Treatment of Acne

What is acne? Acne vulgaris: a chronic condition linked to the onset of puberty Not a physical threat; However, acne may have a significant negative psychological effect: low self esteem, social phobia and depression; Universal incidence; 85% of those between 15-24 years;

Pilosebaceous Unit: most commonly on face, chest and back Anatomy and Physiology of skin Pilosebaceous unit=hair follicle + sebaceous gland Pilosebaceous Unit: most commonly on face, chest and back

Etiology of Acne Abnormal keratinization of the epithelial cells in the infindibulum (duct); An increase in sebum production; An accelerated growth of Propiobacterium acnes; The occurrence of inflammation;

Pathophysiology of Acne Abnormal keratinization of the cells in the infundibulum results in obstruction of the follicle with impacted cells and sebum to form a plug; This plug will distend the follicle and form a microcomedone Microcomedone is the initial pathologic lesion of acne

Microcomedone

Pathophysiology of Acne As more sebum accumulate, the microcomedone enlarges and becomes visible as a closed comedo, or white head The whitehead: is a small pale nodule just beneath the skin surface that may form a precursor for other acne lesions An open comedo (blackhead) occurs: when the desquamated epithelial cells and sebum accumulate behind the plug and the orifice of the follicular canal becomes distended, allowing the plug to protrude The tip of the plug may darken because of melanin NOT dirt;

Closed comedone (whitehead)

Open comedo (blackhead)

Pathophysiology of Acne Increase in the level of circulating androgens stimulates production of sebum, which is prevented from reaching the skin surface by the obstructing plug; At same time; P. acnes colonizes the pilosebaceous duct; Bacterial colony counts are higher in patients with acne than in those without acne P. acnes: major contributor to causing inflammatory acne lesions lipase: breakdown of sebum to highly irritating free fatty acids The resultant inflammation: localized tissue destruction

Pathophysiology of Acne Inflammatory acne begins with closed comedones that distend the follicle, causing the cellular lining of the walls to spread and become thin; Primary inflammation results from disruption of the epithelial lining + lymphocyte infiltration A severe inflammatory reaction happens if the follicle wall ruptures spontaneously or is ruptured by picking, squeezing, or attempted expression with a comedo extractor

Papules Pustules

Pathophysiology of Acne Contents are discharged into surrounding tissue: abscesses scars or pits after healing Pustules or purulent nodules of inflammatory acne are more likely to cause scarring than those of non-inflammatory acne Pits

Exacerbating Factors for Acne Several factors are known to exacerbate existing acne or cause periodic flare-ups of acne in some patients; Some may have control over, while others not (e.g. heredity); Factors: environmental and physical, cosmetic use, hormonal factors and medication use

Environmental & Physical Hydration: decreases size of duct orifice and prevents loosening of comedone. e.g. high humidity environment or prolonged sweating and occlusive clothing Irritation and friction (acne mechanica): may increase symptoms of acne. E.g. occlusive clothing, headbands, helmets, resting chin or cheek on hand etc Occupational acne: exposure to dirt, vaporized cooking oils, or certain industrial chemicals

Cosmetic Use Acne cosmetica: mild form of acne on the face, cheek and chin; Typically: closed, non-inflammatory comedones; Occurs as a result of using oil-based products on the skin that causes occlusion of the pilosebaceous unit; Oil-based cosmetics may exacerbate acne or even induce it; Moisturizers or tanning oils may contain comedogenic oils (e.g. lanolin, mineral oil, cocoa butter)

Rosacea Comedo extractor Pomade acne Pustules (purulent nodules) pustule

Emotional Factors Hormonal Factors Severe or prolonged periods of stress may exacerbate acne; however they do not induce acne! Mechanism is not known Hormonal Factors Many women with acne experience a premenstrual flare-up of symptoms (i.e. ovulation, pregnancy). OCP with high androgenic progestin are implicated in the production of acne

Medication Use P I M L E S Phenytoin Isoniazid Moisturizers Phenobarbital Lithium Ethionamide Steroids

Unsubstantiated Etiologic Factors Little evidence supports link between: diet and acne; A rule of thumb: people should be advised to avoid any particular food that seems to exacerbate their acne; Excessive scrubbing in attempt to open blocked pores may exacerbate rather than improve acne

