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;

4. Epidemiology of Acne Universal incidence;
85% of those between years;
Males: and females: 15-17
Papular lesions: mid-teens, nodular lesions: late teens;
Males: clears by mid 20s. In females: 3rd or 4th decades and may worsen during menopause

5. 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

6. Scalp folliculitis “Acne necrotica miliaris”
calp folliculitis is characterised by small, very itchy pustules on the scalp, often most troublesome on the frontal hairline. There may be only a small number of lesions or they may be very numerous. They are hard to leave alone because of the itch. They often become sore and crusted.
The cause of scalp folliculitis is not well understood. It is generally considered to be an inflammatory reaction to components of the hair follicle, particularly the micro-organisms. These include:
Bacteria (especially Propionibacterium acnes, but in severe cases, also Staphylococcus aureus)
Yeasts (Malassezia species)
Mites (Demodex folliculorum)
What is the treatment for scalp folliculitis?
The scalp affected by folliculitis should be washed with a mild normal shampoo as often as desired. Antidandruff shampoos containing antifungal agents such as ketoconazole or ciclopirox are sometimes helpful. Conditioner can be used if desired.
The following medications may be helpful for scalp folliculitis:
Topical antibiotics eg fusidic acid gel, clindamycin solution, erythromycin solution
Mild topical steroid lotions or creams
Oral antihistamines
Oral antibiotics, particularly long-term tetracycline
Oral isotretinoin – long-term low dose treatment may be required

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

8. 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

9. Microcomedone

10. 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;

11. Closed comedone (whitehead)

12. Open comedo (blackhead)

13. 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

14. 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

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 factors, 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. “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?”
!!!!!

24. !!
Can I pop a pimple?
Opinion differs (Some say popping a pimple can scar, others say it can't scar)
Most: lancing and gently squeezing pimples that are at the surface and white will usually not lead to scarring.
However, trying to squeeze and pop a pimple which is still below the surface may lead to major problems.
Some say popping a pimple can scar, others say it can't scar. I tend to think that lancing and gently squeezing pimples that are at the surface and white will usually not lead to scarring. However, trying to squeeze and pop a pimple which is still below the surface may lead to major problems.
Suggestions on how to pop a zit vary. Read through some of these opinions from around the internet and decide for yourself. If you have a serious cystic lesion, your dermatologist may have methods of reducing the swelling which may also help prevent scarring. Also, alpha hydroxy acid may help prevent a spot from becoming a behemoth in the first place.
Tip: follow the Clear Skin Regimen to prevent future whiteheads from occurring in the first place.
Take a warm shower or bath to soften your skin.
Wash your face and remove all makeup.
Wash your hands to prevent spreading germs and infecting the pimple.
Sterilize a needle by running it through a flame (a dirty needle will cause an infection and maybe a bigger pimple).
Gently prick the tip of the pimple with the needle.
Take a clean tissue or piece of toilet paper and wrap it around your index fingers.
Gently apply pressure to the sides of the pimple to ease out the pus. Stop when blood or clear fluid comes out.

25. 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

26. Papule
pimple
whiteheads
blackheads
pustule

27. Signs and Symptoms of Acne
More extensive penetration into surrounding and underlying tissue produces necrotic purulent nodular lesions (previously designated as cysts), and may lead to pitting or scarring if untreated
Typical acne patient presents with a combination of lesions: comedones (open and closed), papules and pustules
Usually found on the face, chest and back (sometimes on neck and upper arms too)

28. Very severe acne, cystic acne, acne conglobata

29. 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

30. Treatment of Acne Non-pharmacologic therapy Cleansing of Skin
Minimize Exacerbating factors
Pharmacologic Therapy

31. Pharmacologic Therapy
Benzoyl Peroxide
Salicylic acid
Sulfur
Sulfur-Resorcinol combination products
Alpha-hydroxy acids

32. Benzoyl Peroxide
Available in variety of concentrations (2.5%, 5% and 10%) and dosage forms (lotions, gels, creams, cleansers, masks and soaps);
MOA: (1) irritation & desquamation-prevents closure of pilosebaceous duct. Increase turnover rate of epithelial cells. (2) Oxidizing potential-antibacterial activity, decreasing P.acnes
Safety studies are ongoing

33. 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
Different formulations are not equivalent: alcohol gel is superior to lotion of the same concentration;
Washes and cleansers: have little or no comedolytic effect
New formulation: phospholipid liposomes (not commercially available) promise for papulopustular acne

34. Benzoyl Peroxide
Adverse Effects: excessive dryness, peeling, some skin sloughing, erythema or edema lower concentrations must be used for shorter duration
Stinging/burning: non alarming unless persist or worsen
Precautions: (1) bleach hair, clothes, bed linens, (2)avoid excessive sun or sunlamps, (3) alcohol-based products (e.g. after shave lotion)( may exacerbate stinging/burning

35. Salicylic Acid Available in wide range: 0.5%-2%
A milder, less effective alternative for teretoin
MOA: acts as a surface keratolytic, mild comedolytic agent
When used in cleansing preparations: adjunctive treatment

36. 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

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

38. Alpha-hyrdoxy Acids
They occur naturally in sugar cane, fruits and milk products;
The most useful AHAs in dermatologic practice are glycolic acid, lactic acid and gluconic acid
MOA: facilitate desquamation of the stratum corneum.
Effective in treatment of comedonal acne

39. Therapeutic Comparison
Benzoyl Peroxide
Salicylic Acid
Sulfur
Bactericidal
Yes -
Keratolytic
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

40. Product Selection Guidelines
Cosmetic appearance may influence compliance
Cleansers (bars, liquids, suspensions, lotions, creams, gels, and pads/wipes) are not of much value (WHY?)
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

41. Patient Education:
The goal of self-treatment is to control mild acne, thus preventing more serious form from developing
Acne usually goes away on its own
Symptoms can usually be managed with diligent and long term treatment
Best approach is use cleansers and medications to keep skin ducts and orifices open

42. 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

43. 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 minimise acne related to cosmetic use, do not use oil based cosmetics and shampoos

44. 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;
Try to maintain proper diet, although a link between diet and acne is not found;
Avoid stressful situations. Stress may play a role in acne flare-ups but it does not cause acne

45. Selected websites for acne information

46. Glossary:
Comedo: A plug of keratin and sebum within the dilated orifice of a hair follicle, frequently containing the bacteria Propionibacterium acnes, Staphylococcus albus and Pityrosporon ovale, also called blackhead.
Propiobacterium acnes: a gram positive anearobic rod found on the skin
Pustule: a vesicle or an elevation of the cuticle with an inflamed base, containing pus.

47. Glossary:
Blemish: Any mark of deformity or injury, whether physical or moral; anything; that diminishes beauty, or renders imperfect that which is otherwise well formed
Pimple: Any small acuminated elevation of the cuticle, whether going on to suppuration or not
Papule: A small circumscribed, superficial, solid elevation of the skin