Acne Vulgaris II Acne Vulgaris II

Topical medications Retinoids Retinoids Keratolytics (comedolytics) Keratolytics (comedolytics) Antibiotics Antibiotics

Comedolytics Agents that loosen hard plugs and open pores such as: Agents that loosen hard plugs and open pores such as: Benzoyl peroxide Benzoyl peroxide Azelaic acid Azelaic acid Salicylic acid Salicylic acid Tretinoin (Retin-A) Tretinoin (Retin-A) Tretinoin Adapalene (Better tolerated than Tretinoin) Adapalene (Better tolerated than Tretinoin) AdapaleneTretinoin AdapaleneTretinoin

Benzoyl Peroxide Benzoyl Peroxide A comedolytic: peeling and keratolytic effect A comedolytic: peeling and keratolytic effect It is converted in the skin into benzoic acid that has an antibacterial action (specifically P. acnes) It is converted in the skin into benzoic acid that has an antibacterial action (specifically P. acnes)P. acnesP. acnes No resistance develops No resistance develops Frequent use inhibits the development of bacterial resistance Frequent use inhibits the development of bacterial resistance Two common combination drugs, include benzoyl peroxide/ clindamycin and adapalene / benzoyl peroxide, Two common combination drugs, include benzoyl peroxide/ clindamycin and adapalene / benzoyl peroxide,combination drugsbenzoyl peroxide/ clindamycinadapalene / benzoyl peroxidecombination drugsbenzoyl peroxide/ clindamycinadapalene / benzoyl peroxide

Benzoyl Peroxide Side effects: 1-Skin dryness & irritation, erythema (limit its use to short periods, Use water based instead of acetone or alcohol product, Use Lotion or cream instead of gel, Avoid contact with eyes, mouth, m.m, Start treatment with lower strength preparations) 2- Allergic contact dermatitis 3- Bleaches hair and skin 4- Bleaching of clothing may also occur Other uses: Higher concentrations are used for hair bleach and teeth whitening

Azelaic Acid Azelaic Acid is a naturally occurring dicarboxylic acid used for the treatment of acne and pigmentary disorders Azelaic Acid is a naturally occurring dicarboxylic acid used for the treatment of acne and pigmentary disorders Mechanism of action It has a comedolytic and peeling action It has a comedolytic and peeling action It has antibacterial activity against P. acens It has antibacterial activity against P. acens It has additional anti-inflammatory properties It has additional anti-inflammatory properties Azelaic acid may be synergistic with retinoids Azelaic acid may be synergistic with retinoids

Azelaic Acid Side effects: Local irritation, but less than benzoyl peroxide and tertinoin Local irritation, but less than benzoyl peroxide and tertinoin Burning, tingling Burning, tingling Local erythema Local erythema Therapeutic uses: Rx of mild- moderate acne of the face Rx of mild- moderate acne of the face Rx of skin pigmentation including melasma and post inflammatory hyperpigmentation (inhibition of tyrosinase, the rate-limiting enzyme in the synthesis of melanin) Rx of skin pigmentation including melasma and post inflammatory hyperpigmentation (inhibition of tyrosinase, the rate-limiting enzyme in the synthesis of melanin)

Salicylic acid Salicylic acid is a b-hydroxy acid, a keratolytic. It belongs to the same class of drugs as aspirin (salicylates). Salicylic acid is a b-hydroxy acid, a keratolytic. It belongs to the same class of drugs as aspirin (salicylates).aspirin MOA: It dissolves the intercellular cement (the substance that causes the skin cells to stick together). This makes it easier to shed the skin cells. MOA: It dissolves the intercellular cement (the substance that causes the skin cells to stick together). This makes it easier to shed the skin cells. a key ingredient in many skin-care products for the treatment of seborrhoeic dermatitis, acne, psoriasis, corns, and warts a key ingredient in many skin-care products for the treatment of seborrhoeic dermatitis, acne, psoriasis, corns, and wartsseborrhoeic dermatitisacnepsoriasis cornswartsseborrhoeic dermatitisacnepsoriasis cornswarts Products containing salicylic acid include facial cleansers and antidandruff shampoos Products containing salicylic acid include facial cleansers and antidandruff shampoos

Salicylic acid Local irritation even ulceration with the use of high concentration Local irritation even ulceration with the use of high concentration Systemic absorption with prolonged use causing salicylate poisoning = salicylism (headache, confusion, blurred vision, ringing in the ear) Systemic absorption with prolonged use causing salicylate poisoning = salicylism (headache, confusion, blurred vision, ringing in the ear) Allergic reactions Allergic reactions N. B. should not be used on the face or on moles, birthmarks, warts with hair growing from them, or genital/anal warts or inside the nose or mouth as it may cause severe irritation. N. B. should not be used on the face or on moles, birthmarks, warts with hair growing from them, or genital/anal warts or inside the nose or mouth as it may cause severe irritation.

