Dr Noori Moti-Joosub Dermatologist

Laserderm, Dunkeld/ DGMC

Acne vulgaris is a self-limited disorder of the pilosebaceous unit that is seen primarily in adolescents. Most cases of acne present with a pleomorphic variety of lesions, consisting of comedones, papules, pustules and nodules. Although the course of acne may be self-limiting, the sequelae can be lifelong, with pitted or hypertrophic scar lifelong.

Almost every teenager can experience acne to a certain degree during adolescent years.

Boys>girls

Tend to “grow out of it” in early 20s

Females can continue until post-menopausal

Hair follicle has a hair and sebaceous gland. The gland produces too much oil which becomes clogged with keratin, bacteria and cells.

Whitehead

Blackhead

Papule Pustule

Cyst

Excoriations (picked or scratched spots)

Erythematous macules (red marks from recently healed spots, mostly in fair skin)

Pigmented macules (dark marks from old spots, mostly in dark skin)

Scars

HYPERTROPHIC ATROPHIC

Normal physiological reaction in puberty Disease of the ovaries ◦ Polycystic ovarian syndrome ◦ Benign or malignant ovarian tumors

Disease of the adrenal gland ◦ Partial deficiency of the adrenal enzyme 21 Hydroxylase ◦ Benign or malignant adrenal tumors

Disease of the pituitary gland ◦ Cushing’s syndrome due to excessive adrenocorticotrophic

hormone ◦ Acromegaly due to excessive growth hormone production ◦ Adenoma of the adrenal gland especially prolactinoma

Obesity and the metabolic syndrome Medication-phenytoin,steroids,barbiturates,OCPills

Patients with acne often have increased production of sebum, hence oily skin. This may be because of:

High overall levels of sex hormones (mainly the androgen, testosterone).

Hyperandrogenism in females

Increased free testosterone because of low levels of circulating sex-hormone-binding-globulin (SHBG).

More active conversion of weaker androgens to stronger androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin.

Higher sensitivity of the skin to DHT.

Stress

Diet

High GI diet

ACNE

Mild: Comedones

Moderate: Papules, pustules

Severe: Nodules, cysts, conglobate lesions

Grade 1: Comedones only

Grade 2: Inflammatory papules

Grade 3: Pustules

Grade 4: Nodules, cysts, conglobate lesions

Unpleasant form of nodulocystic acne Interconnecting abscesses and sinuses, which

result in unsightly hypertrophic (thick) and atrophic (thin) scars.

There are groups of large macrocomedones and cysts that are filled with smelly pus.

It is occasionally associated with hidradenitis suppurativa,

Allergic reaction to P. acne Abrupt onset Inflammatory and ulcerated nodular acne on

chest and back Severe acne scarring Fluctuating fever Painful joints Malaise (i.e.. the patient feels unwell) Loss of appetite and weight loss Raised white blood cell count.

Infantile acne Generally affects the cheeks, and

sometimes the forehead and chin, of children aged six months to three years.

More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months.

The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.

The cause of infantile acne is unknown. It is thought to be genetic in origin. Hormone abnormalities in older children

with acne may be associated with the following conditions:

Congenital adrenal hyperplasia Cushing's Disease 21-Hydroxylase deficiency Precocious puberty Androgen-secreting tumors

Acne can be effectively treated, but response is usually slow

Face washing-rock of management Where possible, avoid excessively humid

conditions Ultraviolet light helps Abrasive skin treatments can aggravate

acne Try not to scratch or pick the spots

Important part of acne treatment

Wash face once or twice a day

Gentle cleansers

Foam cleansers best

Exfoliative cleansers can be used

Often not needed in acne

Do not dry skin out

Mattifying moisturisers

Often extra moisturisers needed with Isotretinoin treatment

Not necessary

Use non-alcoholic type

Often too oily

Use non-comedogenic types

Shade-seeking behaviour

Protective clothing

With Isotretinoin treatment, sun protection imperative

Liquid foundation better than powders

Powders block pores

The more you use, the worse it is

Make sure adequately removed

Non-comedogenic

Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.

Acne products should be applied to all areas affected by acne, rather than just put on individual spots.

They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this.

Apply an oil-free moisturizer only if the affected skin is obviously peeling.

Anti-bacterial

Antibiotics

Retinoids

Other

Benzoyl peroxide 2.5-10% wash, gel, cream

Gel: drying

Cream: tolerant

Wash: Chest and Back

MOA: kill bacteria, dry up oil, slough dead skin cells

Problem: dryness, irritation, flakiness

Erythromycin 4% and Zinc 1,2%

Clindamycin

MOA: anti-inflammatory, kill bacteria

Problem: Resistance Gram negative folliculitis

Adapalene 0.1% Photo-stable Gel: drying Cream: more tolerant Tretinoin 0.1-0.25% Isotretinoin 0.05% MOA: Promote cell turnover, prevent plugging

of hair follicles Problems: dryness, irritation, redness, sun-

sensitivity

Oral or topical

Often in combination

Safe in pregnancy

MOA: unknown??

