1. Monday, February 6th, 2012 Acne! José L. González, MD

2. Risk Factors first degree relative no data suggesting dietary influences endocrine  steroids anabolic cortico-  androgen excess PCOS

3. Classification inflammatory  open comedo (whitehead)  closed comedo (blackhead) non-inflammatory  papule < 5mm tender, erythematous bump  pustule < 5mm bump containing visible material  nodule / cyst > 5mm

4. Types of Acne & Acne Impersonators acne conglobata / acne fulminans drug-induced acne rosacea – telengectasias, central face acne excoriée des jeunes filles bacterial folliculitis – s. aureus granulomatous & neoplastic d.o.  sarcoidosis, tuberous sclerosis, multiple trichoepitheliomas

5. female pts & signs of androgen excess testosterone (free & total) dehydroepiandrosterene sulfate LH, FSH PCOS?  fasting glucose & insulin levels

6. pathogenesis 1. hyperkeratinization 2. increased sebum production 3. propionobacterium acnes 4. inflammation

7. treatment non-inflammatory (comedolysis + keratolysis) – topical tx  retinoids  benzoyl peroxide  salicylic acid  azelaic acid inflammatory – combination tx  topical + oral abx  benzoyl peroxide + tetracycline

8. common oral abx & SEs Tetracyclines – phototoxicity, nausea  doxycylcine – tooth staining & vertigo  minocylcine – SLE-like reaction Macrolides  erythro & azithromycin – GI upset / diarrhea Bactrim – Stevens Johnson

9. Other Oral Therapies Hormonal  OCPs – 50 – 60% improvement norethindrone acetate-ethinyl estradiol norgestimate-ethinyl estradiol  SEs: migraines, nausea, VTE Steroids  high dose → taper; short term  low dose; long term

10. Isotretinoin aka Retinoic Acid long term remission use in severe nodular acne, resistant to abx SEs  birth defects, iPLEDGE  skin: dry eyes, mm, epistaxis, hair shedding  MSK: hyperostosis, premature epiphyseal closure  neuropsych: it'll make you crazy! (but beautiful)  liver: check triglycerides & LFTs

11. Other Options Newer treatments  blue light, phototherapy, laser therapy, radiofrequency non-ablative  high cost  relapse in 3-6 months Referral to Dermatologist  very severe acne  use of isotretinoin