Acne Dr Josephine Yeatman 154 Grimshaw Street Greensborough 3088 Austin Health Mercy Hospital for Women

Acne lesions Inflammatory Papules Pustules Nodules Cysts Draining Sinuses Non Inflammatory Open comedones Closed comedones

Predisposing Factors Age Young preteen comedones only Later teen papules and pustules as well Peak age Adults Change in distribution classically jawline 15% of adult women and 5% of men have acne

Diet Western diet the Kitavan Islanders of Papua New Guinea and the Ache hunter-gatherers of Paraguay do not get acne Suggest acne diet (low GI diet) Have usually tried zinc by the time they see me

Genetics Often positive family history and also gives and idea about prognosis, especially with parents with ongoing acne

Hormones PCOS Ask about premenstrual flare, hirsutes, menstrual irregularities Also a good time to ask about reproductive plans in adults to determine optimum timing of treatment eg in 35 year old wanting isotretinoin

Treatment

Antibiotics Systemic doxycycline, minocycline, erythromycin, trimethoprim, cotrimoxizole Effective and rapid but only work on inflammatory component and only while used so acne will usually recur after cessation Warn to use condoms for first month if on the pill

Antibiotics Topical erythromycin clindamycin Can be very effective but generally only play role in mild acne also can be expensive

Anti-androgens Diane 35ED and clones, Yasmin, Yaz, Valette, spironolactone, cyproterone acetate Very effective especially in hormonal acne Slow minimum two months for onset of action 2x risk of thrombosis vs regular pill Standard pill will have some anti-acne effect due to elevation of SHBG Progesterone only contraception eg Implanon can exacerbate acne

Retinoids Work on both inflammatory and non- inflammatory components Contra-indicated in pregnancy

Retinoids Topical Initially irritating but tolerance usually develops Take at about three months to show effect Can flare inflammatory acne initially if used alone so usually combine with antibiotic at start

Retinoids Topical preparations adapalene retinoic acid - Retin A gel 0.01% 30ml and cream 0.05% 20g, ReTrieve 0.05% 50g, Steiva A 25g 0.025% 0.05% 0.1% isotretinoin - Isotrex

Retinoids Systemic Isotretinoin Well established role in severe cystic acne, scarring acne and refractory acne Avoid in summer, poorly compliant especially females, depression, pilots, armed force aspirants, VCE

Benzoyl peroxide (BP) Useful adjunct especially for inflammatory disease and helps reduce antibiotic resistance Popular product Proactiv expensive, usually tried by the time they see me Other cheaper OTC preps New combination preparations clindamycin/BP,adapalene/BP More effective but expensive

Physical Treatment Comedone extraction Laser and light therapies Controversial for active acne Main use is for scarring

Acne in pregnancy Benzoyl peroxide and erythromycin safe Tetracyclines contra-indicated in second and third trimester and until children 8 years of age (some say 12)

Other types of acne and related conditions Infantile acne Acne excoriee Acne keloidalis nuchae Hidradenitis suppurativa Senile comedones and Favre- Racouchot syndrome

Infantile acne

Acne excoriee

Acne keloidalis nuchae

Hidradenitis suppurativa

Senile comedones

Favre-Racouchot syndrome

Other related diseases Perioral dermatitis Erythematous and pustular perioral rash Fluctuates in severity and is irritable rather than itchy Related to use of occlusive moisturisers and exacerbated by topical steroid use Treat with oral tetracyclines

Perioral dermatitis

Perioral (periorifial) dermatitis

Rosacea Erythema, flushing, telangiectasia, papules, pustules, swelling (rhinophyma) No comedones but sometimes co-exists with acne ie redness, flushing and comedones Treat with antibiotics, topical metronidazole for maintenance, vascular laser for redness and telangiectasia