1. HELP! MY FACE IS RED Christine Rivet MD,CM,CCFP(EM),MClScFM,FCFP,DipPDerm Montebello presentation to colleagues September 21, 2014

2. Agenda Introduction Objectives Warm-up quiz Discussion of photos in pairs Group discussion

3. Objectives for today’s session At the end of the session you will be able to : 1-discuss treatment of acne with oral retinoids. 2-describe the differences between acne and conditions with a similar appearance. 3-discuss treatment of rosacea, perioral dermatitis and seborrheic dermatitis. 4-give advice to patients about the natural history of these chronic skin conditions and the limitations of treatments.

4. WARM-UP QUIZ

5. Question 1: in a patient with perioral dermatitis A)The lip vermilion and adjacent skin are inflamed and scaly. B)Treatment should include mild topical corticosteroids to reduce the inflammation. C)Oral tetracyclines given over a 4-6 week period are likely to be the most successful agents. D)Topical retinoids are likely to be of benefit. E)As the condition is inherited, other family members will be affected

6. Question 2: A man of 30 has developed a reddened face and nose. On examination he has scars, comedones and a greasy skin. Which of the following are true? A) The diagnosis is likely to be rosacea. B) A diagnosis of acne would be supported by the finding of papules and papulopustules on the back. C) Prominent closed comedones are a feature of rosacea. E) Seborrhoea(greasy skin) is not a feature of rosacea.

7. Question 3:Regarding emollients the following are true in atopic dermatitis (eczema): A)Once the eczema is treated emollient use should be discontinued to avoid folliculitis. B)Pump dispensers are a way of storing emollient to lessen the risk of contamination. C)Patients can be advised to bathe daily. D)Emollient should be applied more than 30 minutes after bathing.

8. Question 4:Which of the following statements regarding isotretinoin are true? A)Relapse rates are < 30% on stopping treatment B)Pre-treatment kidney function tests are recommended C)Night blindness has been reported D)Patients should be advised to avoid pregnancy for 6 months following treatment E)Dermatitis is a common side effect

9. Question 5: The following are recognised side effects of acne therapies: A)Bleaching of clothes with topical adapalene B)Benign intracranial hypertension with tetracycline C)Light-sensitive eruption with doxycycline D)Dermatitis with benzoyl peroxide E)GI side effects with tetracyclines

10. A 13 y o boy who complains of a rash on his face It started at age 11 but has been worse in recent months. How do you describe his face? What is the likely diagnosis? Differential? What do you tell the patient?

11. The 13 y o boy’s arm

12. How does KP differ from acne?

13. How does keratosis pilaris differ from acne? Keratosis pilaris has small uniform papules KP is associated with dry skin and chapping Acne papules and pustules vary in size. Acne is associated with oily skin

14. Keratosis pilaris Very common and peaks in adolescence then tends to improve. Small rough follicular papules or pustules can occur at any age. Frequently upper arms and anterior thighs but any area except palms and soles may be involved. Usually asymptomatic.

15. Treatment for keratosis pilaris Urea (10-40%) or salicylic acid lotion 6% or ammonium lactate ( LaC-Hydrin) reduce roughness. Avoid abrasive washing. Consider tazarotene (topical retinoid) in slowly increasing timed applications: start with 5 min then wash off etc. Before an important event: a short course of medium strength steroid reduces the redness: eg betamethasone valerate (betaderm).1% BID for 3-4 weeks. Patients often need the reminder that these treatments do not cure but only control keratosis pilaris.

16. 15 y o girl who is discouraged about her acne She’s tried prescription creams and tetracycline by mouth but it is not improving. She avoids social outings because she is embarrassed. What treatments do you discuss with her? What can she expect from the treatments?

17. Severe inflammatory acne For women only: Diane 35 ( 35 mcg EE and cyproterone 2mg); ALL OCs may be beneficial. Spironolactone 100 mg/d Isotretinoin 1 mg/kg x 16-20 wks; goal is to reach 120-150 mg/kg/course to avoid relapse Monitor: LFTs, cholesterol and tg: 0, 1 and q3 mos Pregnancy test before, monthly and 1 mo after stopped

18. The logistics of starting oral retinoids Weigh the patient eg wt of 60 Kgs Accutane and Clarus exist in 10 and 40 mg capsules Do not prescribe the 10 mg capsules since the overall course will cost twice as much as using 40 mg capsules. Start with.5 mg/kg first month: in 60 Kg woman, this would be 30 mg but use 40 mg cap/day first month, then increase to usual dose of 1 mg/kg: this would be 60 mg/d: use 40 mg caps and give 40 mg and 80 mg on alternate days. Follow-up visits: at one month and do BW: CBC, LFTs, lipids and pregnancy test. Avoid other topical acne treatments: too drying.

