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 Vulgaris
Most common skin disease presenting to primary care physicans.
Chronic disease for some patients
Don’t underestimate the social and psychological effect of acne on patients
Acne is not necessarily a rite of passage
20% of

3. Pathophysiology
Four primary pathogenic factors which interact in complex manner
Sebum production by the sebaceous gland
P. acnes follicular colonization
Alteration in the keratinization process
Release of inflammatory mediators into the skin
Other factors
Androgens, stress, occupational exposure, underlying metabolic abnormalities
Treatment should target these pathogenic factors
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.

4. Clinical Features Non-inflammatory Lesions Inflammatory Lesions
Open comedones (blackheads)
Closed comedones (whiteheads)
Inflammatory Lesions
Pustules/papules
Nodules
Cysts
Help determine treatment modalities

5. Primary Lesions

6. Variants of Acne Acne cosmetica Acne excoriee Senile comedones Milia
Acne mechanica
Gram-negative acne
Steroid-induced acne
Occupational acne
Favre-Racouchot syndrome
Solid facial edema
Neonatal acne
Drug-induced acne

7. Treatment Choice of treatment depends on Evaluate patient Type of acne
Severity
Age
Location
Patient preference
Evaluate patient
Current medications, allergies
Menstrual history
Tanning habits, hobbies
Expectations, myths, fears
Scarring
Pregnancy

8. Treatment Approach should be multi-therapy, not monotherapy Topicals
Antibiotics
Retinoids
Benzoyl peroxide
Combination therapies
Other therapies
Oral therapy
Isotretinoin
Adjunctive therapy
Hormonal/anti-androgen therapy
Chemical peels
Scar 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 Inflammatory
Acne
Pregnant
Azelaic Acid (Cat B)
Clindamycin Lotion (Cat B)
Topical Therapies
Retinoids
Antibiotics
Salacylic Acid
BPO
+/- Washes
Oral antibiotics
Tetracyclines
Adjunctive Therapies
Severe or Scarring
Isotretinoin
Adjunctive Therapies
OCPs, chemical peels,
anti-androgens
Failure of oral
antibiotics

11. Treatment Approach
Early, appropriate treatment is best to minimize potential for acne scars
Combination of a topical retinoid and antimicrobial agent remains the preferred approach for almost all patients with acne
Attacks 3 of the 4 major pathogenic factors of acne: abnormal desquamation, P. acnes colonization, and inflammation
Retinoids are anticomedogenic, comedolytic, and have some anti-inflammatory effects
BPO is antimicrobial with some keratolytic effects and antibiotics have anti-inflammatory and antimicrobial effects
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.

12. Treatment Approach
Topical retinoids should be first-line agents in acne maintenance therapy
Avoid contributing to antibiotic resistance
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.

13. Benzoyl Peroxide Mechanism of action1 Advantages Formulations
Bactericidal for P. acnes
Inhibits triglyceride hydrolysis
Decreases inflammation of acne lesions
Advantages
No resistance demonstrated to date1
When used in combination with a topical antibiotic can help to prevent resistance2
Activity is enhanced when combined with other topicals (i.e. clindamycin)1,2
Formulations
OTC & prescription
Washes, gels, lotion, solution
1. 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 Am
Acad Dermatol 2009;60:S1-50.

14. Retinoids Most important class of drugs used to treat acne
Topical form of vitamin A
Mechanism of Action1
Normalize follicular keratinization
Act on the microcomedone
Proper instruction on application is essential to compliance
Gradual 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 strains
Usage fallen out of favor
Clindamycin phosphate 1%
Generic, Cleocin T® (lotion, gel, solution), Evoclin® foam
Antibiotic-associated colitis very unlikely
Work best in combination with BPO
Good choice for pregnant women (Pregnancy Category B)
Azelaic acid
Finacea™
Bacteristatic/bactericidal against P. acnes
Wolverton 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. acnes
Used most commonly for rosacea
Metronidazole1
Benefit for acne debatable
Metronidazole lotion (generic), Metrogel 1%®
Dapsone gel 5% (Aczone®)2
Approved for moderate to severe acne
BID dosing
May cause a temporary yellow or orange discoloration of skin and facial hair if used along with BPO
Low risk of hemolytic anemia in G6PD deficient patients
1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.
2. Aczone® prescribing information. January 2009.

