1. Treatment of Acne

2. What is acne?
Acne vulgaris: a chronic condition linked to the onset of puberty
Not a physical threat;
However, acne may have a significant negative psychological effect: low self esteem, social phobia and depression;
Universal incidence;
85% of those between years;

4. Pilosebaceous Unit: most commonly on face, chest and back
Anatomy and Physiology of skin
Pilosebaceous unit=hair follicle + sebaceous gland
Pilosebaceous Unit: most commonly on face, chest and back

5. Etiology of Acne
Abnormal keratinization of the epithelial cells in the infindibulum (duct);
An increase in sebum production;
An accelerated growth of Propiobacterium acnes;
The occurrence of inflammation;

6. Pathophysiology of Acne
Abnormal keratinization of the cells in the infundibulum results in obstruction of the follicle with impacted cells and sebum to form a plug;
This plug will distend the follicle and form a microcomedone
Microcomedone is the initial pathologic lesion of acne

8. Microcomedone

9. Pathophysiology of Acne
As more sebum accumulate, the microcomedone enlarges and becomes visible as a closed comedo, or white head
The whitehead: is a small pale nodule just beneath the skin surface that may form a precursor for other acne lesions
An open comedo (blackhead) occurs: when the desquamated epithelial cells and sebum accumulate behind the plug and the orifice of the follicular canal becomes distended, allowing the plug to protrude
The tip of the plug may darken because of melanin NOT dirt;

10. Closed comedone (whitehead)

11. Open comedo (blackhead)

12. Pathophysiology of Acne
Increase in the level of circulating androgens stimulates production of sebum, which is prevented from reaching the skin surface by the obstructing plug;
At same time; P. acnes colonizes the pilosebaceous duct;
Bacterial colony counts are higher in patients with acne than in those without acne
P. acnes: major contributor to causing inflammatory acne lesions lipase: breakdown of sebum to highly irritating free fatty acids
The resultant inflammation: localized tissue destruction

13. Pathophysiology of Acne
Inflammatory acne begins with closed comedones that distend the follicle, causing the cellular lining of the walls to spread and become thin;
Primary inflammation results from disruption of the epithelial lining + lymphocyte infiltration
A severe inflammatory reaction happens if the follicle wall ruptures spontaneously or is ruptured by picking, squeezing, or attempted expression with a comedo extractor

14. Papules
Pustules

15. Pathophysiology of Acne
Contents are discharged into surrounding tissue: abscesses scars or pits after healing
Pustules or purulent nodules of inflammatory acne are more likely to cause scarring than those of non-inflammatory acne
Pits

16. Exacerbating Factors for Acne
Several factors are known to exacerbate existing acne or cause periodic flare-ups of acne in some patients;
Some may have control over, while others not (e.g. heredity);
Factors: environmental and physical, cosmetic use, hormonal factors and medication use

17. Environmental & Physical
Hydration: decreases size of duct orifice and prevents loosening of comedone. e.g. high humidity environment or prolonged sweating and occlusive clothing
Irritation and friction (acne mechanica): may increase symptoms of acne. E.g. occlusive clothing, headbands, helmets, resting chin or cheek on hand etc
Occupational acne: exposure to dirt, vaporized cooking oils, or certain industrial chemicals

18. Cosmetic Use
Acne cosmetica: mild form of acne on the face, cheek and chin;
Typically: closed, non-inflammatory comedones;
Occurs as a result of using oil-based products on the skin that causes occlusion of the pilosebaceous unit;
Oil-based cosmetics may exacerbate acne or even induce it;
Moisturizers or tanning oils may contain comedogenic oils (e.g. lanolin, mineral oil, cocoa butter)

19. Rosacea
Comedo extractor
Pomade acne
Pustules (purulent nodules)
pustule

20. Emotional Factors Hormonal Factors
Severe or prolonged periods of stress may exacerbate acne; however they do not induce acne!
Mechanism is not known
Hormonal Factors
Many women with acne experience a premenstrual flare-up of symptoms (i.e. ovulation, pregnancy).
OCP with high androgenic progestin are implicated in the production of acne

21. Medication Use P I M L E S Phenytoin Isoniazid Moisturizers
Phenobarbital
Lithium
Ethionamide
Steroids

22. Unsubstantiated Etiologic Factors
Little evidence supports link between: diet and acne;
A rule of thumb: people should be advised to avoid any particular food that seems to exacerbate their acne;
Excessive scrubbing in attempt to open blocked pores may exacerbate rather than improve acne

