Adult Acne Mary S. Stone MD Department of Dermatology Guidelines of care for the management of acne vulgaris. J Amer Acad of Dermatol 74:945-973, 2016

Acneiform Disorders Acne Vulgaris Acne Rosacea Perioral Dermatitis Topical Steroid Induced Acne Neonatal and Infantile Acne Drug Induced Acne

Pathogenesis of Acne Vulgaris Androgen related overproduction of sebum Abnormal desquamation within the sebaceous follicle Proliferation of Propionibacterium acnes producing inflammation Genetic factors

Relationship between sebaceous glands and acne Acne occurs in the neonatal period Sebum is comedogenic Sebaceous gland activity is increased in acne Inhibition of sebaceous gland function improves acne

Adult Female Acne (>age25) 2x more than adult men seek care 1/23 of all can office visits made by females > 25 years old Distribution typically perioral or mandibular May persist beyond menopause Premenstrual flares very common

Principles of Therapy Correct defects in keratinization Decrease sebaceous gland activity Reduce the population of P. Acnes and thereby its extracellular products Produce an anti-inflammatory effect

Correct Defect in Keratinization Topical Retinoids (tretinoin, adapalene, tazarotene) Alpha hydroxy acids Salicylic acid Systemic 13 cis retinoid acid (Accutane)

Reduce P. Acnes Population Topical Benzoyl peroxide Azelaic acid Topical antibiotics Systemic Antibiotics Retinoids

Produce an Anti-inflammatory Effect Local intralesional corticosteroids acne surgery Topical dapsone – may be more effective in adult females Systemic Antibiotics Tetracycline, doxycycline, minocycline corticosteroids

Dapsone 5% gel BID Appears to act an anti-inflammatory agent More effective in adult female acne than in adolescents or men Can be oxidised by BPO casuing orange-brown coloration (can be washed off).

Decrease Sebaceous Gland Activity Hormonal Therapy OCP’s FDA approved for acne: Ortho Tri-Cyclen, Estrostep and Yaz Least androgenic progestins: desogestrel, norgestimate Drospirenone has antiandrogenic properties Spironolactone Oral Retinoids

Oral Contraceptives As effective as oral antibiotics, but slower (equal efficacy at 6 months, antibiotics win at 3 months) Improve both inflammatory and non-inflammatory acne Risks must be considered. Especially useful in women who wish contraseption or have other indications such as menorrhagia

OCP’s Only 4 FDA approved for acne: Ethinyl estradiol/norgestimate (Ortho TriCyclen) Ethinyl estradiol/norethindrone (Estro step) Ethinyl estradiol/drospirenone (Yaz) Ethinyl estradiol/drospirenone/levomefolate (Beyaz)

Spironolactone 50-200 mg/day No need to check potassium in young healthy women

Diet AAD Guidelines: No specific dietary changes recommended in manage of acne Low glycemic index diets may improve acne Limited evidence suggest that some dairy, especially skim milk may aggravate acne

13-cis retinoic acid (Accutane) Extremely effective agent in acne vulgaris Extremely potent teratogen Other side effects include: Dryness of the skin Hyperlipidemia Boney spur formation Rarely depression Inflammatory bowel disease- debated, but likely no relationship

13-cis-retinoid acid dosing 1mg/kg x 20 weeks 120-150mg/kg total dosage Must be prescribed through the ipledge program Some advocating higher dosing 220mg/kg to reduce recurrence

Drug-induced Acne Anabolic steroids Corticosteroids Phenytoin Lithium INH EGFR inhibitors

Acne Rosacea Etiology Vasomotor Liability menopause alcohol and spicy foods Disruption of epidermal barrier Triggering of innate immune system Demodex Mites

Rosacea: 4 types Erythematous/telangiectatic Papulopustular Phymomatous Ocular Unlike acne rosacea does not cause comedones. Patient’s can have both.

Rosacea Treatment Avoid triggers of flushing Topicals Metronidazole cream/gel Sodium sulfacetamide Clindamycin lotion Azelaic acid Ivermectin (Soolantra) Brimonidine (Mirvaso) Oral antibiotics- doxycycline 13-cis retinoid acid

Brimonidine (Mirvaso) Vasoconstrictive Selective α2-adrenergic receptor agonist 10-20% may have rebound erythema

Perioral Dermatitis Primarily young women Discontinue topical steroids Topical metronidazole, erythromycin, clindamycin, pimecrolimus may help Low dose tetracyclines very effective

Topical Steroids Can induce either perioral dermatitis or acne rosacea In general, no topical steroids stronger than 1% hydrocortisone should be used on the face