Acne vulgaris and Acne Acne vulgaris and Acne related disordersrelated disorders

Dr. Mohammed A. Al-Shahwan Dr. Mohammed A. Al-Shahwan M.DM.D..

College of MedicineCollege of Medicine

King Saud UniversityKing Saud University

ObjectivesObjectives

Acquiring knowledge of the etiology and Acquiring knowledge of the etiology and pathogenesis of acne vulgaris.pathogenesis of acne vulgaris.

Understanding the disease spectrum of Understanding the disease spectrum of acne vulgaris.acne vulgaris.

Acquiring knowledge of the therapeutic Acquiring knowledge of the therapeutic options for acne vulgaris and their options for acne vulgaris and their indications.indications.

To be familiar with the etiology, clinical To be familiar with the etiology, clinical types and treatment of rosacea.types and treatment of rosacea.

Acne vulgarisAcne vulgaris

Is a chronic inflammatory disorder of Is a chronic inflammatory disorder of the pilosebaceous apparatus of the pilosebaceous apparatus of certain body areas resulting in certain body areas resulting in greasiness and polymorphic skin greasiness and polymorphic skin eruption. eruption.

IncidenceIncidence

Acne affects all skin types, the male Acne affects all skin types, the male and female ratio is virtually the same and female ratio is virtually the same but tends to be more severe in males.but tends to be more severe in males.

85% affects the age group 12 – 24 years85% affects the age group 12 – 24 years

8% affects the age group 25 – 34 years 8% affects the age group 25 – 34 years

3% affects the age group 35 – 44 years3% affects the age group 35 – 44 years

Pathogenesis Pathogenesis ( three main steps ( three main steps recognized and hypothesized)recognized and hypothesized)

1.1. Follicular Hyperkeratosis (the cause Follicular Hyperkeratosis (the cause not fully understood) theory not fully understood) theory suggest:suggest:

deficiency in Linoleic acid deficiency in Linoleic acid the effect of Androgen (DHT)the effect of Androgen (DHT) the effect of Interleukin-1 the effect of Interleukin-1 The effect of P.acneThe effect of P.acne

Perifollicular Hyperkeratosis histology

2.2. Abnormal production of sebum Abnormal production of sebum which can increase further by the which can increase further by the response of sebaceous glands to response of sebaceous glands to testosterone & DHTtestosterone & DHT

3. 3. Colonization of the affected unit with Colonization of the affected unit with bacteria bacteria Propionibacterium acne and Propionibacterium acne and yeast named Malassezia furfuryeast named Malassezia furfur

Propionibacterium Propionibacterium acneacne

Malassezia Malassezia furfurfurfur

Propionobacterium acne lipases act on sebaceous Propionobacterium acne lipases act on sebaceous fatty acid (Triglycrides) to release irritant free fatty acid (Triglycrides) to release irritant free fatty acid and low-molecular- weight peptide an fatty acid and low-molecular- weight peptide an extra cellular factor that penetrate the follicular extra cellular factor that penetrate the follicular wall and stimulate wall and stimulate Polymorphs and Lymphocytes Polymorphs and Lymphocytes initiating inflammationinitiating inflammation

Hydrolytic enzymes released from the Hydrolytic enzymes released from the activated complement antibodies activated complement antibodies complex together with exoenzymes complex together with exoenzymes produced from P acne cause rupture produced from P acne cause rupture of follicular wallof follicular wall

Once the wall is damaged , Various Once the wall is damaged , Various agents agents (prostaglandin-like substance, amino (prostaglandin-like substance, amino acid, short chain fatty acids) that are acid, short chain fatty acids) that are produced by the inflammatory cells produced by the inflammatory cells and P acne extrude to the dermis and P acne extrude to the dermis causing more inflammationcausing more inflammation

Clinical featuresClinical features polymorphic skin eruption composed of polymorphic skin eruption composed of

: :

PapulesPapules Comedones (Open Comedones (Open ““BlackheadsBlackheads”” or or

closed closed ““WhiteheadsWhiteheads””)) Inflammatory papulesInflammatory papules

