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Acne

New Thoughts on Acne

-Resistance -Op6ons

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No Conflict of Interest

Defini6on: Acne is a disease of the pilosebaceous unit, appears in males and females who live in westernized socie6es and are near puberty, and in most cases acne becomes less ac6ve as adolescence ends. The intensity and dura6on of ac6vity vary for each individual.

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Mostpa.entswithacnecanbemanagedbycompetentcaringpediatricians,familyandgeneralprac..onersandinternist.

Incidence

~95%ofadolescentsinwesterncultures

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E6ology

Diseaseofpilosebaceousgland1.  Increasesebumproduc.on2.  Prolifera.onofpropionbacteriumacne3.  Follicularplugging4.  Allresul.ngininflamma.onofsebaceousgland

Pathogenesis •  Acnemaybeaninheriteddiseasewithvariable

penetrance•  Diet,ac.vity,andstressmayinfluenceacne

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Two non-westernized popula6on do not have acne in adolescents:

-Kit Ivan Islands of Papua, New Guinea

-Ache-hunter gathers on Paraguay

Dietary Management of Acne�

• www.acnemilk.com• www.thepaleodiet.com• www.godairyfree.org• www.glycemicindex.com• www.hs-founda.on.org

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Initial Evaluation of Acne

•  Typeoflesion•  Severityofacne

•  Previoustreatmentregimes

•  Skintype

•  Cosme.cs•  Tanning

Comedonal Acne

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Mild Inflammatory

Moderate-to-severe inflammatory acne

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Nodulocys6c Acne

Nodulocys6c Acne

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Topical Agents for Acne

• Benzoylperoxide• Adapalene• Re.noid• Azelaicacid

Benzoyl Peroxide

1)  An.-bacterial2)  OTCandRx3)  Combina.onproducts-BP/Cleocin-BP/Erythromycin4)  2.5to10%5)  OTC“proac.ve”6)  2%maydevelopcontactderma..s7)  Bestusedinshower-30secondcontacttoarea-Rinsewell-Avoidsbleaching

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Retinoids: Reverse abnormal pattern of keratinization

•  Tre.noin“re.n-a”-gel,cream•  Tazorac“tazarotene”-gel,cream,foam•  Peasizeamount,en.reface•  Applymoisturizer• Maystarteveryothernight

Adapalene •  Re.noidlikeac.vity•  An.-inflammatoryac.vity•  Di\erivgel/cream0.1-0.3%

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Azelaic Acid An.-kera.nizing,an.bacterialac.vityandan.-inflammatoryproper.ve

Topical Dapsone

• Aczonegel7.5%• Effec.ve• >12years• AvoidBactrimDS• AvoidBenzoylperoxide• CategoryC

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Topical An6bio6cs

• Erythromycin• Cleocin• Combina.onproducts

Alltopicalacneprepara.ons

drying,besuretousemoisturizersregularlyanddose.Accordingto

pa.entsskintype

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Systemican,bio,cs:• Majorproblemisresistance!!!• Limitusefor3to6months• An.bio.cshavebeenusedfor>40years

Common Systemic

An6bio6c

Doxycycline50-100mg,photosensi.vityMinocycline50-100mgo MinocinSyndrome-fever,rash,jointpain,lupus-likereac.on,headache,eyepain,visualchanges,orbluishpigmenta.ontoskin.

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Systemic An6bio6cs

•  Clindamycin75-100mg-severepseudomembranouscoli.s,C.Diff

•  Ampillicn/Amoxicillin-Ampillicnokduringpregnancy

•  Trimethoprim/sulfametoxazole-Bactrim/Septra

•  Macrolides-Erythromycin

Anypa.entonasystemican.bio.cshould/mustbeadvisedofcommonsideeffects.

• Photosensi.vity-doxycycline

• Erythemia-bactrim• Bluishdiscolora.on-minocycline

• Diarrhea-clindamycin

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Allpa.entsonansystemican.bio.cshould:• Avoidtanningbeds• Eatyogurtortakeacrdophiluscapsule2-4x/wk

HormonalTherapy

Birthcontrolpillsareeffec.veformanywomen,slowac.ngwhencomparedto

systemican.bio.cs

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Acne in women may be a marker for underlying diseases

Polycys.cOvarianSyndrome

1Anovula.on

2Cushing’sdisease

3Androgen-secre.ngtumor

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Hormonal treatment

Spironolactone25-200mg/day

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Women Best Suited for Hormonal Treatment

MostlikelytorespondtoHormonalTreatment:-  Increasedfacialoiliness(seborrhea)-  Premenstrualacneflare-ups-  Inflammatoryacneonmandibularlineandneck

INDICATIONS

1.  Adultwomenwithinflammatoryfacialacne2.  Hormonalinfluencesuggestedbya)Premenstrualflaresb)Onseta\erage25yearsc)Distribu.ononthelowerface,includingthe

mandibularlineandchind)Increaseinoilinessonthefacee)Coexistentfacialhirsu.sm3.Inadequateresponseorintolerancetostandardtreatmentwithtopicaltherapies,systemican.bio.cs,orisotre.noin4.Presenceofcoexis.ngsymptomssuchasirregularmenses,premenstrualweightgain,orothersymptomsofpremenstrualsyndrome

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Whenpa.entsdonotrespondby3monthstheyareontopicalbenzoylperoxide,atopicalre.noid,andsystemicconsider:

1.  Changingan.bio.cs2.  ForwomenaddBCP

3.Star.ngisotre.noin/Accutane

Isotretinion

•  Approved1982•  Indica.on

-Severe,recalcitrantcys.cacne-Severe,recalcitrantnodularand inflammatoryacne-Moderateacneunresponsiveto conven.onaltherapy-Pa.entswhoscar-Excessiveoiliness-Severlydepressedordysmorphicpa.ents

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Enroll in the I-pledge system

Dosage0.5-1.0mg/kgfor4-8monthsRelapse39%(usuallywithin3years,mostwithin18months)23%requirean.bio.cs16%requireaddi.onalisotre.noin

TEST COMMENTSPregnancy SeeiPLEDGEprogram

guidelinesTriglyceridelevel Performedduring

pretreatment,a\er2- 3weeksof

treatment, andthenat4-week intervals.Stopisvalue exceeds700-800 mg/dltoreducerisk ofpancrea..sCompletebloodcellcount Performedbefore

treatmentanda\er4- 6weeksoftreatmentLiverfunc.on Performedbefore

treatmentanda\er4- 6weeksoftreatment

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Mucocutaneous Adverse Events as a Percentage

Drychappedlips Dryskin Itching Drynessinmouth Thirst Rashorredness(face) Dryeyes Peelingoffinger.ps Nosebleeding

Ihaveprescribedisotre.noinsince1982.Noserioussideaffectnoted-moreserious

reac.oninmyexperiencewithBactrimandminocycline

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Prednisone

Alimited,butdefiniteplaceinmanagementofacne

IntralesionalCor,losteriod30gaugeneedle

2.5-10mg/mlintocyst

Other Types of Acne

• Gramnega.veacne• Steriodacne• Neonatalacne• Intan.leacne• AcneMechanica• Acnecosme.ca• Excoriatedacne

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Perioral Derma66s

Acne Rosacea

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Inconclusionmostofyoushouldbeabletomanagemostacnepa,ents.Theuseofisotre,noinisnotlimited

toDermatologist

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Thankyou,

Anyques,ons?