19. Commonly asked questions about oral retinoids What is the ideal duration of oral retinoids? 120-150 mg/kg/course; eg in 60 Kg woman: 9000 mg which is 5 months. Can this treatment be repeated? Yes, the same dose and course can be repeated; wait at least 8 wks and more usually 4-5 months before retreatment. What is the likelihood that this treatment will work? remission rate 70-90% with long-term remission 55-80% after one course. When can a patient safely become pregnant after stopping oral retinoids? 6 weeks.

20. Side effects of oral retinoids Dry skin and mucous membranes: lips, mouth, eyes. Headache. Sun sensitivity. Minor aches. Serious: abrupt decrease in night vision, depression and suicide (controversial).

21. WHO ARE CANDIDATES FOR ORAL RETINOIDS?

22. Candidates for oral retinoids: Cystic acne. No response to oral antibiotics for 2 courses of 3 mos each. Scarring. Mild to moderate acne that is causing psychological distress.

23. 28 y o woman She has had acne for years and would like treatment. How would you describe her acne? What do you suggest?

24. Pitted acne scars Difficult problem. Techniques available: dermabrasion, laser resurfacing. Will not respond to usual topical or oral treatments for acne: there are no active lesions.

25. A 35 y old woman who says she is too old for acne! What is this rash and what do you suggest for treatment? What do you tell the patient about what she can expect from the treatment?

26. What are the differences between rosacea and acne?

27. How do rosacea and acne differ? Rosacea affects face only and on convexities Age older onset: 3 rd -4 th decades Red papules not tender and similar size; no comedones Can have pustules Telangiectasia; NO cysts Inflammation around eyes common Acne affects face, shoulders, chest, back Age teens to mid 20s but can last to 40s Comedones; greasy; papules tender and different sizes Several pustules Cysts but NO telangiectasia

28. Treatment of rosacea Patients often need reminder that rosacea can be controlled but not cured. Avoid sun exposure and use sunscreens. Avoid hot drinks (flushing). If mild: topical metronidazole.75% bid or 1% daily (Metrogel). Will help papules but will not affect flushing or telangiectasia.

29. Treatment of rosacea continued Tetracyclines: some can stop when pustules clear and some require long-term suppression (use min. effective dose). New tetracycline: Apprilon 40 mg doxycycline: antiinflammatory but not antibacterial. Cost. If refractory: isotretinoin.5 mg/kg/day for 20 wks. For flushing and telangiectasia: laser but expensive. New treatment for flushing: brimonidine vasoconstrictor lasts 6-9 hours. Very expensive. (same medication as Alphagan for eyes)

30. A 22 y o woman with pimples around her nose She noticed them about 3- 4 months ago and they are increasing. She has tried acne creams for 2 weeks then moisturizers but nothing seems to help. What is the diagnosis and treatment?

31. What is the diagnosis?

34. Perioral dermatitis ( periorificial dermatitis) Typical: papules and pustules confined to chin and nasolabial folds sparing a clear zone around the vermillion border. Initially pustules adjacent to nostrils. Can also be adjacent to eyes and nose. Cause unknown but associated with abundant use of moisturizers and makeup. Aggravated by topical steroids, tretinoin and antibiotic lotions What is the treatment?

35. Treatment of perioral dermatitis 6-8 weeks of oral tetracyclines (or erythromycin) Unlike typical acne which takes longer, perioral dermatitis will improve after initial 2-4 weeks of treatment. Topical antibiotics are not effective. Metronidazole cream reduces papules but is not as effective as oral antibiotics.

36. 52 y o woman who is embarrassed to go to work because of her red face She has had eczema since she was a child. She has been applying 1% hydrocortisone cream bid for 2 weeks but is no better. What do you see? What do you suggest?

37. What do you see? Diffuse erythema face Lichenification: increased skin lines around the eyes.

38. WHAT CAN YOU DO FOR THE FACE WHEN TOPICAL STEROIDS ARE NOT ENOUGH?

39. What can you do for the face when topical steroids are not enough: Immune modulators=calcineurin inhibitors Tacrolimus ointment (Protopic). Suppress cytokine release from T-lymphocytes..1% BID for adults and.03% BID for age 2-15. Indicated if failure of topical steroids or when steroids not advisable (face) since no risk of atrophy. Efficacy similar to mid-potency steroid. Advise patient: burning at site of application.(can be lessened by keeping in refrigerator.) Do not use on infected skin. Expensive: $89/30g

40. Tips about treating eczema Remember tachyphylaxis (tolerance) and use topical steroids in ‘bursts’ of 2-4 wks and stop for at least 1 week before retreating to reduce tolerance. Recommend moisturizers every day to protect the skin barrier: petrolatum is cheap and effective. Use ointment base with topical steroids for moisturizing effect; also creams are complex substances and can be sensitizing.

