A treatment guide Dr Paul Charlson GPSI Dermatology East Yorkshire ACNE A treatment guide Dr Paul Charlson GPSI Dermatology East Yorkshire

Treatment Psychological Mild Moderate and Severe Scarring

Actions of Anti Acne Therapies Topical retinoids: Normalize desquamation Reduce inflammatory response Oral Isotretinoin: Reduces sebum Normalizes desquamation Inhibits P acnes Reduces inflammatory response Antibiotics: Kill microorganisms Reduce inflammatory response ACTIONS OF ANTI-ACNE THERAPIES Topical retinoid drugs have a dual role in acne: 1) they have a direct effect on both inflammatory lesions and comedones and 2) they target the microcomedo – a microscopic precursor of all acne lesions (pimples, whiteheads, and blackheads). By stopping the formation of microcomedones, topical retinoids prevent the formation of new acne lesions (both inflammatory lesions and comedones). Antibiotics and benzoyl peroxide act by reducing P acnes concentrations; antibiotics also reduce the inflammatory response. Hormonal therapy reduces sebum production by blocking ovarian and/or adrenal androgens. Oral isotretinoin is the only available therapy that acts on all four areas of acne pathophysiology. However, isotretinoin is highly teratogenic and thus is reserved for use in severe and recalcitrant acne. Hormones: Reduce sebum production Benzoyl peroxide: Kills microorganisms

Acne-psychology Acne affects 80% of adolescents Don’t underestimate the psychological impact Acne suffers have a higher incidence of anxiety and depression Make sure patients are clear about their treatments, side effects and time scales Involve patients in their treatments

MILD ACNE

TREATING MILD ACNE GENERALLY USE TOPICALS START WITH BPO - LOW TO HIGH STRENGTH ADD TOPICAL RETINOID- OR START WITH IF MAINLY COMEDONES TOPICAL ANTIBIOTICS+ZINC OR BPO OR RETINOID IF INFLAMATION IS PRESENT TOO - TRY AZELIAC ACID 25% CREAM WHICH CAN RED POST INFLAMMATORY PIGMENTATION TOO

Topicals - General rules Make sure patients treat whole area not just spots Avoid abrasive cleansers may worsen acne by provoking inflammation Gels for oily skin but sting dry skin Cream for sensitive/dry skin but can make greasy

BENZOYL PEROXIDE EFFECTIVE AND CHEAP ANTIMICROBIAL, SLIGHT ANTI-INFLAMMATORY TENDS TO BE SLOW-MAY TAKE MONTHS LOW STRENGTH CAN OFTEN BE AS EFFECTIVE AS HIGHER STRENGTH SKIN IRRITANT STAINS CLOTHES

TOPICAL RETINOIDS RETIN A (TRETINOIN),ISOTREX GEL (ISOTRETINOIN),DIFFERIN (ADAPALENE) ANTI COMEDONAL ,SOME ANTI-INFLAMMATORY EFFECT USE ALT NIGHTS FIRST - IF SENS SKIN WASH IT OFF AFTER AN HR, IF IT IRRITATES USE LESS OFTEN-SOME PEOPLE CANT USE IT IF NOT INCREASE TO NIGHTLY THEN BD USE SUNSCREEN AVOID EYES AND MOUTH-APPLY THINLY

TOPICAL ANTIBIOTICS REDUCE BACTERIA NOT AS IRRITANT AS BPO BUT CAN CAUSE CONTACT DERMATITIS EFFECT ON INFLAMMATION BETTER THAN COMEDONES USE IN COMBINATION WITH BPO OR ZINC

MILD ACNE SUMMARY COMEDONAL -TOP RETINOID OR BPO THEN A COMBINATION INFLAMMATORY - BPO IF NO RESPONSE AFTER 2/12 ADD IN TOPICAL ANTIBIOTIC AZELIAC ACID MAY HAVE A PLACE IF BPO OR RETINOID TOO IRRITANT NICOTINAMIDE AND N-LITE LASER PLACE UNCLEAR

MODERATE ACNE

MODERATE ACNE USE TOPICALS AND ADD AN ORAL ANTIBIOTIC USE ANTIBIOTIC FOR 3/12 BEFORE CALLING “FAILURE” AVOID RESISTANCE BY USING ADEQUATE DOSES