PustulePustule

Nodule Nodule

Cyst Cyst

Open Comedones (Blackheads)Open Comedones (Blackheads)

Open Comedones

Closed Comedones (Whitehead)Closed Comedones (Whitehead)

Closed Comedones

Inflammatory papulesInflammatory papules

Inflammatory papules

Pustules Pustules

Pustules

Nodules Nodules

Nodule

CystsCysts

Neonatal acne: the cause is unknown Neonatal acne: the cause is unknown but some believed is due to passing but some believed is due to passing of Transplacental androgen while of Transplacental androgen while others suggest the role of Malassezia others suggest the role of Malassezia furfur furfur .. It present mainly with It present mainly with inflammatory papules on nose and inflammatory papules on nose and cheeks affecting new borns between cheeks affecting new borns between the 1the 1stst and 6 and 6thth week of age week of age

Neonatal Acne and Infantile Acne Neonatal Acne and Infantile Acne

Infantile Acne: affect males more Infantile Acne: affect males more than females, usually between 3 and than females, usually between 3 and 6 months of age, and tend to be 6 months of age, and tend to be severer than the neonatal one and severer than the neonatal one and believed to be due to believed to be due to EndogenousEndogenous androgen from the infants gonads.androgen from the infants gonads.

Acne FulminansAcne Fulminans

Affect youngsters 13 Affect youngsters 13 –– 17 years of age, 17 years of age, very severe with ulceration and pus very severe with ulceration and pus discharge, associated symptoms discharge, associated symptoms include (fever, malaise, myalgia, include (fever, malaise, myalgia, arthritis and bone pain) laboratory arthritis and bone pain) laboratory investigations shows elevation of investigations shows elevation of ESR & WBCESR & WBC

Can be induced by starting the patient Can be induced by starting the patient on high dose of isotretinion on high dose of isotretinion (Roaccutane).(Roaccutane).

Acne Conglobata Acne Conglobata

Very severe Nodulocystic form with Very severe Nodulocystic form with abscess formation, affecting Torso abscess formation, affecting Torso more than the face. It usually affect more than the face. It usually affect males more that females.males more that females.

Other forms of acne Other forms of acne

Acne excoriee Acne excoriee Acne Aestivalis Acne Aestivalis Acneform eruption Acneform eruption e.g. e.g.

Chloracne (Halogenated Chloracne (Halogenated Hydrocarbons or Chlorinated Phenols Hydrocarbons or Chlorinated Phenols (Dioxin) (Dioxin)

Pomade acne ( Oil Folliculitis )Pomade acne ( Oil Folliculitis )

Steroid acneSteroid acne

TREATMENTTREATMENT

Topical Keratolytic ( anti-inflammatory Topical Keratolytic ( anti-inflammatory & comedolytic)& comedolytic)

Retinoid ( Retinoic acid 0.025, 0.05, Retinoid ( Retinoic acid 0.025, 0.05, 0.1%0.1%

& Adapalene 0.1%)& Adapalene 0.1%) Salicylic acid 2% (beta-hydroxy acid)Salicylic acid 2% (beta-hydroxy acid) Azelaic Acid 20 %Azelaic Acid 20 %

Topical antibiotic ( anti-inflammatory & Topical antibiotic ( anti-inflammatory & anti-microbial)anti-microbial)

clindamycinclindamycin ErythromycinErythromycin Benzoyl peroxide Benzoyl peroxide Sodium Fusidic acid Sodium Fusidic acid

Systemic therapySystemic therapy

Systemic Antibiotic :Systemic Antibiotic :

1.1. TetracyclineTetracycline

2.2. DoxycyclineDoxycycline

3.3. Minocycline Minocycline

4.4. AzithromycineAzithromycine

Systemic Retinoids :Systemic Retinoids :

Isotretinoin caps (Roaccutane): 0.5 – 1 mg/kgIsotretinoin caps (Roaccutane): 0.5 – 1 mg/kg

Indicated for severe forms (nodulocystic , fulminant and Indicated for severe forms (nodulocystic , fulminant and conglobate) but also for milder forms associated with conglobate) but also for milder forms associated with scarring or with significant psychological impact.scarring or with significant psychological impact.

