By Sapna Prabhakaran, MD Acne By Sapna Prabhakaran, MD

Objectives Types Diagnosis Treatments

Types Neonatal – may occur at birth, usu. occurs at 2-3 weeks of age, cause not known but some believe it’s from maternal androgens and others propose it’s an inflammatory response to resident yeast, s/s: inflammatory erythematous papules and macules, rarely comedones, primarily in the cheeks, rare on the trunk tx: spontaneous resolves Infantile - usually around 2-3 months of age, may represent persistance of neonatal acne or a true acne variant, usually resolves by 6-12 months of age similar to neonatal acne but comedones maybe present tx: topical 2.5% benzoyl peroxide or topical 2% erythromycin solution or gel or topical retinoids such as adaplene Acne vulgaris

Acne Vulgaris Epidemiology of acne vulgaris Most common skin disease that is treated by physicians Affects about 45 million individuals in the US, including at least 85% of all teenagers and young adults Has the potential for significant negative impact on quality of life

Pathophysiology Result of a complex interaction between hormonal changes and their effects on the pilosebaceous unit - specialized structures consisting of a hair follicle and sebaceous glands that are concentrated on the face, chest and back Onset at puberty because of increased androgen production Disordered function of the pilosebaceous unit with abnormal follicular keratinization (tendency toward increased follicular plugging)

Pathophysiology Increased density of Propionibacterium acnes, a normal resident of the skin Increased sebum production, under the influence of adrenal and gonadal androgens Breakdown of sebum by P acnes results in production of proinflammatory mediators, which leads to the development of the characteristic inflammatory lesions

Pathophysiology Factors Factors that may exacerbate acne Trauma – scrubbing the skin too vigorously or picking of lesions Comedogenic cosmetics or other skin care products Tight fitting sports equipment Medications: corticosteroids and anabolic steroids, antiepileptic drugs, lithium and certain contraceptives Hormonal dysregulation as in conditions like PCOS or Cushing syndrome

NORMAL PILOSEBACEOUS UNIT

MICROCOMEDONE

WHITEHEAD (CLOSED)

BLACKHEAD(OPEN)

PAPULE

PUSTULE

CYST

Signs and Symptoms Early on, acne lesions often appear on the forehead and middle third of face (T-zone) and are obstructive; inflammatory lesions tend to develop later and lesions may occur on all areas of the face, neck, chest and back Comedones and inflammatory lesions Open comedones – blackheads: dilated follicles Closed comedones – (whiteheads): white or skin colored papules without surrounding erythema

Signs and Symptoms Inflammatory lesions typically appear later in the course of acne vulgaris and vary from 1-2mm micropapules to nodules larger than 5mm Large (5-15mm) inflammatory nodules and cysts occur in most severe cases and such nodulcystic presentations are most likely lead to permanent scarring Mild, moderate and severe inflammatory acne can be associated with disfiguring post-inflammatory discoloration, which can be red, violaceous or grey- brown hyperpigmentation Pigmentary lesions may persist for many months

Treatment 4-6 weeks or longer maybe required to observe a benefit from treatment Optimize skin care - use a facial cleanser that has salicylic acid or benzoyl peroxide, if using prescription products, then want to use a mild cleanser Classify acne into mild moderate and severe to be able to pick the appropriate treatment regimen

Treatment Treatment strategies are based on severity of disease Mild acne – (face: one fourth of the face is involved, few to several papules or pustules, but no nodules or scarring) Topical therapy are usually adequate as an initial intervention and include a choice of topical retinoids, topical benzoyl peroxide, and topical benzoyl/antibiotic combinations Retinoid pearls – apply to a dry face apply no more than a pea size amount for the entire face If the entire face needs to be covered - touch pea size aliquot to each side of forehead, each cheek and chin and rub it in Apply to all areas and not as spot therapy Use a noncomedogenic moisturizer sparingly to counteract the dryness assoc with retinoid therapy

Treatment

Treatment Moderate acne ( face: about one half of the face to be involved; there are several to many papules or pustules and a few to several nodules; a few scars maybe present) Benzoyl peroxide/topical antibiotics combination products, along with topical retinoids, are an effective treatment strategy – one is applied in the morning and one is applied in the evening Another option is a topical antibiotic and a topical retinoid If inflammatory lesions are present , use of oral antibiotics should be added but still need to add benzoyl peroxide because has shown that benzoyl peroxide decreases risk of developing antibiotic resistance Female patients who have significant inflammatory acne, particularly those who have premenstrual or menstrual flares, may benefit from hormonal intervention such as oral contraceptive pills

Treatment Severe acne (face: three fourths or more of the face is involved; there are many papules and pustules, and many nodules; scarring is present) Nodulocystic acne or the presence of scarring warrant prompt consideration for isotretinoin therapy( with referral to a dermatologist) High dose oral antibiotics in combination with topical therapy is an option while considering isoretinoin.

