Acne Bill V. Way, D.O. Dermatology Residency Program Director

What is Acne? Acne is a skin disorder resulting from the action of hormones on the skin’s oil glands (sebaceous glands) which leads to plugged pores and outbreaks of the lesions of papules, pustules, comedones, inflammatory cysts commonly called pimples or zits.

Acne Over 17 million people in the US have acne today. It is the most common skin disease. Not a serious health threat, but severe acne can lead to disfiguring, permanent scarring, low self esteem.

Acne The disease of the pilosebaceous units of the skin. Most commonly on the face, neck, chest, back and shoulders were more of the pilosebaceous units are located.

Acne The basic acne lesion is called the comedo (KOM-e-do), simply an enlarged and plugged hair follicle. If it remains below the surface it is called a closed comedo and produces a whitish bump called a whitehead, this is not a milium.

Acne: Comedo If the comedo reaches the surface, it is called an open comedo or blackhead The black color is not dirt, but is from the oil oxidizing when it reaches the surface of the skin

Acne: Papule Inflammed lesions that usually appear as small pink bumps on the skin and may be tender to the touch

Acne: Pustule Inflammed papules with a pustule on the top that may be red at the base and usually tender. (Pimple)

Acne: Nodules Large, painful, solid lesions that are lodged deep within the skin

Acne: Cysts Deep,painful, pus-filled lesions that can cause scarring

What causes Acne? Exact cause of acne is unknown. Several factors may play a role. One important factor is an increase in androgens (male hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.

What causes Acne? Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing Hormone changes related to pregnancy or starting and stopping birth control pills can also be a cause of acne.

What causes Acne? Propionibacterium acnes (P.acnes) are the anaerobic bacteria responsible for causing acne. Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing Hormone changes related to pregnancy or starting or stopping birth control pills can also be a cause of acne.

Propionibacterium acnes Anaerobic bacteria in hair follicle. These bacteria use the sebum as food and break the sebum down into irritating substances, which cause inflammation. The abnormal flaking of the cells inside the hair follicle and the irritating substances lead to a plug formation and the to follicle swelling and then rupturing and developing into the papule then to the pustule.

What can make Acne worse? Changing hormone levels in adolescent girls and adult women 2-7 days before their menstrual period starts Friction by leaning or rubbing skin Pressure from helmets, backpacks Environment: pollution and high humidity Squeezing or picking at pimples Hard scrubbing of the skin

Myths about causes of Acne Foods; chocolate, greasy or fried foods. No foods cause acne. Dirt. Acne is not the result of uncleanliness or infrequent washing. Stress. Just the opposite, Acne may cause the patient more stress. Sunlight or tanning clears acne. No tanning will lead to sundamaged skin, wrinkles and skin cancers. Skin must be scrubbed. No, too much scrubbing may actually make acne worse.

Who gets Acne? People of all races and ages. Most common in adolescents and young adults 85% between ages Resolves with time around age Few patients may have persistent acne into their 40’s and 50’s

Who should be treating Acne? Family Practice Pediatrics Internal Medicine Dermatology

What are the goals in treating Acne? Heal existing lesions Stop new lesions from forming Prevent scarring Minimize the psychological stress and embarrassment, thus improving self-esteem and self-confidence and avoiding depression Teach the patient what acne is, how to treat their acne and what to expect from treatment

Acne Treatment Medical treatment is aimed at reducing several problems that play a role in causing acne; abnormal clumping of cells in the follicles, increased oil production, bacteria and inflammation.

Grading Acne Scale – no acne, clear +1– mild acne, comedos, papules, few pustules +2 – moderate acne, comedos, multiple papules and pustules +3 – moderately severe, multiple comedos, papules and pustules, mild scarring +4 – severe, multiple comedos, papules, pustules, inflammatory cysts, nodules, scarring

Treatment for Blackheads, Whiteheads and mild inflammatory Acne OTC or Rx Benzoyl peroxide, resorcinol, salicyclic acid and sulfur Benzoyl peroxide products kill P.acnes and may reduce oil production Resorcinol and salicyclic acid and sulfur help break down blackheads and whiteheads

OTC Treatment Benzoyl peroxide washes and gel Salicyclic Acid washes Must be used twice daily regularly for weeks, then reevaluate

Treatment of Moderate to Severe Inflammatory Acne Prescription topical and or oral medications alone or in combination Recheck patient every 4-8 weeks for results and to adjust acne treatment program