Relapse is minimal with cumulative dose of 120 – 150 Relapse is minimal with cumulative dose of 120 – 150 mg/kg.mg/kg.

Side effects include: cheilitis, dryness, alopecia , Side effects include: cheilitis, dryness, alopecia , photosensitivity, xerophthalmia, decreased night vision, photosensitivity, xerophthalmia, decreased night vision, keratitis, benign intracranial hypertension (incresed risk keratitis, benign intracranial hypertension (incresed risk with concomitant use of tetracyclines), photosensitivity, with concomitant use of tetracyclines), photosensitivity, hypertriglyceridemia, hypercholesterolemia, elevated liver hypertriglyceridemia, hypercholesterolemia, elevated liver enzymes, depression (controversial), skeletal enzymes, depression (controversial), skeletal hyperostosis, myalgias.hyperostosis, myalgias.

Teratogenicity (category X)Teratogenicity (category X) so, Pregnancy must be prevented during treatment and for so, Pregnancy must be prevented during treatment and for

at least 1 month after discontinuing the drug.at least 1 month after discontinuing the drug.

Other forms of therapyOther forms of therapy Oral steroid for acne fulminans and Oral steroid for acne fulminans and

Intralesional steriods for cystic acne.Intralesional steriods for cystic acne. Photodynamic therapy and Laser therapy Photodynamic therapy and Laser therapy

(pulse dye laser)(pulse dye laser) Hormonal therapy (Anti-androgen)Hormonal therapy (Anti-androgen)

e.g. OCP , flutamide and Spironolactone in e.g. OCP , flutamide and Spironolactone in treatment of acne associated with treatment of acne associated with hyperandrogenism e.g. PCOS (Polycystic hyperandrogenism e.g. PCOS (Polycystic Ovary Syndrome). Ovary Syndrome).

RosaceaRosacea

A controversial topic in dermatology largely A controversial topic in dermatology largely because of its uncertain pathophysiology because of its uncertain pathophysiology and clinical variation.and clinical variation.

Primary features of rosacea is flushing, Primary features of rosacea is flushing, papules, pustules and telangiectasia that papules, pustules and telangiectasia that affect the central face sp. Convex areas like affect the central face sp. Convex areas like nose , cheek ,chin and foreheadnose , cheek ,chin and forehead

EpidemiologyEpidemiology

Common in Caucasian populationCommon in Caucasian population women>menwomen>men Onset typically begins after age 30Onset typically begins after age 30

Etiology and Etiology and pathogenesispathogenesis

1.Vascular reactivity1.Vascular reactivity::

Which usually induced by chronic repeated exposure Which usually induced by chronic repeated exposure to certain triggers e.g.: to certain triggers e.g.:

1)1) Hot or cold temperature Hot or cold temperature

2)2) SunlightSunlight

3)3) Hot drinks, Spicy foods and Alcohol Hot drinks, Spicy foods and Alcohol

4)4) Emotional distressEmotional distress

5)5) Certain medications and cosmetics Certain medications and cosmetics e.g. calcium e.g. calcium channel blockers, nicotinic acid, morphine, amyl and channel blockers, nicotinic acid, morphine, amyl and butyl nitrite, cholinergic drugs, bromocriptine, butyl nitrite, cholinergic drugs, bromocriptine, tamoxifen, cyproterone acetate, systemic steroids tamoxifen, cyproterone acetate, systemic steroids and cyclosporine.and cyclosporine.