Topical Antibiotics They are protein synthesis inhibitors that have inhibitory effect on Propionibacterium acnes They are protein synthesis inhibitors that have inhibitory effect on Propionibacterium acnes Suitable for mild to moderate inflammatory cases Suitable for mild to moderate inflammatory cases Come in a variety of forms, including lotions, gels, pads and toner-like solutions Come in a variety of forms, including lotions, gels, pads and toner-like solutions Possible side effects; 1-Dryness, irritation of the skin  burning sensation 2- Photosensitivity (use sunscreen) 3- Resistance: For this reason, monotherapy with topical or systemic antibiotics is discouraged. The concurrent use of topical benzoyl peroxide has been shown to inhibit and decrease resistance

Topical Antibiotics  Erythromycin 2%  Clindamycin 1 %  Tetracyclines (used less often)  Erythromycin-benzoyl peroxide combinations (Benzamycin) in patients with an inflammatory component

Oral medications Oral Antibiotics Oral Antibiotics Retinoids Retinoids Oral corticosteroids Oral corticosteroids Anti-androgens Anti-androgens

Oral Antibiotics Systemic therapy is prescribed when wide distribution of lesions makes topical therapy impractical and for patients resistant to topical therapy  Oral antibiotics are usually administered twice daily for 4- 6 months  Tetracycline  Erythromycin  Clindamycin (oral and topical)  Minocycline  Trimethoprim-sulfamethoxazole

Tetracycline Tetracycline is the most commonly employed antibiotic because it is inexpensive, safe, and effective Tetracycline is the most commonly employed antibiotic because it is inexpensive, safe, and effective Although tetracycline is an antimicrobial agent, its efficacy in acne may be more dependent on its anti-inflammatory activity Although tetracycline is an antimicrobial agent, its efficacy in acne may be more dependent on its anti-inflammatory activity

Tetracycline: side effects It must be taken on an empty stomach It must be taken on an empty stomach Tetracycline should not be given to pregnant women or children under 9 years Tetracycline should not be given to pregnant women or children under 9 years Photosensitization Photosensitization Tooth discoloration Tooth discoloration Vaginal candidiasis is a common complication that is readily treated with local administration of antifungal drugs Vaginal candidiasis is a common complication that is readily treated with local administration of antifungal drugs

Minocycline is a tetracycline derivative, better GIT absorption than tetracycline and may be less photosensitizing than tetracycline Minocycline is a tetracycline derivative, better GIT absorption than tetracycline and may be less photosensitizing than tetracycline Side effects: Dizziness Dizziness Hyperpigmentation of the skin and mucosa Hyperpigmentation of the skin and mucosa Containdicated in pregnant or breastfeeding women Containdicated in pregnant or breastfeeding women If used by younger children, it can cause permanent tooth discoloration If used by younger children, it can cause permanent tooth discoloration Minocycline

Erythromycin It has several advantages It has several advantages it has anti-inflammatory properties it has anti-inflammatory properties Can be taken with food Can be taken with food Erythromycin is a better antibiotic option for pregnant or breastfeeding moms Erythromycin is a better antibiotic option for pregnant or breastfeeding moms It also can be used by younger children because, unlike some of the other oral antibiotics, it won’t cause tooth discoloration It also can be used by younger children because, unlike some of the other oral antibiotics, it won’t cause tooth discoloration

Oral Retinoids

Isotretinoin Oral vitamin A (Accutane) Treatment of severe acne with cysts and nodules Treatment of severe acne with cysts and nodules Indicated only for use in females who are not pregnant and males Indicated only for use in females who are not pregnant and males 4-5 months provides long-term disease control 4-5 months provides long-term disease control It normalizes keratinization in the sebaceous follicle, decreases sebum synthesis, and reduces P. acnes It normalizes keratinization in the sebaceous follicle, decreases sebum synthesis, and reduces P. acnes May be used with topical or oral antibiotics May be used with topical or oral antibiotics

Isotretinoin Side effects:  Sever dryness of the skin and m.m  Cheilitis, epistaxis   liver enzymes,  blood TG, and C  Myalgia and arthralgia are common  Regular liver function tests should be performed regularly

Contraindications Pregnancy Pregnancy People with liver disease (it can further impair the liver) People with liver disease (it can further impair the liver) Patients with advanced kidney disease Patients with advanced kidney disease Patients with high cholesterol are strongly advised not take this medication Patients with high cholesterol are strongly advised not take this medication

Isotretinoin and Pregncncy Pregnancy is an absolute contra- indication to the use of isotretinoin Pregnancy is an absolute contra- indication to the use of isotretinoin If the drug is given within the first 3 weeks of gestation (not dose-related) teratogenic effects include CNS, cardiac and craniofacial abnormalities If the drug is given within the first 3 weeks of gestation (not dose-related) teratogenic effects include CNS, cardiac and craniofacial abnormalities Spontaneous abortion occurs Spontaneous abortion occurs in one-third of patients in one-third of patients

Hormonal Therapy  Corticosteroids are used in treatment of severe inflammatory acne mostly in adolescent males (with isotretinoin)  MOA :Corticosteroids suppress inflammation and androgen production  used orally or by direct injection into the cysts  Commonly used corticosteroids include prednisone and dexamethasone

Side effects when taken orally, can cause truncal obesity, moon face, can also weaken the immune system Topical corticosteroids (creams or ointments) should not be applied to skin affected by acne, as they may exacerbate the condition Dermatologists sometimes offer steroid injections to make pimples less noticeable. These injections can cause lightening and thinning of the skin.

Anti-androgens  Acne-prone women tend to have higher levels of androgens  Drugs that inhibit androgen production, are used to treat women who are unresponsive to other therapies  Cyproterone acetate which: sebum Reduces sebum productionsebum comedone Reduces comedone formation comedone