Acne VulgarisAcne Vulgaris
(Otherwise known as zits, pimples and blackheads)(Otherwise known as zits, pimples and blackhea...
Conference GoalsConference Goals
 Review pathogenesis as a way to help usReview pathogenesis as a way to help us
understa...
EpidemiologyEpidemiology
Onset?Onset?
 Males 10-17 yrsMales 10-17 yrs Females 14-19 yrsFemales 14-19 yrs
 May persist th...
Causes?Causes?
 Majority of patients have a family history ofMajority of patients have a family history of
acneacne
 Emo...
PathogenesisPathogenesis
 Plugging of the hair folliclePlugging of the hair follicle
w/ abnormally keratinizedw/ abnormal...
““Doctor my skin is breaking out!”Doctor my skin is breaking out!”
 34yo Latina comes to your office stating34yo Latina c...
HPIHPI
 When was the onset?When was the onset? AdolescenceAdolescence
 Where?Where? Face, neck, trunk &Face, neck, trunk...
Differential DiagnosisDifferential Diagnosis
 FaceFace
 Staph aureusStaph aureus folliculitisfolliculitis
 RosaceaRosac...
Types of AcneTypes of Acne
 ComedonalComedonal
 PapulopustularPapulopustular
 NodulocysticNodulocystic
 Why is this im...
Comedonal AcneComedonal Acne
 Closed comedones (whiteheads)Closed comedones (whiteheads)
 Sebum accumulation results in ...
Papulopustular AcnePapulopustular Acne
 Papules/PustulesPapules/Pustules
 Follicular wall rupturesFollicular wall ruptur...
Nodulocystic AcneNodulocystic Acne
 Soft nodules that areSoft nodules that are
secondary comedones fromsecondary comedone...
ManagementManagement
 Acne often spontaneously clearsAcne often spontaneously clears
 Flares may occur in the winter &Fl...
Four Major Goals of TreatmentFour Major Goals of Treatment
 Correct the abnormal follicular keratinizationCorrect the abn...
RetinoidsRetinoids
CostCost
 Tretinoin (Retin-A)Tretinoin (Retin-A) $42 (20g)$42 (20g)
 Adapalene (Differin)Adapalene (D...
Topical AntibioticsTopical Antibiotics
CostCost
 Clindamycin Gel (Cleocin)Clindamycin Gel (Cleocin) $32 (30 g)$32 (30 g)
...
OtherOther
CostCost
 Benzoyl peroxide gelBenzoyl peroxide gel $24 (90g)$24 (90g)
 Reduces antibiotic resistanceReduces a...
Comedonal AcneComedonal Acne
TretinoinTretinoin 0.025% cream0.025% cream oror 0.01% gel0.01% gel qhsqhs
0.05% cream0.05% c...
Papulopustular AcnePapulopustular Acne
TretinoinTretinoin 0.025% cream0.025% cream oror 0.01% gel qhs0.01% gel qhs
0.05% c...
Oral antibioticsOral antibiotics
CostCost
 TetracyclineTetracycline $8 (30caps)$8 (30caps)
 Least efficacious but cheapL...
Papulopustular AcnePapulopustular Acne
 Tetracycline 500mg po tid-qid x 3 monthsTetracycline 500mg po tid-qid x 3 months
...
ConsiderConsider
 Hormone TherapyHormone Therapy
 Ortho-Tricyclen, Desogen, Ortho-CyclenOrtho-Tricyclen, Desogen, Ortho-...
Nodulocystic AcneNodulocystic Acne
 Only indication to use AcutaneOnly indication to use Acutane
 Acts against the four ...
EducationEducation
 Improvement occurs over 2-5 monthsImprovement occurs over 2-5 months
 Face, upper arms and legs tend...
 Soaps, detergents, and astringentsSoaps, detergents, and astringents
remove sebum from the skin surface butremove sebum ...
Completing TherapyCompleting Therapy
 Once acne cleared you can attempt toOnce acne cleared you can attempt to
wean meds....
Follow-up on PatientFollow-up on Patient
 Sent labs for PCOS – all negativeSent labs for PCOS – all negative
 Concern fo...
ConclusionsConclusions
 KeratinizationKeratinization  androgensandrogens  bacteriabacteria
 inflammationinflammatio...