Etiology and Etiology and pathogenesispathogenesis

2. Dermal matrix degeneration and 2. Dermal matrix degeneration and endothelial damage: endothelial damage:

due to Inherent problems with vessels due to Inherent problems with vessels permeability and Delayed clearance of permeability and Delayed clearance of inflammatory mediators and waste productsinflammatory mediators and waste products

Photodamaged connective tissue (solar Photodamaged connective tissue (solar elastosis is a common background on which elastosis is a common background on which rosacea histologic features are rosacea histologic features are superimposedsuperimposed

Etiology and Etiology and pathogenesispathogenesis

3. Microbe – induced folliclular inflammation: 3. Microbe – induced folliclular inflammation:

Commensal organisms e.g. Demodex Commensal organisms e.g. Demodex folliculorum (mite) or bacillus oleronius folliculorum (mite) or bacillus oleronius (bacteria) which reside in hair follicles and (bacteria) which reside in hair follicles and sebaceous glands may trigger sebaceous glands may trigger folliculocentric inflammatory process .folliculocentric inflammatory process .

Sub-type classificationSub-type classification

Sub types were defined by the National Rosacea Sub types were defined by the National Rosacea Society (NRS) expert committee in 2002.Society (NRS) expert committee in 2002.

1)1) Erythematotelangiectatic :Erythematotelangiectatic : persistent erythema and persistent erythema and telangiectasias on the central face.telangiectasias on the central face.

2)2) Papulopustular: Papulopustular: papules and pustules predominate on papules and pustules predominate on convex areas on a background of persistent erythemaconvex areas on a background of persistent erythema

3)3) Phymatous: Phymatous: prominent follicular orifices, thickened skin prominent follicular orifices, thickened skin and nodularity which is due to sebaceous gland and nodularity which is due to sebaceous gland hyperplasiahyperplasia

Most often affect the nose (rhinophyma)Most often affect the nose (rhinophyma)

Almost exclusively affecting menAlmost exclusively affecting men

4) Ocular: 4) Ocular: Blepharitis is the most common feature Blepharitis is the most common feature

It can present also by Conjuctivitis, iritis, scleritis, It can present also by Conjuctivitis, iritis, scleritis, keratitiskeratitis

Erythematotelangiectatic Erythematotelangiectatic RosaceaRosacea

Papulopustular RosaceaPapulopustular Rosacea

RhinophymaRhinophyma

Rosacea variantsRosacea variants

Granulomatous rosacea: Granulomatous rosacea: Rosacea Rosacea variant characterised by variant characterised by monomorphic yellow- brown or monomorphic yellow- brown or red-brown papules/ nodules red-brown papules/ nodules located on the facelocated on the face

Histology shows granulomaHistology shows granuloma

TreatmentTreatment

SunscreensSunscreens Avoidance of Avoidance of aggravating factors.aggravating factors. Topical therapy include:Topical therapy include: MetronidazoleMetronidazole

Azelaic acidAzelaic acid

Benzoyl peroxideBenzoyl peroxide

TretinoinTretinoin

Erythromycin and ClindamycinErythromycin and Clindamycin Oral therapy include:Oral therapy include:Oral Tetracyclines e.g. Doxycycline and minocycline Oral Tetracyclines e.g. Doxycycline and minocycline

Oral IsotretinoinOral Isotretinoin

Laser and light therapyLaser and light therapy Laser and Intense Pulsed light IPL is useful in Laser and Intense Pulsed light IPL is useful in

treating persistent erythema and treating persistent erythema and telangiectasias.telangiectasias.

Superficial small telangiectasias require short Superficial small telangiectasias require short wavelengths:wavelengths:

Pulsed dye laser (585 or 595 nm)Pulsed dye laser (585 or 595 nm)

KTP laser (532nm) KTP laser (532nm)

Deep facial vessels require longer wavelengths :Deep facial vessels require longer wavelengths : Diode laser (810)Diode laser (810)

Alexandrite laser (755nm)Alexandrite laser (755nm)

ND:YAG (1064nm)ND:YAG (1064nm)

Treatment of Phymatous Treatment of Phymatous RosaceaRosacea

Early Phymatous changes could be treated Early Phymatous changes could be treated with Isotretinoin.with Isotretinoin.

Advanced changes is treated with surgery Advanced changes is treated with surgery

Scalpel tangential excisionScalpel tangential excision

ElectrosurgeryElectrosurgery

CO2 laser ablation.CO2 laser ablation.