1. Adult Acne Mary S. Stone MD Department of Dermatology
Guidelines of care for the management of acne vulgaris.
J Amer Acad of Dermatol 74: , 2016

2. Acneiform Disorders Acne Vulgaris Acne Rosacea Perioral Dermatitis
Topical Steroid Induced Acne
Neonatal and Infantile Acne
Drug Induced Acne

3. Pathogenesis of Acne Vulgaris
Androgen related overproduction of sebum
Abnormal desquamation within the sebaceous follicle
Proliferation of Propionibacterium acnes producing inflammation
Genetic factors

4. Relationship between sebaceous glands and acne
Acne occurs in the neonatal period
Sebum is comedogenic
Sebaceous gland activity is increased in acne
Inhibition of sebaceous gland function improves acne

5. Adult Female Acne (>age25)
2x more than adult men seek care
1/23 of all can office visits made by females > 25 years old
Distribution typically perioral or mandibular
May persist beyond menopause
Premenstrual flares very common

6. Principles of Therapy Correct defects in keratinization
Decrease sebaceous gland activity
Reduce the population of P. Acnes and thereby its extracellular products
Produce an anti-inflammatory effect

7. Correct Defect in Keratinization
Topical
Retinoids (tretinoin, adapalene, tazarotene)
Alpha hydroxy acids
Salicylic acid
Systemic
13 cis retinoid acid (Accutane)

8. Reduce P. Acnes Population
Topical
Benzoyl peroxide
Azelaic acid
Topical antibiotics
Systemic
Antibiotics
Retinoids

9. Produce an Anti-inflammatory Effect
Local
intralesional corticosteroids
acne surgery
Topical dapsone – may be more effective in adult females
Systemic
Antibiotics Tetracycline, doxycycline, minocycline
corticosteroids

10. Dapsone 5% gel BID Appears to act an anti-inflammatory agent
More effective in adult female acne than in adolescents or men
Can be oxidised by BPO casuing orange-brown coloration (can be washed off).

11. Decrease Sebaceous Gland Activity
Hormonal Therapy
OCP’s
FDA approved for acne: Ortho Tri-Cyclen, Estrostep and Yaz
Least androgenic progestins: desogestrel, norgestimate
Drospirenone has antiandrogenic properties
Spironolactone
Oral Retinoids

12. Oral Contraceptives
As effective as oral antibiotics, but slower (equal efficacy at 6 months, antibiotics win at 3 months)
Improve both inflammatory and non-inflammatory acne
Risks must be considered. Especially useful in women who wish contraseption or have other indications such as menorrhagia

13. OCP’s Only 4 FDA approved for acne:
Ethinyl estradiol/norgestimate (Ortho TriCyclen)
Ethinyl estradiol/norethindrone (Estro step)
Ethinyl estradiol/drospirenone (Yaz)
Ethinyl estradiol/drospirenone/levomefolate (Beyaz)

14. Spironolactone 50-200 mg/day
No need to check potassium in young healthy women

15. Diet
AAD Guidelines: No specific dietary changes recommended in manage of acne
Low glycemic index diets may improve acne
Limited evidence suggest that some dairy, especially skim milk may aggravate acne

16. 13-cis retinoic acid (Accutane)
Extremely effective agent in acne vulgaris
Extremely potent teratogen
Other side effects include:
Dryness of the skin
Hyperlipidemia
Boney spur formation
Rarely depression
Inflammatory bowel disease- debated, but likely no relationship

17. 13-cis-retinoid acid dosing
1mg/kg x 20 weeks
mg/kg total dosage
Must be prescribed through the ipledge program
Some advocating higher dosing 220mg/kg to reduce recurrence

18. Drug-induced Acne Anabolic steroids Corticosteroids Phenytoin Lithium
INH
EGFR inhibitors

19. Acne Rosacea Etiology Vasomotor Liability
menopause
alcohol and spicy foods
Disruption of epidermal barrier
Triggering of innate immune system
Demodex Mites

20. Rosacea: 4 types Erythematous/telangiectatic Papulopustular
Phymomatous
Ocular
Unlike acne rosacea does not cause comedones. Patient’s can have both.

21. Rosacea Treatment Avoid triggers of flushing Topicals
Metronidazole cream/gel
Sodium sulfacetamide
Clindamycin lotion
Azelaic acid
Ivermectin (Soolantra)
Brimonidine (Mirvaso)
Oral antibiotics- doxycycline
13-cis retinoid acid

22. Brimonidine (Mirvaso)
Vasoconstrictive
Selective α2-adrenergic receptor agonist
10-20% may have rebound erythema

23. Perioral Dermatitis Primarily young women Discontinue topical steroids
Topical metronidazole, erythromycin, clindamycin, pimecrolimus may help
Low dose tetracyclines very effective

24. Topical Steroids Can induce either perioral dermatitis or acne rosacea
In general, no topical steroids stronger than 1% hydrocortisone should be used on the face