Treatment of Severe Nodular or Cystic Acne Should be seen and treated by a dermatologist Failure to respond to a variety of topical antibiotics, topical retenoids and oral antibiotics Consider Accutane Therapy

OTC Topical Acne Cleansers Neutrogena Acne Wash Cetaphil Facial Cleanser Oil of Olay Facial Cleanser Various Benzoyl Peroxide Cleansers, Clearsil, Clean and Clear, others

Acne Treatment Clean skin gently Avoid squeezing, pinching, picking or scratching the acne lesions. Bleeding leads to scarring Shave carefully Avoid sunburn or suntan Choose cosmetics carefully, oil-free, water based

OTC Acne Topicals Benzoyl peroxide cleansers Sulfur products Salicyclic acid pads

Prescription Acne Cleansers Benzoyl Peroxide Brevoxyl 4%, 8% Triaz 3%, 6%, 10% Benzac 5%, 10%

Prescription Cleanser Plexion Cleanser: Sodium Sulfacetamide 10% & Sulfur 5%

Topical Antibiotics Clindamycin: Solution,Gel, Lotion, Pads Erythromycin:Solution,Gel,Pads, Ointment Combination: Benzoyl peroxide and topical antibiotic Sodium Sulfacetamide and Sulfur

Topical Antibiotics Cleocin T Solution, Lotion, Gel, Pads Erycette Pads Benzamycin Gel BenzaClin Gel Klaron Lotion Plexion SCT

Topical Retenoids Retin A: gel, cream, microgel Differin: gel, cream, pad Generic Tretinoin: gel, cream

Retin A Microgel 0.04% and 0.1% 20gm and 45gm Apply at hs Recommend sunscreens in am

Oral Antibiotics Tetracycline Minocycline Doxycycline Erythromycin Azithromycin

Oral Tetracycline Generic Tetracycline is ok Must be taken correctly, 1 hour before meal or 2 hours after meal with glass of water Not to taken with milk Increased change of inducing vaginal yeast infections

Oral Minocycline Dynacin, Minocin, Adoxa, Generic Better absorption, less GI upset May be taken with food, minimal loss of effect 1-2 times daily Avoid 100mg bid for it may induce a blue gray hyperpigmentation in areas of cysts, bleeding or brusing

Oral Minocycline Increased cost Very effective May be used long term

Oral Doxycycline Doryx, Generic Good absorption, less GI upset May be taken with food, minimal loss 1-2 times daily Occasional photosensitivity, rare Increased cost, very effective, may be used long term

Oral Erythromycin Eryc 250mg 1 bid Effective for short times, then bacterial resistance starts to develop Low cost, increased GI upset May have other drug interactions

Oral Azithromycin Recommend use only by dermatologist due cost

Accutane (Isotrenoin) 10mg, 20mg, 40mg Used by itself Patients must be enrolled into the SMART Program and rules and regulations must be followed exactly Recommend patient be referred to dermatologist

Accutane (Isotretinoin) Very effective Useful to help prevent scarring weeks of therapy SMART Program Expensive Patient must be monitored very closely No other acne treatment needed

Accutane: Disadvantages Can cause birth defects Female patients must not get pregnant while on Accutane Depression, Irritability Loss of appetite, hair thinning, curling Dry eyes, mouth, lips, nose and skin, itching, nosebleeds, muscle aches, sensitivity to sun, poor night vision

Accutane: Disadvantages Changes in blood such as increase in triglycerides and choesterol or a change in liver function Must monitor blood prior to starting and every 4 weeks while on Accutane CBC, CMP, Lipid Panel, UA, Urine pregnancy test

Adjunct Derm Treatment Acne Surgery Mild Chemical Peels Microdermabrasion New ClearLight treatment Dermabrasion or Laser tx for scarring Surgical scar revision Fillers for scars, fat transfer Intralesional steroid injections

How often should the Acne Patient be seen? Initially every 4-8 weeks Then every 8-12 weeks Then every 3-4 months Acne is monitored and treated for several years from ages 12-25

Hormonally Influenced Acne Increased excessive androgen levels in females may present as hirsutism, premenstrual acne flares, irregular menstrual cycles, elevated blood levels of certain androgens Birth control pills with increased androgens will increase acne Birth control pills with increased estrogens decrease acne

Recommend OrthoTri-Cyclen or Demulen Occasionally but rare use of low dose corticosteroid drugs, prednisone or dexamethasone may be used to suppress the androgen production by the adrenal gland Occasional use of spironolactone to reduce excessive oil production.

Web Sites on Acne www. aad.org