SourcesSources
 AAFPAAFP
 UptodateUptodate
 Fitzpatrick, et al Color Atlas & Synopsis ofFitzpatrick, et al Color Atlas ...
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  • Lower incidence in Asians and African-Americans
    Despite lower incidence in darker skinned people it is important to note that the prevalence of acne-induced scarring and hyperpigmentation is increased in these groups compared light skinned patients. 65% of AA 52% of Latinos47% Asians
  • P. acnes, are present in increased numbers in persons who have acne.
    Much of the inflammation that eventually occurs arises from the action of enzymes produced by the bacteria. These enzymes hydrolyze sebum into free fatty acids, which stimulate the inflammatory process.
    Chemotactic factors are released by this reaction, attracting neutrophils.
    As the follicular wall becomes inflamed, an erythematous papule appears at the skin surface. With increased sebum production, obstruction and bacterial colonization, the follicular unit ruptures, spilling its contents into the dermis. The inflow of neutrophils causes the formation of pustules.
    Continuation of severe inflammation leads to formation of nodules and subsequent cysts.
  • Comedonal acne consists predominantly of open or closed comedones with little or no accompanying inflammation (Figure 2). This type of acne typically responds to topical keratolytic agents that decrease the cohesiveness of the follicular cells. Erythematous papules and pustules characterize inflammatory acne, but comedones may also be present (Figure 3). Topical agents alone may be insufficient to treat inflammatory acne, which may benefit from systemic antibiotics. Nodulocystic acne may consist of comedones and inflammatory lesions, as well as deeper nodules and cysts (Figure 4). Although a six-month course of systemic antibiotics may be effective, nodulocystic acne frequently requires treatment with isotretinoin (Accutane).
    . Comedonal acne. In closed comedones (whiteheads), a mass of desquamated cells plugs the follicular canal above the opening of the sebaceous gland. Sebum accumulates within the follicular canal and results in a white papule visible at the skin surface. In open comedones (blackheads), when the opening of the follicular canal dilates, the plug protrudes from the canal and turns a dark color.
  • Adjuvant therapy with other agents may be considered during isotretinoin treatment. Topical antibiotics may be beneficial, but use of topical keratolytics and drying agents should be discontinued because concomitant use may lead to extensive dryness. Occasionally, oral erythromycin or prednisone is used at the beginning of isotretinoin therapy to control the initial acne flare-up. None of the tetracyclines should be used for this purpose because the combination of a tetracycline and isotretinoin increases the likelihood of pseudotumor cerebri development.20
    Pustules generally clear more rapidly than papules or nodules. Lesions on the face, upper arms and legs tend to respond more quickly than those on the trunk. After reaching the goal dosage of 120 to 150 mg per kg, isotretinoin therapy should be discontinued even if the acne is not completely clear because improvement continues for one to two months following cessation of treatment.
  • It can be taken with food and, unlike the other tetracyclines, only infrequently causes photosensitivity. Most adverse effects of minocycline are similar to those of the other tetracyclines (Table 3). However, minocycline may cause cutaneous hyperpigmentation in scars, vertigo and, in rare instances, the development of a lupus-like syndrome
  • sfghdean.ucsf.edu

    1. 1. Acne VulgarisAcne Vulgaris (Otherwise known as zits, pimples and blackheads)(Otherwise known as zits, pimples and blackheads) Cynthia Salinas, M.D.Cynthia Salinas, M.D. PGY-3 Patient ConferencePGY-3 Patient Conference February 2, 2005February 2, 2005
    2. 2. Conference GoalsConference Goals  Review pathogenesis as a way to help usReview pathogenesis as a way to help us understand why we use certain medsunderstand why we use certain meds  Differentiate common types of acneDifferentiate common types of acne  Generate a quick differential diagnosisGenerate a quick differential diagnosis  Apply a stepwise approach to treatmentApply a stepwise approach to treatment priorprior toto referral to dermatologyreferral to dermatology
    3. 3. EpidemiologyEpidemiology Onset?Onset?  Males 10-17 yrsMales 10-17 yrs Females 14-19 yrsFemales 14-19 yrs  May persist through 4May persist through 4thth decade or olderdecade or older Prevalence?Prevalence?  Asians 10%Asians 10%  African-American 25%African-American 25%  Caucasians 29%Caucasians 29%
    4. 4. Causes?Causes?  Majority of patients have a family history ofMajority of patients have a family history of acneacne  Emotional stressEmotional stress  AndrogensAndrogens  Dioxins, lithiumDioxins, lithium  Occlusion and pressure “acne mechanica”Occlusion and pressure “acne mechanica”  NOT DUE TO CHOCOLATE OR FATTYNOT DUE TO CHOCOLATE OR FATTY FOODS!FOODS!