18. Combination Therapies
Clindamycin/Benzoyl peroxide
Clindamycin 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 peroxide
Erythromycin 3%/benzoyl peroxide 5% (Benzamycin®)
Retinoid/Benzoyl peroxide
Adapalene 0.1%/benzoyl peroxide 2.5% (Epiduo™ Gel)
Retinoid/Clindamycin
Tretinoin 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 activity
Dosing
Start high then taper down after control is achieved
Use PRN during flares
Do not use as monotherapy
Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

20. Oral Antibiotics Antibiotic Choice
Tetracylcine Class (minocycline, doxycycline, tetracycline)
Solodyn® (minocycline HCl), Minocin ® (minocycline)
Doryx® (doxycycline hyclate), Adoxa® (doxycycline monohydrate)
Erythromycin (Ery-tab®)
Trimethoprim/sulfamethoxazole
Amoxicillin
Anti-inflammatory antibiotics/no antimicrobial activity
Doxycycline 20 mg (Periostat®)
Doxycycline 40 mg (Oracea®)
Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

21. How to Prevent Resistance
Combine a topical retinoid plus an antimicrobial
Limit the use of antibiotics to short periods and discontinue when there is no further improvement or the improvement is only slight
Co-prescribe a BPO-containing product or use as washout
Oral and topical antibiotics should not be used as monotherapy
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.

22. Hormonal Therapy FDA-approved OCPs for acne Anti-androgens
Ortho Tri-Cyclen®
Estrostep®
Yaz®
Anti-androgens
Spironolactone
Doses range between mg
Not FDA-approved for acne
Monitor side effects: menstrual irregularities, hyperkalemia
Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

23. Isotretinoin
Approved for the treatment of severe recalcitrant nodular acne in 1982
Member of the Vitamin A family
Effects on acne
Normalizes the keratinization process
Reduces sebocytes and secretions
Reduces inflammation
Reduction in numbers of P. acnes
Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

24. Isotretinoin Pre-medication counseling Dosing 1-2 mg/kg/day
Side Effects
Contraception
Compliance/duration of treatment
Laboratory monitoring
iPledge registration
Dosing 1-2 mg/kg/day
Goal mg/kg over course of treatment
Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

25. Case Studies

26. Case One 15-year-old male Non-inflammatory & inflammatory acne
Face only
Open/closed comedones
Papules
Treatment Plan?

27. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne
Moderate-Severe Inflammatory
Acne
Pregnant
Azelaic Acid (Cat B)
Clindamycin Lotion (Cat B)
Topical Therapies
Retinoids
Antibiotics
Salacylic Acid
BPO
+/- Washes
Oral antibiotics
Tetracyclines
Adjunctive Therapies
Severe or Scarring
Isotretinoin
Adjunctive Therapies
OCPs, chemical peels,
anti-androgens
Failure of oral
antibiotics

28. Case Two 17-year-old-female Inflammatory acne Treatment plan?
Regular menstrual
cycles (-flares)
Face, chest, back involved
Pustules, papules
Open & closed
comedones
Treatment plan?

29. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne
Moderate-Severe Inflammatory
Acne
Pregnant
Azelaic Acid (Cat B)
Clindamycin Lotion (Cat B)
Topical Therapies
Retinoids
Antibiotics
Salacylic Acid
BPO
+/- Washes
Oral antibiotics
Tetracyclines
Adjunctive Therapies
Severe or Scarring
Isotretinoin
Adjunctive Therapies
OCPs, chemical peels,
anti-androgens
Failure of oral
antibiotics

30. Case Three 22-year-old female Mild-moderate inflammatory acne
Regular menstrual
cycles (+ flares)
Face involved
Chest, back spared
Nodular lesions along
jawline
Comedones
Treatment plan?

31. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne
Moderate-Severe Inflammatory
Acne
Pregnant
Azelaic Acid (Cat B)
Clindamycin Lotion (Cat B)
Topical Therapies
Retinoids
Antibiotics
Salacylic Acid
BPO
+/- Washes
Oral antibiotics
Tetracyclines
Adjunctive Therapies
Severe or Scarring
Isotretinoin
Adjunctive Therapies
OCPs, chemical peels,
anti-androgens
Failure of oral
antibiotics

32. Atopic Dermatitis and Eczema

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 2yo
Ddx: 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 HX
60% 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 → itch
If >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 lesions
Often 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 life
New-onset in adulthood: HIV can be a trigger

38. Modified Criteria for Children with Atopic Dermatitis
Essential Features
Pruritus
Eczema
Typical Morphology and age-specific pattern
Chronic or relapsing history
Important Features
Early age at onset
Atopy
Personal and/or family history
IgE reactivity
Xerosis
Associated Features
Atypical vascular responses (e.g. facial pallor, white dermatographism)
Keratosis pilaris/ichthyosis/hyperlinear palms
Orbital/periorbital changes
Other 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 eyelid
Prominent nasal crease
“Normal” skin is subclinically inflamed, dry, scaly
Pityriasis alba: hypopigmentation with sclight scale on cheeks, upper arms, trunk in young children. Responsive to emollients and topical steroids
Keratosis pilaris: horny follicular lesions of outer aspects of upper arms, legs, cheeks, and buttocks; refractory to treatment
Dirty neck appearance due to hyperkeratosis and hyperpigmentation

40. Features Associated with Atopy
Perioral, perinasal, and periorbital pallor
White dermatographism
Increased susceptibility of cataracts
Increased susceptibility of infection;
Patients heavily colonized with Staph. Treatment of lesional skin reduces colonization even w/o ABX
Chronic suppressive ABX therapy may stabilize disease: Cephs, Bactrim, clinda, doxy
Eczema herpeticum: generalized herpes simplex, sudden vesicular, pustular, crusted or eroded lesions. Become secondarily infected.
Eczema vaccinatum: widespread vaccinia infxn
Extensive 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 itch
Dietary restriction for a specific known antigen

44. Management of Atopy Adults Avoid temperature extremes
Hydrate dry skin especially in winter
Avoid overbathing and hot water
Avoid wool
Biofeedback 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 face
1-2x a day is enough to saturate receptors; more provides only emollient effect
Occlusion increases penetration and receptor saturation
Must be strong enough to control pruritus and remove inflammation
Regular emollients: petrolatum, hydrophilic creams with ceremides
Anti-Staph therapy for acute flares
Topical calcineurin inhibitors

46. Systemics for Atopy
Antihistamines for sedation: hydroxyzine, diphenhydramine, or clopheniramine.
The nonsedating antihistamines do not relieve pruritus
Short courses of anti-Staph ABX, topical mupirocin for nasal carriage
Systemic steroids only for acute exacerbations, in short courses of 3 weeks or less
Cyclosporin is usefule but expensive; symptoms recur on stopping meds
Immunosuppressives and antiproliferatives (Immuran, Cellcept, MTX) can be effective for unresponsive dz
Phototherapy: 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 flare
Short course of systemic steroids
3-4 days of home hospitalization:
Bedrest and isolation of stressors with large doses of antihistamine at bedtime
Daily tub soaks followed by topical steroid ointment under wet pajamas and a sauna suit

48. Eczema
Broad range of conditions beginning as spongiotic progressing to lichenified
Acute: red edematous plaque with small grouped vesicles
Subacute: erythematous plaques with scale or crusting
Chronic: dry scale and lichenification

49. Regional Eczemas
Ear: 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 both
Breast/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/psoriasis
Allergens: glyceryl monothioglycolate, ammonium persulfate, isothiazolinones, formaldehyde, paraben, Compositae plants, nickel, dyes (p-phenylenediamine)

51. Hand Eczema Acute Vesiculobullous Hand
Most commonly in atopic patients
Acute Vesiculobullous Hand
Eczema (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, fissured
Hyperkeratotic 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 exposure
Glycerin and dimethicone barrier products
Moisturizing 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 common
Topical calcineurin inhibitors, tar soaks, phototherapy, PUVA can be effective
Oral MTX, azathioprine, cellcept may be helpful
Superpotent 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 Dermatitis
Irritant: 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 growth
Protection of skin with superabsorbant gel diapers, frequent changing, Zn oxide paste, mixture of Nystatin ointment and 1% hydrocortisone ointment after each diaper change