41. More tips for atopic dermatitis (AD) If 1% HC ointment is not sufficient for the face, do not use 2.5% HC ointment: same potency category. Instead use desonide.05%: low potency but slightly more potent than HC; safe for the face of children. For the body of adults use moderate (eg betamethasone valerate.1%) to high potency(betamethasone dipropionate.05%) topical steroid. Safe to use for 2-4 wks.

42. If topical steroids are not working Consider: Non-adherence to treatment Superinfection Sensitivity/allergy to the vehicle in the topical steroid The topical steroid is not sufficiently potent.

43. BACK TO THE QUIZ

44. Question 1: in a patient with perioral dermatitis A)The lip vermilion and adjacent skin are inflamed and scaly. B)Treatment should include mild topical corticosteroids to reduce the inflammation. C)Oral tetracyclines given over a 4-6 week period are likely to be the most successful agents. D)Topical retinoids are likely to be of benefit. E)As the condition is inherited, other family members will be affected

45. Question 1: in a patient with perioral dermatitis A)The lip vermilion and adjacent skin are inflamed and scaly. B)Treatment should include mild topical corticosteroids to reduce the inflammation. C)Oral tetracyclines given over a 4-6 week period are likely to be the most successful agents. D)Topical retinoids are likely to be of benefit. E)As the condition is inherited, other family members will be affected

46. Question 2: A man of 30 has developed a reddened face and nose. On examination he has scars, comedones and a greasy skin. Which of the following are true? A) The diagnosis is likely to be rosacea. B) A diagnosis of acne would be supported by the finding of papules and papulopustules on the back. C) Prominent closed comedones are a feature of rosacea. E) Seborrhoea(greasy skin) is not a feature of rosacea.

47. Question 2: A man of 30 has developed a reddened face and nose. On examination he has scars, comedones and a greasy skin. Which of the following are true? A) The diagnosis is likely to be rosacea. B) A diagnosis of acne would be supported by the finding of papules and papulopustules on the back. C) Prominent closed comedones are a feature of rosacea. E) Seborrhoea(greasy skin) is not a feature of rosacea.

48. Question 3:Regarding emollients the following are true in atopic dermatitis (eczema): A)Once the eczema is treated emollient use should be discontinued to avoid folliculitis. B)Pump dispensers are a way of storing emollient to lessen the risk of contamination. C)Patients can be advised to bathe daily. D)Emollient should be applied more than 30 minutes after bathing.

49. Question 3:Regarding emollients the following are true in atopic dermatitis (eczema): A)Once the eczema is treated emollient use should be discontinued to avoid folliculitis. B)Pump dispensers are a way of storing emollient to lessen the risk of contamination. C)Patients can be advised to bathe daily. D)Emollient should be applied more than 30 minutes after bathing.

50. Question 4:Which of the following statements regarding isotretinoin are true? A)Relapse rates are < 30% on stopping treatment B)Pre-treatment kidney function tests are recommended C)Night blindness has been reported D)Patients should be advised to avoid pregnancy for 6 months following treatment E)Dermatitis is a common side effect

51. Question 4:Which of the following statements regarding isotretinoin are true? A)Relapse rates are < 30% on stopping treatment B)Pre-treatment kidney function tests are recommended C)Night blindness has been reported D)Patients should be advised to avoid pregnancy for 6 months following treatment E)Dermatitis is a common side effect

52. Question 5: The following are recognised side effects of acne therapies: A)Bleaching of clothes with topical adapalene B)Benign intracranial hypertension with tetracycline C)Light-sensitive eruption with doxycycline D)Dermatitis with benzoyl peroxide E)GI side effects with tetracyclines

53. Question 5: The following are recognised side effects of acne therapies: A)Bleaching of clothes with topical adapalene B)Benign intracranial hypertension with tetracycline C)Light-sensitive eruption with doxycycline D)Dermatitis with benzoyl peroxide E)GI side effects with tetracyclines

54. references -Naldi L,Rebora A. Seborrheic Dermatitis NEJM 2009;360:387-96 -Bieber T. Atopic Dermatitis. NEJM 2008;358:1483-94 -Lewis-Jones S,Mugglestone MA. Management of atopic eczema in children aged up to 12 years: summary of NICE guidance.BMJ 2007;335:1263-4 -Laubscher T,Regier L,Jin M. Taking the stress out of acne management. CFP 2009,55:266-69. -Goldgar C,Keahey DJ,Houchins J.Treatment Options for Acne Rosacea. Am Fam Physician. 2009;80(5):461-468,505. -Habif T. Clinical Dermatology: A Color guide to diagnosis and Therapy. 5 th edition 2010.