ACNE

Jason M Cheyney, MPAS, PA-CDermatologic Surgery Specialists

Macon, Ga 31211

Pathogenesis of Acne

Causative Factors

Therapy

On the horizon

Approximately 45 million Americans have acne

It is often the first assault on teenagers ego

It can become an overly emotional situation

Acne is much worse than a bad hair day

Acne can affect ~ 40% of people over 25 y/o

Over $100 million spent annually to treat acne

Hair follicle plugged by abnormally keratinized cells

Increased oil retention by pilosebaceous unit

Proprionibacterium overgrowth and digestion of oil and production of free fatty acids

Free fatty acids induce inflammation

Androgen induced sebaceous gland hyperactivity

Diet plays a role with increased carbohydrate intake triggers insulin release which causes excess hormone production

Comedonal (Non-inflammatory)Open = blackheads

Closed = whiteheads

Papules: Solid inflamed elevations above the skin

Pustules: pus-filled inflammatory bumps

Nodules: Deeper lesions, often painful and can lead to discoloration and scarring.

Inflammatory or Not?- Determines Need for Antibiotics (topical or oral)

Depth of the Lesions?- Determines Role of Oral Medication

PIH or Scarring Present?- Determines How Aggressive you NEED to Be- Is Patient a Candidate for Isotretinoin?

Psychological Impact?- Will Determine How Aggressive to Get

TopicalRetinoids

BPO

Antibiotics

AHA/BHA

Azaleic Acid

Dapsone

Ivermectin

Brimonidine

SystemicAntibiotics

Doxycycline and Minocycline

Spironolactone

IsotretinoinDon’t let the rumors scare you

Has been a life-saver for many patients

A Cornerstone of Treatment for All Stages

Maintenance Therapy

MOA: Normalizes Desquamation of Skin Cells

Reduces obstruction in the follicle which reduces P. acnes growth, facilitates the removal of existing comedones, and hinders formation of new lesions and reduces inflammation

Adverse effects: skin irritation, “worse before better”

“Pea-sized” amount to a clean and DRY face

Avoid eyelids – no breakouts there anyway

Wash hands after application

Often a period before skin is “retinized”

May get worse before it gets better

May get dry with use; use moisturizer

If too irritating, use every other day until ready for daily use

Mechanism of Action:- Decreases P. acnes (bactericidal)- Comedolysis

Preparations:- OTC/RX 2.5% - 10%- Wash, creams, gel, foam, combination products

Safety:- Bleaches clothes - Irritation and dryness

Retinoid + Benzoyl Peroxide

1 + 1 = 3

Available by prescription only: Lotion, Gel, Cream

Erythromycin, clindamycin, sulfacetamide, metronidazole

MOA: Reduces the bacterial population, also possess anti-inflammatory properties.

Should not be used as monotherapy

Increased incidence of bacterial resistance

Erythromycin is virtually ineffective at this point

Adverse effects: generally mild dermatitis, allergy

Available over the counter and prescription in concentrations ranging from 0.5% to 10% for the treatment of Acne vulgaris (higher concentrations are for the removal of warts).

Most often found in facial cleansers

MOA: Possesses a keratolytic effect and is a mild antiseptic.

Adverse effects: erythema, pruritus, burning/stinging sensation

Apply up to twice daily

Helpful in skin of color due to skin lightening affect

Stinging most common side effect

Apply twice daily

?G6PD

Stinging burning can occur

Apply once daily

Effective against demodex

Improvement with continued usage

Apply in AM

Rebound erythema after 10-12 hours

Significant improvement with continued usage

Generally reserved for moderately severe to severe acne

Inflammatory acne only (not effective for comedonal acne)

Cystic or inflammatory acne resistant to topical treatment

Systemic treatment options:Oral antibioticsIsotretinoinHormonal therapy

Isotretinoin

Indicated for the treatment of severe, nodulocystic acneAffects RNA synthesis at a cellular level which in turn modifies the cell turnover rate, decreases follicle and sebaceous gland size, and decreases sebum production.Also possesses anti-inflammatory properties.Dose: 0.5 – 2.0 mg/kg/day x 20 weeksRemission can be permanent after one course of treatment.Use is governed by the iPledge program

- Used Rx Exactly as Prescribed

- No OTC meds unless told to do so

- Never pop, squeeze or pick lesions

- Avoid using abrasive products

- Use hands or gentle washcloth to wash your face

- Wait 5 – 30 min after showering or washing to apply topical medications

- It is possible for your acne to get worse before it gets better- Add moisturizer early on in treatment

Tips for Better Outcomes

Use only oil-free skincare and hair care products

This is your condition; It is your responsibility to use meds as directed

Apply medications before make-up or facial moisturizers

Use only non-comedogenic products

Continue to use medications even after skin clears

Gently cleanse skin after sweating

Give your medications adequate time to work

Tips for Better Outcomes

Too Many Steps to the Regimen (especially boys)

Inadequate Patient Education

Unrealistic Expectations

Patient Frustration

Your Patient Won’t Succeed If:

“YOU, Make the Call”

Best Method to Treat Scarring?

Don’t Let the Redness Fool You!

Acne Rosacea

Primarily seen in Northern European decent

Called the “curse of the Celts” in Europe

3x more common in women

Predominantly seen in caucasions

Typically arises between the ages of 30-50

Acne Rosacea

Cause unknown

Sunlight is most common trigger

Heat can induce

FoodCaffeine

Alcohol

Spicy foods

DemodexFeces?

Bacteria in Feces?

Acne Rosacea

Erythematotelangectatic

Papulopustular

Phymatous

Ocular

SubtypesPerioral dermatitis

Treatment

Directed at type

ErythematotelangectaticMetrocream

Mirvaso

Cleocin/hydrocortisone

Laser

TopicalsMetrocream

Azaleic acid

Ivermectin

BPO/clindamycin combo

SystemicAntibiotics- low dose

Isotretinoin?

Spironolactone

Isotretinoin

Surgery

TopicalBPO/Clinda combo

Metrocream

SystemicAntibiotics

Blue light

Biofilm agents

Retinoic acid blockers

Cytokine blockers - Th1