Signs and Symptoms of Acne Non-inflammatory acne is characterized by whiteheads or blackheads Inflammatory acne is characterized by pimples (i.e. small, prominent inflamed elevations of the skin) which may rupture to form a papule Papules are inflammatory lesions appearing as raised, reddened areas on the skin, which may enlarge to form pustules Pustules appear as raised reddened areas filled with pus

Papule pimple whiteheads blackheads pustule

Very severe acne, cystic acne, acne conglobata

Classification of Acne Grade of Acne Qualitative Description Quantitative Description I Comedonal acne Comedones only, < 10 on face, none on trunk, no scars, noninflammatory lesions only II Papular acne 10-25 papules on face and trunk, mild scarring, inflammatory lesions < 5 mm in diameter III Pustular acne More than 25 pustules, moderate scarring, size similar to papules but with visible purulent core IV Severe persistent pustulocyctis acne Nodules or cysts, extensive scarring, inflammatory lesions > 5 mm in diameter - Recalcitrant severe cystic acne Extensive nodules/cysts

Treatment of Acne Non-pharmacologic therapy Cleansing of Skin (avoid abrasive producs) Staying well-hydrated Minimizing Exacerbating factors Physical treatment with acrylate glue-based strips (help in extraction of impacted comedones) – better alternatives to picking acne that may result in scarring) Pharmacologic Therapy

Topical retinoid: 1-Tazarotene 2-Adapalene adapalene 0.1% gel is the first and only OTC topical retinoid (2016) 3-Tretinoin Antibiotics -tetracycline, minocycline, doxycycline -erythromycin -Clindamycin

Important points to remember! Self-treatment of acne is effective in patients mature enough to understand that acne can be controlled but not cured; Treatment of noninflammatory acne: pharmacologic agents + nonpharmacologic measures; Self treatment is appropriate only for grade I acne (i.e. noninflammatory acne of mild to moderate severity), presenting with open or closed comedones

Exclusion for Self-Treatment Grades II-IV acne: papules, pustules, nodules, cysts and/or scarring Severe, recalcitrant acne (extensive nodules/cysts) Exacerbating factors (e.g. comedogenic drugs) Possible rosacea (If acne lesions persist beyond mid-20s or develop in the mid-20s or later, the symptoms may signal rosacea rather than acne vulgaris)

Comedonal acne - topical treatment appropriate: Pustular - an oral antibiotic would be best: Comedonal acne - topical treatment appropriate:

Severe acne treated with Isotretinoin: A) Before treatment: B) After 5 months

OTC Therapy Benzoyl Peroxide Salicylic acid Sulfur Sulfur-Resorcinol combination products Alpha-hydroxy acids

Benzoyl Peroxide Available in variety of concentrations (2.5%, 5% & 10%) & dosage forms (lotions, gels, creams, cleansers, masks & soaps); MOA: (1) irritation & desquamation-prevents closure of pilosebaceous duct. Increase turnover rate of epithelial cells. (2) Oxidizing potential-antibacterial activity, decreasing P.acnes Is frequently combined with topical antibiotics (reduces the P. acnes resistance)

Benzoyl Peroxide The most effective and widely used OTC drug for non-inflammatory acne; Clinical response to all concentrations is similar in reducing the number of inflammatory lesions Should be applied to the entire affected area, & not only to visible blemishes Should not be applied for 20 min. after washing with a cleanser to minimize irritation Use only one application per day or every other day Leave initial application for only 15 min., then wash off New formulation: phospholipid liposomes (not commercially available) promise for papulopustular acne

If no discomfort, increase time the product is left on the skin in 15 min. increments Once tolerated for 2 hours, leave on the skin overnight After initial 1-2 weeks, application can be increased to 2-3 TD over a period of 2-3 days, as tolerated Fair skinned patients should apply 2.5% product initially Max. effect may develop only after 4-6 weeks If necessary, strength may be increased to 5% after 1 wk, then to 10% after 2 wks

Continue treatment even after clearance of lesions If no improvement after 6 wks or if ADRs, seek medical attention, Use carefully around nose, lips, eyes & near cuts Use other acne products only as indicated Avoid sun & UV lamps, use sunscreens with SPF > 15

Benzoyl Peroxide Adverse Effects: some skin sloughing, erythema or edema lower concentrations must be used for shorter duration Allergic reactions – should be tested on antecubital area Precautions: (1) bleach hair, clothes, bed linens, (2)avoid excessive sun or sunlamps, Concern: tumorigenic potential

Salicylic Acid Available in wide range: 0.5%-2% A milder, less effective alternative for tretinoin MOA: acts as a surface keratolytic, mild comedolytic agent Milder effect that tretynoin Is used as adjunctive treatment in cleansers Should not be used in DM & in poor circulation Use on large surface for long periods may result in toxicity Needs sunscreen In case of irritation, limit to once daily use

Sulfur Keratolytic and antibacterial (precipitated or colloidal) 3%-10% Generally: accepted as effective in promoting the resolution of existing comedones, but, on continued use, may have a comedogenic effect Alternative forms of sulfur: Na thiosulfate, Zn sulfate, Zn sulfide NGRSE Applied in thin film to skin 3 times daily Have noticeable color and odor

Sulfur-Resorcinol combination 3-8% sulfur with resorcinol 2-3% (enhances effect of sulfur) MOA: keratolytics, fostering cell turnover & desquamation Resorcinol produces a reversible dark brown scale on some darker-skinned individuals

Sulfur-Sodium sulfacetamide Combination destroys PABA, essential component for bacterial growth

Alpha-hyrdoxy Acids They occur naturally in sugar cane, fruits & milk products; Are keratolytic Less potent & are used when patient cannot tolerate other topical products The most useful AHAs in dermatologic practice are glycolic, lactic & citric acids MOA: facilitate desquamation of the stratum corneum. No evidence to support use in acne – but may be useful after acne control as peeling agents to control scarring & hyperpigmentation

Therapeutic Comparison Benzoyl Peroxide Salicylic Acid Sulfur Bactericidal Yes - Keratolytic Slight Comedolytic Concentration 2.5%-20% 0.5%-2% 2%-10% Frequency of use 1-2 times daily Used mainly as cleanser, then rinsed off 1-3 times daily Adverse effects Bleached hair and clothing Potent keratolytic at high concentration Color, unpleasant odor

CAM Tea tree oil: comparative to benzoyl peroxide but: slower onset Oral zinc: may be used as alternative to tetracycline esp. in summer (photosensitivity). ADRs: nausea & gastralgia Nicotinamide: used in Europe for inflammatory acne

Product Selection Guidelines Cleansers (bars, liquids) are not of much value (WHY?) Gels are the most effective (WHY?) Gels & solutions cause drying - sometimes contact dermatitis but are beneficial for oily skin Lotions & creams with low fat content are intended to counteract drying (astringent effect) and peeling (keratolytic effect): alternative to more effective gels for dry sensitive skin or during winter weather Ointments are greasy & may worsen acne

Patient Education: Acne is not caused by poor hygiene or eating greasy or sugary foods Can be controlled by certain medications but not cured The goal of self-treatment is to control mild acne, thus preventing more serious form from developing Best approach is use cleansers and medications to keep skin ducts and orifices open Many OTC products are used with prescription ones

Patient Education: Cleanse skin thoroughly but gently at least twice daily to produce a mild drying effect that loosens comedones, using soft wash cloth, warm water and facial soap without moisturizing oils To prevent or minimize acne flare-ups, avoid or reduce exposure to environmental factors, such as dirt, dust, petroleum products, cooking oils or chemical irritants

Patient Education: To prevent friction or irritation that may cause acne flare-ups, do not wear tight-fitting clothes, headbands, or helmets, avoid resting the chin on the hand; To minimize acne related to cosmetic use, do not use oil based cosmetics and shampoos

“I know you're never supposed to squeeze a zit, but I'm not about to leave the house with a major eruption on my face. Isn't there any good way to pop it?” !!!!!

Patient Education: To prevent excessive hydration of the skin, which can cause flare-ups, avoid areas of high humidity and do not wear tight fitting clothes that restrict air movement; Avoid stressful situations & practice stress management techniques. Stress may worsen only existing acne. Do not pick or squeeze pimples – may worsen acne & lead to scarring