    5. 5. PathogenesisPathogenesis  Plugging of the hair folliclePlugging of the hair follicle w/ abnormally keratinizedw/ abnormally keratinized cellscells  Androgen-inducedAndrogen-induced sebaceous glandsebaceous gland hyperactivityhyperactivity  Proliferation of bacteriaProliferation of bacteria -- Propionibacterium acnesPropionibacterium acnes  InflammationInflammation
    6. 6. ““Doctor my skin is breaking out!”Doctor my skin is breaking out!”  34yo Latina comes to your office stating34yo Latina comes to your office stating that she has had “bad skin forever” andthat she has had “bad skin forever” and her face is the worse it’s ever been. Sainther face is the worse it’s ever been. Saint Ivy’s scrub is not helping. She’s trying toIvy’s scrub is not helping. She’s trying to eat healthy but despite her best effortseat healthy but despite her best efforts keeps gaining weight. She wonders if shekeeps gaining weight. She wonders if she is doing the wrong things and asks foris doing the wrong things and asks for your help.your help.
    7. 7. HPIHPI  When was the onset?When was the onset? AdolescenceAdolescence  Where?Where? Face, neck, trunk &Face, neck, trunk & buttocksbuttocks  Does it itch or hurt?Does it itch or hurt? Pustules painfulPustules painful  How have the individual lesions changed?How have the individual lesions changed?  Triggers?Triggers? Worse in fall/winterWorse in fall/winter  Hirsutism? Oligomenorrhea?Hirsutism? Oligomenorrhea?
    8. 8. Differential DiagnosisDifferential Diagnosis  FaceFace  Staph aureusStaph aureus folliculitisfolliculitis  RosaceaRosacea  Perioral dermatitisPerioral dermatitis  TrunkTrunk  PityrosporumPityrosporum folliculitisfolliculitis  ““Hot Tub” folliculitisHot Tub” folliculitis  Acne AestivalisAcne Aestivalis  Appears after sun exposureAppears after sun exposure
    9. 9. Types of AcneTypes of Acne  ComedonalComedonal  PapulopustularPapulopustular  NodulocysticNodulocystic  Why is this important?Why is this important?  Directs treatment optionsDirects treatment options
    10. 10. Comedonal AcneComedonal Acne  Closed comedones (whiteheads)Closed comedones (whiteheads)  Sebum accumulation results in a whiteSebum accumulation results in a white papule visible at the skin surfacepapule visible at the skin surface  Open comedones (blackheads)Open comedones (blackheads)  Plug protrudes from canal and turnsPlug protrudes from canal and turns darkdark  Non-inflammatoryNon-inflammatory  Usually responds to topicalUsually responds to topical keratolytickeratolytic
    11. 11. Papulopustular AcnePapulopustular Acne  Papules/PustulesPapules/Pustules  Follicular wall rupturesFollicular wall ruptures  Releases sebum andReleases sebum and bacteria into dermisbacteria into dermis  Topical agents aloneTopical agents alone usually insufficientusually insufficient  Consider topicalConsider topical retinoidsretinoids plusplus systemic antibioticssystemic antibiotics
    12. 12. Nodulocystic AcneNodulocystic Acne  Soft nodules that areSoft nodules that are secondary comedones fromsecondary comedones from repeated rupturesrepeated ruptures reencapsulations andreencapsulations and abscess formationsabscess formations  Painful and disfiguringPainful and disfiguring  Psychological impactPsychological impact  Treatment consists of topicalTreatment consists of topical agents, oral antibiotics oragents, oral antibiotics or isotretinoinisotretinoin