23. Signs and Symptoms of Acne
Non-inflammatory acne is characterized by whiteheads or blackheads
Inflammatory acne is characterized by pimples (i.e. small, prominent inflamed elevations of the skin) which may rupture to form a papule
Papules are inflammatory lesions appearing as raised, reddened areas on the skin, which may enlarge to form pustules
Pustules appear as raised reddened areas filled with pus

24. Papule
pimple
whiteheads
blackheads
pustule

25. Very severe acne, cystic acne, acne conglobata

26. Classification of Acne
Grade of Acne
Qualitative Description
Quantitative Description I
Comedonal acne
Comedones only, < 10 on face, none on trunk, no scars, noninflammatory lesions only II
Papular acne
10-25 papules on face and trunk, mild scarring, inflammatory lesions < 5 mm in diameter
III
Pustular acne
More than 25 pustules, moderate scarring, size similar to papules but with visible purulent core IV
Severe persistent pustulocyctis acne
Nodules or cysts, extensive scarring, inflammatory lesions > 5 mm in diameter -
Recalcitrant severe cystic acne
Extensive nodules/cysts

27. Treatment of Acne Non-pharmacologic therapy
Cleansing of Skin (avoid abrasive producs)
Staying well-hydrated
Minimizing Exacerbating factors
Physical treatment with acrylate glue-based strips (help in extraction of impacted comedones) – better alternatives to picking acne that may result in scarring)
Pharmacologic Therapy

31. Topical retinoid:
1-Tazarotene
2-Adapalene
adapalene 0.1% gel is the first and only OTC topical retinoid (2016)
3-Tretinoin
Antibiotics
-tetracycline, minocycline, doxycycline
-erythromycin
-Clindamycin

33. Important points to remember!
Self-treatment of acne is effective in patients mature enough to understand that acne can be controlled but not cured;
Treatment of noninflammatory acne: pharmacologic agents + nonpharmacologic measures;
Self treatment is appropriate only for grade I acne (i.e. noninflammatory acne of mild to moderate severity), presenting with open or closed comedones

34. Exclusion for Self-Treatment
Grades II-IV acne: papules, pustules, nodules, cysts and/or scarring
Severe, recalcitrant acne (extensive nodules/cysts)
Exacerbating factors (e.g. comedogenic drugs)
Possible rosacea
(If acne lesions persist beyond mid-20s or develop in the mid-20s or later, the symptoms may signal rosacea rather than acne vulgaris)

35. Comedonal acne - topical treatment appropriate:
Pustular - an oral antibiotic would be best:
Comedonal acne - topical treatment appropriate:

36. Severe acne treated with Isotretinoin:
A) Before treatment:
B) After 5 months

37. OTC Therapy Benzoyl Peroxide Salicylic acid Sulfur
Sulfur-Resorcinol combination products
Alpha-hydroxy acids

38. Benzoyl Peroxide
Available in variety of concentrations (2.5%, 5% & 10%) & dosage forms (lotions, gels, creams, cleansers, masks & soaps);
MOA: (1) irritation & desquamation-prevents closure of pilosebaceous duct. Increase turnover rate of epithelial cells. (2) Oxidizing potential-antibacterial activity, decreasing P.acnes
Is frequently combined with topical antibiotics (reduces the P. acnes resistance)

39. Benzoyl Peroxide
The most effective and widely used OTC drug for non-inflammatory acne;
Clinical response to all concentrations is similar in reducing the number of inflammatory lesions
Should be applied to the entire affected area, & not only to visible blemishes
Should not be applied for 20 min. after washing with a cleanser to minimize irritation
Use only one application per day or every other day
Leave initial application for only 15 min., then wash off
New formulation: phospholipid liposomes (not commercially available) promise for papulopustular acne

40. If no discomfort, increase time the product is left on the skin in 15 min. increments
Once tolerated for 2 hours, leave on the skin overnight
After initial 1-2 weeks, application can be increased to 2-3 TD over a period of 2-3 days, as tolerated
Fair skinned patients should apply 2.5% product initially
Max. effect may develop only after 4-6 weeks
If necessary, strength may be increased to 5% after 1 wk, then to 10% after 2 wks

41. Continue treatment even after clearance of lesions
If no improvement after 6 wks or if ADRs, seek medical attention,
Use carefully around nose, lips, eyes & near cuts
Use other acne products only as indicated
Avoid sun & UV lamps, use sunscreens with SPF > 15

