal acne

ACNE Therapy (Mechanisms) Hormonal regulation Sebum suppression Keratolysis and inhibition of follicular proliferation Antibacterial / antiinflammatory

Hormonal regulation Oral contraceptives Spironolactone particularly estrogen predominant Ortho-Tri-Cyclen Spironolactone

Sebum suppression Isotretinoin (Accutane) oral synthetic Vitamin A analog shrinks sebaceous gland

Keratolysis and inhibition of follicular proliferation OTC preparations salicylic acid (Stridex) Benzoyl Peroxide Isotretinoin (Accutane) Topical retinoids tretinoin (Retin-A) adapalene (Differin) tazarotene (Tazorac) Azelaic Acid (Azelex)

ACNE Topical retinoids Contemporary Peds Dec. 2000

ACNE Adapalene (Differin) Derivative of Naphthoic acid Has more specific retinoid receptor activity Some studies have shown less irritation

ACNE Azelaic Acid (Azelex) Dicarboxylic acid produced by P. ovale demonstrated activity against P. acne demonstrated ability to inhibit microcomedo Prevents hyperpigmentation inhibits tyrosinase (melanin synthesis) adresses postinflammatory hyperpigmentation

Antibacterial / antiinflammatory Topical Erythromycin Clindamycin Oral Tetracycline Doxycycline Minocycline

ACNE Topical antibiotics Contemporary Peds Dec. 2000

ACNE Oral Antibiotics Contemporary Peds Dec. 2000

ACNE therapy (vehicle effects efficacy) Creams Less potent than gels Less drying than gels May not be good for the patient with oily complexion Gels, solutions more drying tend to cause more irritation oily skin

ACNE Counseling Poor hygiene is not a cause of acne Effect of diet has not been demonstrated 4 – 6 weeks of treatment before any improvement is expected Warn patients about skin irritation BP, topical retinoids Warn patients about photosensitivity topical retinoids, tetracycline, Doxycycine apply at night consider noncomedogenic sunscreen (SPF =15)

ACNE Counseling II Apply topical therapy to entire region not just to lesion Start at low dose, infrequent applications and increase gradually Apply to thoroughly dried skin 30 minutes of air-drying not right after washing your face Avoid cosmetics, mechanical friction harsh scrubbing tight chin straps, caps bangs

ACNE Treatment Plans

ACNE Treatment Plans

ACNE Treatment Plans Consultant April 1999

ACNE When to refer No improvement despite therapy Cysts or scars sometimes require intralesional steroids Consideration of Accutane or spironolactone Associated menstrual irregularity or hirsutism polycystic ovarian syndrome

ACNE Treatment Plans

ACNE Treatment Plans Contemporary Peds Dec. 2000

ACNE Treatment Plans

ACNE Treatment Plans Contemporary Peds Dec 2000

ACNE Treatment Plans

ACNE Treatment Plans Contemporary Peds Dec 2000

ACNE References (required reading) Pediatric Clinics North America August 2000 Contemporary Pediatrics Dec 2000 Pediatric Annals January 2000 Available in the Peds Office