Acne Dr. Jerald E. Hurdle Kennebec Medical Consultants

Learning Objectives  To manage the patient with acne vulgaris,  To review the clinical presentation and management of Acne Rosacea, and  To recognize acneiform rashes & folliculitis.

Case Study 1 28 yr old ♀ Always had dandruff Using over the counter cream for facial rash

Attends Primary Care PCP prescribes 2.5% HC Cream Initially improves then returns PCP stops HC and rash gets much worse Pt demands referral to dermatology

Diagnosis: peri-oral dermatitis

Acne Vulgaris Common Puberty onwards Disease of pilosebaceous unit Gets better with time Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo (whitehead); (D) papule; (E) pustule.

Acne Vulgaris: pathogenesis 4 factors Presence of hormones (androgens) Sebaceous gland activity (due to #1) P. acnes (bacteria) in the hair follicle (it lives on the oil and breaks it down to free fatty acids which cause inflammation) Plugging of the hair follicle (abnormal keratinization of the upper portion)

Acne Vulgaris: classification By severity By type of lesions By distribution Mild Moderate Severe

Acne Vulgaris: classification By severity By type of lesions By distribution Papules & Pustules Nodules & Cysts Open Comedones Closed Comedones

Acne Vulgaris: classification By severity By type of lesions By distribution

Acne Vulgaris: Rx Patient Education Diet Cleanliness Cosmetics Picking UV light

Acne Vulgaris: Rx Patient Education Treatment Response & Time Course Prognosis excellent All treatments take up to 3 months to see improvement No one ever becomes zit free for the rest of their life

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Gel, wash or cream 5-10% 1-2 x daily Side effects: redness, dryness & bleaching

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Tretinoin (Retin-A) % 1 x night Adapalene (Differin) 0.1% gel or cream 1-2 x daily SEs: dryness, redness & sun sensitivity

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Tretinoin (Retin-A) % 1 x night Adapalene (Differin) 0.1% gel or cream 1-2 x daily SEs: dryness, redness & sun sensitivity

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics

Acne Vulgaris: Rx Mild Disease Topicals Benzoyl Peroxide Tretinoin & adapalene Topical Antibiotics Clindamycin 1% Gel, lotion & solution 2x Daily Erythromycin 2% gel or sol, 2x daily

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset Minocycline mg 1-2x daily Hyperpigmentation

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone Tetracycline 250mg 2x daily Empty stomach Erythromycin 250mg 2x daily GI upset Minocycline mg 1-2x daily Hyperpigmentation Doxycycline mg 1-2x daily Photosensitivity

Acne Vulgaris: Rx Moderate Disease Systemics Oral Antibiotics Oral Contraceptive Pills Spironolactone

Acne Vulgaris: Rx Severe Disease

Isotretinoin Refer to Dermatology Women of childbearing potential need adequate contraception Check LFTS & fasting lipids I-Pledge process bureaucratic: warn patient Likely to require 6 months of Rx Dry skin, cracked lips : inevitable side effects Acne Vulgaris: Rx Severe Disease

Photography Useful for treatment monitoring

Acne Variants: acne excoriee Predominantly in young women Comedones & papules excoriated +++ Often underlying psych component (anxiety, OCD or personality disorder)

Acne Variants: peri-oral dermatitis Commoner in women Eczematous patches and papules around mouth Occasionally around eyes Exacerbated by topical steroids Treat as acne vulgaris & stop steroids

Case 2 33-year-old female complains of red cheeks Homeless, chronic alcoholic

Case 2: Physical Exam Red Cheeks Papules and pustules on the central face and nose NO Comedones

Case 2: Diagnosis? A. Systemic Lupus Erythematosus B. Bacterial Folliculitis with cellulitis C. Acne Rosacea D. Pellagra from nutritional deficiency

Case 2: Diagnosis? A. Systemic Lupus Erythematosus (no pustules) B. Bacterial Folliculitis with cellulitis (acute and systemic symptoms) C. Acne Rosacea D. Pellagra from nutritional deficiency (scale, diarrhea, but no pustules)

Case 2: Acne Rosacea Chronic inflammatory condition of the “flush” areas of the face (nose, cheeks > brow, chin) F > M Middle age (30-50) Affected persons blush easily

Case 2: Question 2 Which of the following might trigger this patient’s rosacea? A. Alcohol B. Heat/Hot Beverages C. Sunlight D. Hot, spicy foods E. All of the above

Case 2: Question 2 Which of the following might trigger this patient’s rosacea? A. Alcohol B. Heat/Hot Beverages C. Sunlight D. Hot, spicy foods E. All of the above

Acne Rosacea: triggers Alcohol Sunlight Hot Beverages (heat) Hot, Spicy food If it makes you flush it can flare rosacea Rosacea is NOT related to androgens!!

Acne Rosacea: clinical features Erythema and Telangiectasias Papules and Pustules (NO COMEDONES!) Rhinophyma (W.C. Fields nose) Ocular Rosacea (keratitis, blepharitis, conjunctivitis)

Acne Rosacea

Acne Rosacea Treatment Medical treatment only effective for the papular and pustular component Topical Antibiotics (metronidazole) Topical Sulfur Oral Antibiotics (tetracyclines) Therapy is suppressive and may be required lifelong

Acne Rosacea: Surgical Treatment Laser therapy can help the telangiectasias and the rhinophyma, once the papulopustular component is controlled.

Steroid Rosacea Topical Steroids may exacerbate or induce an acneiform eruption resembling rosacea Treatment: Stop the topical steroids; give oral tetracyclines. Never treat central facial papular eruptions with topical steroids. It may be rosacea which will flare severely when the topical steroids are stopped

Case 3

Acneiform Eruptions: Drugs Systemic/topical steroids Anabolic steroids Lithium Phenytoin (Dilantin ® ) Epidermal growth factor receptor inhibitors

Acneiform Eruptions: Acne Keloidalis Nuchae & Pseudofolliculitis Barbae Predominantly affects men of African descent Due to ingrowing hairs Avoid shaving Treat as acne

Folliculitis Confined to hair follicles No comedones Lesions tend to monomorphic Often itchy Common causes Staph, Pityriasporum If HIV positive, consider eosinophilic folliculitis

Learning Objectives  To manage the patient with acne vulgaris,  To review the clinical presentation and management of Acne Rosacea, and  To recognize acneiform rashes & folliculitis.