1. ACNE VULGARIS, ROSACEA AND PERIORAL DERMATITIS Dr M. W. Mokgatle F.C.Derm (S.A.) Consultant 1 Military Hospital 2012 1

2. Acne Vulgaris  Disease of the pilosebaceous unit. Affects both sexes. Onset common around puberty (hormonal growth spurt).  Duration and intensity of the disease vary. 2

3. Aetiopathogenesis  4 main causes.  Follicular/ductal hyperkeratosis – plug – microcomedones.  Increased sebum production (androgenic stimulation) - comedones.  Propionebacterium acnes (P. acnes) proliferation – papules/pustules (increased sebum).  Inflammation – nodules/cysts - P. acnes metabolises sebum, producing free fatty acids – inflammation. 3

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5. Clinical presentation  Affects face, upper chest, back and upper outer arms (areas with large and numerous sebaceous glands).  Non inflammatory lesions – closed (white) and open (black) comedones.  Inflammatory lesions – papules, pustules, nodules and cysts.  Severity grading based on lesion count/type – mild, moderate and severe. 5

6. Acne and Diet  Diet - controversial, but some authors now believe it to play a role in acne.  High glycaemic index foods e.g. breads, doughnuts, cakes, chips, french fries, candy and chocolate. Increased blood glucose – increased insulin production – increased hormone production including androgen – increased sebum – acne.  Others – dairy products. 6

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8. Treatment  Mild – topical medications.  Topical retinoids – retin-A, isotrex, iliotycin- A cream, differin.  Benzoyl peroxide – benzac, brevoxyl, panoxyl.  Topical antibiotics – erythromycin, clindamycin.  Topical resorcinol, sulfar, and salicylic acid 8

9. Treatment  Moderate acne – combination of topical and oral medication.  2 topical agents + oral antibiotics or oral contraceptives.  Oral antibiotics – (doxycycline, minocycline, tetracycline, limecycline),erythromycin, bactrim, dapsone.  Oral contraceptives – use in females ONLY. Diane, yasmin, yaz (contain anti-androgens cyproterone acetate/drosperinone + ethinyl oestradiol). 9

10. Treatment  Severe nodulocystic acne.  Oral isotretinoin. Cumulative dose 120mg/kg divided to 0,5-1mg/kg/month.  Teratogenic.  Various side effects - commonly mucocutaneous. 10

11. Mode of Action of Therapeutic Agents  1. Normalization of follicular hyperkeratosis: Retinoids  2. Inhibition of sebaceous hypersecretion: Oestrogen/Anti-androgens, Retinoids  3. Antibacterial effect: Benzoyl peroxide, Antibiotics, Retinoids  4. Anti-inflammatory effects: Benzoyl peroxide, Antibiotics, Retinoids 11

12. Acne and complications  Ice-pick and depressed scars.  Hyperpigmented marks (type iv-vi skin).  Hypertrophic scars and keloidal.  Acne may lead to low self-esteem, social withdrawal.  Important to treat early to prevent/reduce complications. 12

13. Other acne types  Drug-induced – steroids, anti-convulsants, iodides, bromides, lithium.  Neonatal acne – maternal androgens.  Cosmetic acne.  Pomade acne – greasy hair products.  Occupational acne – industrial solvents, oils, chlorinated hydrocarbons.  Mechanical acne – occlusive bands, straps, helmets. 13

14. Rosacea  Chronic inflammatory acne-like eruption – mid face (cheeks, nose, forehead, chin).  Mainly Caucasian women aged 30 - 40yrs.  Rare and usually severe in men (rhinophyma).  Usually affects cheeks, chin 14

15. Aetiopathogenesis  Abnormal vasomotor response to heat and other stimuli – flushing.  Hot beverages and sunlight exposure  Alcohol – induces flushing.  Prolonged use of topical corticosteroids.  ? Demodex folliculorum (mites).  Chronic vasodilatation and oedema - telangiectasia, and fibrosis. 15

16. Clinical features  4 main stages:  Erythema.  Telangiectasia.  Erythematous papules and/or pustules.  Hypertrophy (rhinophyma).  May get eye involvement (stinging, burning, gritty). 16

17. Differential diagnosis  Malar erythema: SLE –erythematous stage.  Acne vulgaris: look for comedones, cysts etc 17

18. Treatment  Avoidance of flushing triggers.  Sunscreens daily.  Mild cases – topical metronidazole or benzoyl peroxide.  Oral tetracyclines the most effective.  Resistant cases – isotretinoin.  Often recurs on stopping Rx – low dose maintanance suppressive Rx oral tetracyclines.  Rhinophyma – surgical (dermabrasion, laser CO2, electrosurgery).  Telangiectasia – pulsed dye laser.  Cosmetic camouflage: erythema/telangiectasia 18

19. Perioral Dermatitis  A distinctive eruption – discrete erythematous papules and pustules in the perioral area, sparing the vermilion border of the lips.  Resembles acne.  Relatively common  Affects mostly women aged 23 – 35yrs.  May also involve periocular area. 19

20. Aetiology  Unknown.  Strong, fluorinated topical corticosteroids.  Fluorinated dentifrices – toothpaste/tooth powder.  Demodex folliculorum.  Excessive use of moisturizing creams and lipsticks 20

21. Treatment  Responds well to tetracyclines (250mg – 1g /day)  Doxycycline, minocycline, erythromycin.  Topical metronidazole/Adapalene/skinoren.  Stop use of topical/inhaled corticosteroids 21