1. ACNE Definition Inflammation of sebaceous follicles Follicle
sebaceous gland
follicular canal
hair

2. ACNE Classification comedonal acne mild inflammatory acne
moderate inflammatory acne
severe inflammatory (nodulocystic)

3. ACNE Pathogenesis Pubertal changes
increased sebaceous production of sebum
abnormal sloughing of follicular wall lining
closed comedone (whitehead)
open comedone (blackhead)

4. ACNE Pathogenesis
Accumulation of Propionobacterium acnes (normal skin flora)
metabolization of sebum release of free fatty acids
attraction of neutrophils  rupture of follicular wall extrusion into the dermis
inflammatory lesions
papules, pustules
nodules, cysts

5. Acne lesions at a glance

6. ACNE Lesions
Inflammatory and comedonal acne

7. ACNE Lesions
Open comedones are evident on the chin

8. ACNE Lesions
inflammatory and comedonal acne

9. ACNE Therapy (Mechanisms)
Hormonal regulation
Sebum suppression
Keratolysis and inhibition of follicular proliferation
Antibacterial / antiinflammatory

10. Hormonal regulation Oral contraceptives Spironolactone
particularly estrogen predominant
Ortho-Tri-Cyclen
Spironolactone

11. Sebum suppression Isotretinoin (Accutane)
oral synthetic Vitamin A analog
shrinks sebaceous gland

12. Keratolysis and inhibition of follicular proliferation
OTC preparations
salicylic acid (Stridex)
Benzoyl Peroxide
Isotretinoin (Accutane)
Topical retinoids
tretinoin (Retin-A)
adapalene (Differin)
tazarotene (Tazorac)
Azelaic Acid (Azelex)

13. ACNE Topical retinoids
Contemporary Peds Dec. 2000

14. ACNE Adapalene (Differin)
Derivative of Naphthoic acid
Has more specific retinoid receptor activity
Some studies have shown less irritation

15. ACNE Azelaic Acid (Azelex)
Dicarboxylic acid produced by P. ovale
demonstrated activity against P. acne
demonstrated ability to inhibit microcomedo
Prevents hyperpigmentation
inhibits tyrosinase (melanin synthesis)
adresses postinflammatory hyperpigmentation

16. Antibacterial / antiinflammatory
Topical
Erythromycin
Clindamycin
Oral
Tetracycline
Doxycycline
Minocycline

17. ACNE Topical antibiotics
Contemporary Peds Dec. 2000

18. ACNE Oral Antibiotics
Contemporary Peds Dec. 2000

19. ACNE therapy (vehicle effects efficacy)
Creams
Less potent than gels
Less drying than gels
May not be good for the patient with oily complexion
Gels, solutions
more drying
tend to cause more irritation
oily skin

20. ACNE Counseling Poor hygiene is not a cause of acne
Effect of diet has not been demonstrated
4 – 6 weeks of treatment before any improvement is expected
Warn patients about skin irritation
BP, topical retinoids
Warn patients about photosensitivity
topical retinoids, tetracycline, Doxycycine
apply at night
consider noncomedogenic sunscreen (SPF =15)

21. ACNE Counseling II
Apply topical therapy to entire region not just to lesion
Start at low dose, infrequent applications and increase gradually
Apply to thoroughly dried skin
30 minutes of air-drying
not right after washing your face
Avoid cosmetics, mechanical friction
harsh scrubbing
tight chin straps, caps
bangs

22. ACNE Treatment Plans

23. ACNE Treatment Plans

24. ACNE Treatment Plans
Consultant April 1999

25. ACNE When to refer No improvement despite therapy Cysts or scars
sometimes require intralesional steroids
Consideration of Accutane or spironolactone
Associated menstrual irregularity or hirsutism
polycystic ovarian syndrome

26. ACNE Treatment Plans

27. ACNE Treatment Plans
Contemporary Peds Dec. 2000

28. ACNE Treatment Plans

29. ACNE Treatment Plans
Contemporary Peds Dec 2000

30. ACNE Treatment Plans

31. ACNE Treatment Plans
Contemporary Peds Dec 2000

32. ACNE References (required reading)
Pediatric Clinics North America
August 2000
Contemporary Pediatrics
Dec 2000
Pediatric Annals
January 2000
Available in the Peds Office