WHERE DRUGS ACT

BENZOYL PEROXIDE Antibacterial and mild comedolytic Ubiquitous treatment for inflammatory and non- inflammatory acne Formulations: 2.5, 5, and 10% gels, lotions and creams Risks: irritation, contact dermatitis, and bleaching of clothes Pearl: start low, brief application during initial days of treatment: 15-30 minutes/day

RETINOIDS Normalizes follicular keratinization Resolves matures comedones Prevents new lesions Enhances penetration of other drugs Basically reverse the ‘stickiness” of the skin cells, allowing them to slough normally

TRETINOIN (RETIN-A) Comedolytic Best topical treatment for comedones Risks: irritation, photosusceptability, hyperpigmentation Formulations: 0.01, 0.025, 0.05, 1% gel, cream Pearl: bedtime use, brief application during initial phase of treatment

TOPICAL ANTIBIOTIC Clindamycin Antibacterial Risks: irritation, rare report of pseudomembranous colitis Formulation: gel,lotion and newer foam (Cleocin)

SYSTEMIC ANTIBIOTICS Tretracycline Antibacterial 500mg BID Inhibits chemotaxis of neutrophils (anti-inflammatory effect Photosensitivity, GI irritation, vaginal candidiasis, teratogenic; possible reduced effect of OCPs Take ½ hr before, or 2hrs after meal

TRIAZ Benzoyl peroxide, glycolic acid, zinc Anti-microbial, anti-comedonal 3, 6 and 9% Less irritation Also successful in pseudofolliculitis barbae

BENZACLIN BP 5%-clindamycin combination Maybe used in lieu of oral antibiotics in mild papular, pustular acne Benzamycin (erythromycin/BP combination) Duac (clinda/BP)

ZIANA Clindamycin/tretinion combo Antibacterial/comedolytic Risks: irritation, GI effects of clinda Expensive

ADAPELENE (DIFFERIN) Synthetic napthalene retinoid derivitive Anti-comedones, some anti-inflammatory Risks: irritation 10-40%; photosusceptible, hyperpigmentation

RETIN A-MICRO Different formulation of Retin-A Anti-comedonal with less irritation

TAZAROTENE (TAZORAC) Retinoid derivitive Anti-comedonal, anti-inflammatory, anti- proliferative Also used in psoriasis Irritation 10-30%; Start brief contact, 2-5 minutes BID

AZELAIC ACID (AZELEX) Dicarboxylic acid Antimicrobial, anti-keratinization Decrease hyperpigmentation 20% Cream BID dosing Useful in pts that prone to hyperpigmenation

ORAL AGENTS

MINOCIN (MINOCYCLINE) Special acne indication 50mg BID dosing Risks: gray-blue discoloration of skin; hepatitis; lupus like illness

DOXYCYCLINE Low dose formulation Periostat 20mg BID Likely anti-inflammatory effect More expensive than regular hight dose doxy

BACTRIM DS BID used 2-3 months Moderate severe cases Consider prior to using accutane

ZITHROMAX Pavone-Italy: Schachner, Miami: Elewski, Miami: 500mg qd x 3 days, then 7 days off, for 3 cycles Schachner, Miami: Z-pak x 5days, then 1 month off Elewski, Miami: Z-pak during menstrual flares

ISOTRETINOIN (ACCUTANE) Most effective agent for severe inflammatory acne or nodularcystic acne Only drug that affects all pathogenic factors Anti-comedonal, anti-bacterial, anti-inflammatory, decrease sebum production; Teratogenic, anemia, thrombocytopenia, hepatitis, ocular/vaginal dryness, arthralgia, pseudotumor cerebri, depression Can have granulomatous reaction initially (can use prednisone) Dermatology/national registry

ORAL CONTRACEPTIVES Increases sex hormone binding globulin Decreases free testosterone Decrease inflammatory acne

OCP Ortho-tri-cyclen, Yaz, Yasmin Risks: nausea, vaginal bleeding Consider using in mod-severe inflammatory acne Trial prior to Accutane

Prognosis Acne vulgaris is often self limited and resolves by late teenage or early adult years Treatment is warranted during periods of disease activity to alleviate disfigurement, enhance well being and prevent scarring. Referral to dermatology is recommended after failure to respond topical and/or oral therapies after 2-3 months of appropriate use Severe acne with presence of nodules, cysts and/or scarring

Treatment

Conclusion Thanks for your time !!!