Immune-modulatory

Anti-bacterial, anti-viral?

Problem: None

Sulfur compounds: 2% sulfur in UEA

Cost-effective

MOA: anti-bacterial, anti-parasitic, anti-fungal, anti-inflammatory

Problems: smell

Gel or cream formulations

MOA: anti-bacterial, anti-inflammatory

Problems: Dry skin, irritation

MOA: keratolytic agent (sloughing of dead skin cells).

Problems: Irritation

Used for acne, wounds, infection, fungal infection

MOA: anti-bacterial, anti-viral, anti-fungal, anti-inflammatory

Problems: slower onset of action compared to benzoyl peroxide, sensitivity

Topical treatment plus Antibiotics

an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond

after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred(pt assessment)

Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen

Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted

MOA: bacteriostatic, anti-inflammatory

First line – Tetracycline (no longer used)

2nd line- doxycycline (abdominal cramping, nausea, vomiting), minocycline(causes SLE), lymecycline (abdominal cramping)

Take with probiotic

Not to be taken with food

Warn females about vaginal thrush

Can have a flare when commencing treatment

MOA: bactericidal activity (2 agents).

Most effective due to lack of resistance (2 agents).

Can be effective on those who failed on tetracycline treatment (different sites of sebum production, less resistance).

S/E: GIT disturbance, drug reaction.

Must be a combination OCP (oestrogen and progesterone)

Often regarded as an adjunctive therapy in acne

Indicated in PCOS, CAH, idiopathic hirsutism

Often combined with cyproterone acetate (25-100mg day 5-19)

MOA: reduces sebum production by an anti-androgenic effect.

Mild Side effects:

Headaches

Nausea

Breast tenderness

Weight gain

Often pass in a few months

Severe side effects:

Thrombosis (minimally raised with the progesterone drospironone)

Risk greatest in first year and as you get older.

Over 35 years use a low oestrogen pill

Strokes

Heart attacks

Smoking

History of thrombosis or cardio-vascular disease

Family history of blood clotting disease or abnormal clotting

Anti-phospholipid syndrome

Severe migraines

Diabetes

Hypertension, hypercholesterolaemia

History of thromboplebitis

Immobilisation

Results have not been consistent

hepatic and endometrial cancer

breast cancer

in younger users, returns to normal 10yrs after stopping it

cervical cancer (? Increased sexual activity in Pill users)

Must be taken every day

Diarrhoea and vomiting decrease effectiveness

Anti-epileptics, anti-virals may interfere with it.

No clear evidence that antibiotics interfere with OCP.

Takes time to work

Family Planning Association of UK, safe to take OCP until 50yrs of age.

Weigh up benefits and risk factors

Many patients will be treated with oral isotretinoin.

If this is not suitable, the following may be used:

High dose oral antibiotics for six months or longer

In females, especially those with polycystic ovary syndrome, oral antiandrogens such as OCP or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect.

Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not licensed

MOA:

Reduces sebum secretion and shrinks sebaceous gland

Anti-bacterial

Promotes normal keratinisation of hair follicle

Anti-inflammatory

Side effects

Teratogenic

Dryness, nosebleeds, dry lips

Body aches and pains

Hair falling out

Staph carriage increased: boils etc

?? Depression, mood changes

May fall pregnant 1 month after stopping Isotretinoin

Blood tests: βHCG. LFTs (ALT, AST), Lipogram (Total cholesterol, triglycerides)

Repeat at 3 months

Dose: 0,5-1mg/kg/day

Cumulative dose: 120-150mg/kg

Low dose?

Take with biggest meal of the day

For greater efficacy bd dosing should be used

Cortisone on commencement

Sunlight is anti-inflammatory and can help briefly. Beware of skin cancer.

Cryotherapy Intralesional steroid injections Comedones can be expressed by cautery or

diathermy. Microdermabrasion can help mild acne. Lasers and light systems (blue light) X-ray treatment-no longer recommended

for acne as it may cause skin cancer. Photo-dynamic therapy

Topicals

Zinc and Erythromycin

Sulfur

Oral meds

Erythromycin

Will resolve in 9-12months

Topical depigmenting agents can speed up recovery

Fractionated lasers can resolve PIH in 3-5 sessions.

Hypertrophic:

I/L steroids

Fractionated laser and rub steroid in

Atrophic

HA fillers

Fractionated laser

CO2 laser

Immediate referral indicated (within a day): have a severe variant of acne such as acne

fulminans or gram-negative folliculitis Urgent referral have severe or nodulocystic acne and could

benefit from oral isotretinoin have severe social or psychological

problems, including a morbid fear of deformity

Routine referral At risk of or are developing scarring despite

management have moderate acne that has failed to

respond to treatment which has included two courses of oral antibiotics, each lasting three months.

are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment