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  1. 1. Acne Bill V. Way, D.O. Dermatology Residency Program Director
  2. 2. What is Acne?  Acne is a skin disorder resulting from the action of hormones on the skin’s oil glands (sebaceous glands) which leads to plugged pores and outbreaks of the lesions of papules, pustules, comedones, inflammatory cysts commonly called pimples or zits.
  3. 3. Acne  Over 17 million people in the US have acne today. It is the most common skin disease.  Not a serious health threat, but severe acne can lead to disfiguring, permanent scarring, low self esteem.
  4. 4. Acne  The disease of the pilosebaceous units of the skin.  Most commonly on the face, neck, chest, back and shoulders were more of the pilosebaceous units are located.
  5. 5. Acne  The basic acne lesion is called the comedo (KOM-e-do), simply an enlarged and plugged hair follicle.  If it remains below the surface it is called a closed comedo and produces a whitish bump called a whitehead, this is not a milium.
  6. 6. Acne: Comedo  If the comedo reaches the surface, it is called an open comedo or blackhead  The black color is not dirt, but is from the oil oxidizing when it reaches the surface of the skin
  7. 7. Acne: Papule  Inflammed lesions that usually appear as small pink bumps on the skin and may be tender to the touch
  8. 8. Acne: Pustule  Inflammed papules with a pustule on the top that may be red at the base and usually tender. (Pimple)
  9. 9. Acne: Nodules  Large, painful, solid lesions that are lodged deep within the skin
  10. 10. Acne: Cysts  Deep,painful, pus-filled lesions that can cause scarring
  11. 11. What causes Acne?  Exact cause of acne is unknown. Several factors may play a role.  One important factor is an increase in androgens (male hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.
  12. 12. What causes Acne? Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing  Hormone changes related to pregnancy or starting and stopping birth control pills can also be a cause of acne.
  13. 13. What causes Acne?  Propionibacterium acnes (P.acnes) are the anaerobic bacteria responsible for causing acne.  Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing  Hormone changes related to pregnancy or starting or stopping birth control pills can also be a cause of acne.
  14. 14. Propionibacterium acnes  Anaerobic bacteria in hair follicle.  These bacteria use the sebum as food and break the sebum down into irritating substances, which cause inflammation.  The abnormal flaking of the cells inside the hair follicle and the irritating substances lead to a plug formation and the to follicle swelling and then rupturing and developing into the papule then to the pustule.
  15. 15. What can make Acne worse?  Changing hormone levels in adolescent girls and adult women 2-7 days before their menstrual period starts  Friction by leaning or rubbing skin  Pressure from helmets, backpacks  Environment: pollution and high humidity  Squeezing or picking at pimples  Hard scrubbing of the skin
  16. 16. Myths about causes of Acne  Foods; chocolate, greasy or fried foods. No foods cause acne.  Dirt. Acne is not the result of uncleanliness or infrequent washing.  Stress. Just the opposite, Acne may cause the patient more stress.  Sunlight or tanning clears acne. No tanning will lead to sundamaged skin, wrinkles and skin cancers.  Skin must be scrubbed. No, too much scrubbing may actually make acne worse.
  17. 17. Who gets Acne?  People of all races and ages.  Most common in adolescents and young adults  85% between ages 12-25  Resolves with time around age 25-30  Few patients may have persistent acne into their 40’s and 50’s
  18. 18. Who should be treating Acne?  Family Practice  Pediatrics  Internal Medicine  Dermatology
  19. 19. What are the goals in treating Acne?  Heal existing lesions  Stop new lesions from forming  Prevent scarring  Minimize the psychological stress and embarrassment, thus improving self-esteem and self-confidence and avoiding depression  Teach the patient what acne is, how to treat their acne and what to expect from treatment
  20. 20. Acne Treatment  Medical treatment is aimed at reducing several problems that play a role in causing acne; abnormal clumping of cells in the follicles, increased oil production, bacteria and inflammation.
  21. 21. Grading Acne  Scale 0-4  0 – no acne, clear  +1– mild acne, comedos, papules, few pustules  +2 – moderate acne, comedos, multiple papules and pustules  +3 – moderately severe, multiple comedos, papules and pustules, mild scarring  +4 – severe, multiple comedos, papules, pustules, inflammatory cysts, nodules, scarring
  22. 22. Treatment for Blackheads, Whiteheads and mild inflammatory Acne  OTC or Rx  Benzoyl peroxide, resorcinol, salicyclic acid and sulfur  Benzoyl peroxide products kill P.acnes and may reduce oil production  Resorcinol and salicyclic acid and sulfur help break down blackheads and whiteheads
  23. 23. OTC Treatment  Benzoyl peroxide washes and gel  Salicyclic Acid washes  Must be used twice daily regularly for 8- 12 weeks, then reevaluate
  24. 24. Treatment of Moderate to Severe Inflammatory Acne  Prescription topical and or oral medications alone or in combination  Recheck patient every 4-8 weeks for results and to adjust acne treatment program
  25. 25. Treatment of Severe Nodular or Cystic Acne  Should be seen and treated by a dermatologist  Failure to respond to a variety of topical antibiotics, topical retenoids and oral antibiotics  Consider Accutane Therapy
  26. 26. OTC Topical Acne Cleansers  Neutrogena Acne Wash  Cetaphil Facial Cleanser  Oil of Olay Facial Cleanser  Various Benzoyl Peroxide Cleansers, Clearsil, Clean and Clear, others
  27. 27. Acne Treatment  Clean skin gently  Avoid squeezing, pinching, picking or scratching the acne lesions.  Bleeding leads to scarring  Shave carefully  Avoid sunburn or suntan  Choose cosmetics carefully, oil-free, water based
  28. 28. OTC Acne Topicals  Benzoyl peroxide cleansers  Sulfur products  Salicyclic acid pads
  29. 29. Prescription Acne Cleansers Benzoyl Peroxide  Brevoxyl 4%, 8%  Triaz 3%, 6%, 10%  Benzac 5%, 10%
  30. 30. Prescription Cleanser  Plexion Cleanser: Sodium Sulfacetamide 10% & Sulfur 5%
  31. 31. Topical Antibiotics  Clindamycin: Solution,Gel, Lotion, Pads  Erythromycin:Solution,Gel,Pads, Ointment  Combination: Benzoyl peroxide and topical antibiotic  Sodium Sulfacetamide and Sulfur
  32. 32. Topical Antibiotics  Cleocin T Solution, Lotion, Gel, Pads  Erycette Pads  Benzamycin Gel  BenzaClin Gel  Klaron Lotion  Plexion SCT
  33. 33. Topical Retenoids  Retin A: gel, cream, microgel  Differin: gel, cream, pad  Generic Tretinoin: gel, cream
  34. 34. Retin A Microgel  0.04% and 0.1%  20gm and 45gm  Apply at hs  Recommend sunscreens in am
  35. 35. Oral Antibiotics  Tetracycline  Minocycline  Doxycycline  Erythromycin  Azithromycin
  36. 36. Oral Tetracycline  Generic Tetracycline is ok  Must be taken correctly, 1 hour before meal or 2 hours after meal with glass of water  Not to taken with milk  Increased change of inducing vaginal yeast infections
  37. 37. Oral Minocycline  Dynacin, Minocin, Adoxa, Generic  Better absorption, less GI upset  May be taken with food, minimal loss of effect  1-2 times daily  Avoid 100mg bid for it may induce a blue gray hyperpigmentation in areas of cysts, bleeding or brusing
  38. 38. Oral Minocycline  Increased cost  Very effective  May be used long term
  39. 39. Oral Doxycycline  Doryx, Generic  Good absorption, less GI upset  May be taken with food, minimal loss  1-2 times daily  Occasional photosensitivity, rare  Increased cost, very effective, may be used long term
  40. 40. Oral Erythromycin  Eryc 250mg 1 bid  Effective for short times, then bacterial resistance starts to develop  Low cost, increased GI upset  May have other drug interactions
  41. 41. Oral Azithromycin  Recommend use only by dermatologist due cost
  42. 42. Accutane (Isotrenoin)  10mg, 20mg, 40mg  Used by itself  Patients must be enrolled into the SMART Program and rules and regulations must be followed exactly  Recommend patient be referred to dermatologist
  43. 43. Accutane (Isotretinoin)  Very effective  Useful to help prevent scarring  15-20 weeks of therapy  SMART Program  Expensive  Patient must be monitored very closely  No other acne treatment needed
  44. 44. Accutane: Disadvantages  Can cause birth defects  Female patients must not get pregnant while on Accutane  Depression, Irritability  Loss of appetite, hair thinning, curling  Dry eyes, mouth, lips, nose and skin, itching, nosebleeds, muscle aches, sensitivity to sun, poor night vision
  45. 45. Accutane: Disadvantages  Changes in blood such as increase in triglycerides and choesterol or a change in liver function  Must monitor blood prior to starting and every 4 weeks while on Accutane  CBC, CMP, Lipid Panel, UA, Urine pregnancy test
  46. 46. Adjunct Derm Treatment  Acne Surgery  Mild Chemical Peels  Microdermabrasion  New ClearLight treatment  Dermabrasion or Laser tx for scarring  Surgical scar revision  Fillers for scars, fat transfer  Intralesional steroid injections
  47. 47. How often should the Acne Patient be seen?  Initially every 4-8 weeks  Then every 8-12 weeks  Then every 3-4 months  Acne is monitored and treated for several years from ages 12-25
  48. 48. Hormonally Influenced Acne  Increased excessive androgen levels in females may present as hirsutism, premenstrual acne flares, irregular menstrual cycles, elevated blood levels of certain androgens  Birth control pills with increased androgens will increase acne  Birth control pills with increased estrogens decrease acne
  49. 49. Recommend OrthoTri-Cyclen or Demulen  Occasionally but rare use of low dose corticosteroid drugs, prednisone or dexamethasone may be used to suppress the androgen production by the adrenal gland  Occasional use of spironolactone to reduce excessive oil production.
  50. 50. Web Sites on Acne  www.   