ORAL ANTIBIOTICS ANTIBACTERIAL-ANTI INFLAMATORY-REDUCE KERATIN USE WITH TOPICAL AGENT-RETINOID +- BPO OXYTET 500 BD-RESPONSE 2-3 MONTHS-IF OK CONTINUE FOR AT LEAST 6/12 AND UP TO A YEAR IF FAILS BY 3/12-CHECK COMPLIANCE-IF OK-CHANGE TO LYMECYCLINE AND ADD BPO? AS WELL AS RETINOID OR TRIMETHOPRIM (UNLICENSED) THERE IS TOO MUCH RESISTANCE TO ERYTHROMYCIN CONSIDER ANTI-ANDROGEN IN WOMEN

MAINTENANCE USE AFTER STOPPING ORAL ANTIBIOTIC USE TOPICAL RETINOIDS FOR MAINTENANCE USE FOR AS LONG AS NECESSARY - EVIDENCE SCANT CAN ADD BPO IF NECESSARY

ANTI ANDROGENS REDUCE SEBUM AND COMEDONES NOT A FIRST LINE TREATMENT DIANETTE IS USUALLY USED-35MCG OF EO-RISKS! TAKES 2-3/12 MAX EFFECT YASMIN MAY BE GOOD OTHERS SPIRONOLACTONE,CYPROTERONE ACETATE ALONE AND FINESTERIDE (IN MALES TOO)

WHEN TO REFER ANY PTS WITH NODULES OR CYSTS THAT ARE SCARRING FAILURE TO CONTROL ACNE WITH ORAL ANTIBIOTICS AT 6/12 PERSISTENT ACNE OVER 25 VERY DISTRESSED PATIENTS

SEVERE ACNE WITH CYSTS

ISOTRETINOIN SPECIALIST ONLY 0.5-1G DAILY FOR 4/12 -6/12 CONTRACEPTION AND PREG TESTS ESSENTIAL VERY EFFECTIVE-40% CURE AFTER ONE COURSE 40% LOW LEVEL RECURRENCE,20% NEED A FURTHER COURSE TERATOGENIC ALL GET DRY LIPS/NOSE DRY EYES, NOSE BLEEDS, MUSCLE ACHES ACNE CAN GET WORSE FOR 2 WEEKS BEFORE IMPROVING MAINTENANCE -RETINOIDS TOPICALLY

SCARS FROM SEVERE ACNE

SCARRING MACULAR ERYTHEMA CAN TAKE A YEAR TO FADE SCARS FLAT SCARS USUALLY IN DARKER SKINS HYPERTROPHIC/KELIOD SCARS LOSS OF TISSUE 1. ICE PICK-SMALL JAGGED SCARS 2.BOX SCARS -U SHAPED FIBROTIC SCARS 3.ROLLING SCARS-DEEP SOFT ROLLED EDGES 4.ATROPHIC -SMALL, WHITE SOFT BARELY RAISED

TREATMENT OF SCARS DEPRESSED SCARS-SUBSCISION AND FILL WITH A DERMAL FILLER- LARESSE? OR HA DERMABRASION-MICRODERMABRASION FOR FAINT SCARS CHEMICAL PEELS-IMPROVES PIGMENTATION AND IMPROVES MACULAR,ICE PICK AND BOX SCARS-MILD TO MEDIUM DEPTH PEELS LASER RESURFACING PUNCH EXCISION + - SKIN GRAFT COMBINATION TREATMENTS

HOT TIPS BE CONFIDENT- MOST CAN BE TREATED IN PRIMARY CARE SUCCESSFULLY GRADE THE ACNE -USING A GRADING SCALE HAVE A CLEAR MANAGEMENT PLAN USE MORE TOPICAL RETINOIDS COMBINATION INDIVIDUALISED TREATMENT IS “IN” MANY TREATMENTS FAIL BECAUSE OF NON COMPLIANCE-EXPLAIN THERE IS NO INSTANT RESULT AND SOME AGENTS MAY HAVE SIDE EFFECTS TREAT THE PSYCHOLOGICAL EFFECTS - IMPORTANT DON’T GIVE UP TOO SOON