42. Benzoyl Peroxide Adverse Effects:
some skin sloughing, erythema or edema lower concentrations must be used for shorter duration
Allergic reactions – should be tested on antecubital area
Precautions: (1) bleach hair, clothes, bed linens, (2)avoid excessive sun or sunlamps, Concern: tumorigenic potential

43. Salicylic Acid Available in wide range: 0.5%-2%
A milder, less effective alternative for tretinoin
MOA: acts as a surface keratolytic, mild comedolytic agent
Milder effect that tretynoin
Is used as adjunctive treatment in cleansers
Should not be used in DM & in poor circulation
Use on large surface for long periods may result in toxicity
Needs sunscreen
In case of irritation, limit to once daily use

44. Sulfur
Keratolytic and antibacterial (precipitated or colloidal) 3%-10%
Generally: accepted as effective in promoting the resolution of existing comedones, but, on continued use, may have a comedogenic effect
Alternative forms of sulfur: Na thiosulfate, Zn sulfate, Zn sulfide NGRSE
Applied in thin film to skin 3 times daily
Have noticeable color and odor

45. Sulfur-Resorcinol combination
3-8% sulfur with resorcinol 2-3% (enhances effect of sulfur)
MOA: keratolytics, fostering cell turnover & desquamation
Resorcinol produces a reversible dark brown scale on some darker-skinned individuals

46. Sulfur-Sodium sulfacetamide
Combination destroys PABA, essential component for bacterial growth

47. Alpha-hyrdoxy Acids
They occur naturally in sugar cane, fruits & milk products;
Are keratolytic
Less potent & are used when patient cannot tolerate other topical products
The most useful AHAs in dermatologic practice are glycolic, lactic & citric acids
MOA: facilitate desquamation of the stratum corneum.
No evidence to support use in acne – but may be useful after acne control as peeling agents to control scarring & hyperpigmentation

48. Therapeutic Comparison
Benzoyl Peroxide
Salicylic Acid
Sulfur
Bactericidal
Yes -
Keratolytic
Slight
Comedolytic
Concentration
2.5%-20%
0.5%-2%
2%-10%
Frequency of use
1-2 times daily
Used mainly as cleanser, then rinsed off
1-3 times daily
Adverse effects
Bleached hair and clothing
Potent keratolytic at high concentration
Color, unpleasant odor

49. CAM Tea tree oil: comparative to benzoyl peroxide but: slower onset
Oral zinc: may be used as alternative to tetracycline esp. in summer (photosensitivity). ADRs: nausea & gastralgia
Nicotinamide: used in Europe for inflammatory acne

51. Product Selection Guidelines
Cleansers (bars, liquids) are not of much value (WHY?)
Gels are the most effective (WHY?)
Gels & solutions cause drying - sometimes contact dermatitis but are beneficial for oily skin
Lotions & creams with low fat content are intended to counteract drying (astringent effect) and peeling (keratolytic effect): alternative to more effective gels for dry sensitive skin or during winter weather
Ointments are greasy & may worsen acne

52. Patient Education:
Acne is not caused by poor hygiene or eating greasy or sugary foods
Can be controlled by certain medications but not cured
The goal of self-treatment is to control mild acne, thus preventing more serious form from developing
Best approach is use cleansers and medications to keep skin ducts and orifices open
Many OTC products are used with prescription ones

53. Patient Education:
Cleanse skin thoroughly but gently at least twice daily to produce a mild drying effect that loosens comedones, using soft wash cloth, warm water and facial soap without moisturizing oils
To prevent or minimize acne flare-ups, avoid or reduce exposure to environmental factors, such as dirt, dust, petroleum products, cooking oils or chemical irritants

54. Patient Education:
To prevent friction or irritation that may cause acne flare-ups, do not wear tight-fitting clothes, headbands, or helmets, avoid resting the chin on the hand;
To minimize acne related to cosmetic use, do not use oil based cosmetics and shampoos

55. “I know you're never supposed to squeeze a zit, but I'm not about to leave the house with a major eruption on my face. Isn't there any good way to pop it?”
!!!!!

56. Patient Education:
To prevent excessive hydration of the skin, which can cause flare-ups, avoid areas of high humidity and do not wear tight fitting clothes that restrict air movement;
Avoid stressful situations & practice stress management techniques. Stress may worsen only existing acne.
Do not pick or squeeze pimples – may worsen acne & lead to scarring