    13. 13. ManagementManagement  Acne often spontaneously clearsAcne often spontaneously clears  Flares may occur in the winter &Flares may occur in the winter & w/mensesw/menses  Scarring can be avoided by properScarring can be avoided by proper treatmenttreatment earlyearly in the course of diseasein the course of disease  Assess the psychological impact ofAssess the psychological impact of cosmetic disfigurementcosmetic disfigurement
    14. 14. Four Major Goals of TreatmentFour Major Goals of Treatment  Correct the abnormal follicular keratinizationCorrect the abnormal follicular keratinization  Decrease sebaceous gland activityDecrease sebaceous gland activity  Decrease follicular bacteriaDecrease follicular bacteria  Inhibit the production of extracellularInhibit the production of extracellular inflammationinflammation Take home points:Take home points: Retinoids, abx, hormonal treatments targetRetinoids, abx, hormonal treatments target different areas responsible for acnedifferent areas responsible for acne
    15. 15. RetinoidsRetinoids CostCost  Tretinoin (Retin-A)Tretinoin (Retin-A) $42 (20g)$42 (20g)  Adapalene (Differin)Adapalene (Differin) $42 (15g)$42 (15g)  Tazarotene (Tazarotene)Tazarotene (Tazarotene) $74 (30g)$74 (30g)  Acts as a keratolytic and anti-inflammatoryActs as a keratolytic and anti-inflammatory  Inactivated by UV lightInactivated by UV light  SE: Dryness, scaling, erythema, burning,SE: Dryness, scaling, erythema, burning, irritation, and photosensitivityirritation, and photosensitivity
    16. 16. Topical AntibioticsTopical Antibiotics CostCost  Clindamycin Gel (Cleocin)Clindamycin Gel (Cleocin) $32 (30 g)$32 (30 g)  Erythromycin Gel (Akne-Mycin)Erythromycin Gel (Akne-Mycin) $18 (30 g)$18 (30 g)  KillsKills propionibacterium acnespropionibacterium acnes  SE: Irritating; stains clothesSE: Irritating; stains clothes
    17. 17. OtherOther CostCost  Benzoyl peroxide gelBenzoyl peroxide gel $24 (90g)$24 (90g)  Reduces antibiotic resistanceReduces antibiotic resistance  SE: erythema, drynessSE: erythema, dryness  Ortho-TricyclinOrtho-Tricyclin $38 (pack)$38 (pack)  Ortho-CyclenOrtho-Cyclen  DesogenDesogen  Anti-androgenicAnti-androgenic  2-4 months before improvement is seen2-4 months before improvement is seen
    18. 18. Comedonal AcneComedonal Acne TretinoinTretinoin 0.025% cream0.025% cream oror 0.01% gel0.01% gel qhsqhs 0.05% cream0.05% cream oror 0.025% gel0.025% gel 0.1% cream0.1% cream PLUSPLUS benzoyl peroxide 5% gelbenzoyl peroxide 5% gel qamqam -Gels have a drying effect-Gels have a drying effect -Creams/lotions tend to be moisturizing-Creams/lotions tend to be moisturizing
    19. 19. Papulopustular AcnePapulopustular Acne TretinoinTretinoin 0.025% cream0.025% cream oror 0.01% gel qhs0.01% gel qhs 0.05% cream0.05% cream oror 0.025% gel0.025% gel 0.1% cream0.1% cream  PLUSPLUS clindamycin 1% gelclindamycin 1% gel oror erythromycin 2% gelerythromycin 2% gel  PLUSPLUS benzoyl peroxide 5% gelbenzoyl peroxide 5% gel
    20. 20. Oral antibioticsOral antibiotics CostCost  TetracyclineTetracycline $8 (30caps)$8 (30caps)  Least efficacious but cheapLeast efficacious but cheap  Decreases efficacy of OCP’s; need backupDecreases efficacy of OCP’s; need backup  Must take 1hr before meals; wait 2hrs after takingMust take 1hr before meals; wait 2hrs after taking  DoxycyclineDoxycycline $75 (30caps)$75 (30caps)  SE: Dyspepsia, nausea, emesisSE: Dyspepsia, nausea, emesis diarrhea, photosensitivity, esophagitisdiarrhea, photosensitivity, esophagitis  MinocyclineMinocycline $117 (30caps)$117 (30caps)  Most effective but also most expensiveMost effective but also most expensive  Can take with food unlike other tetracylinesCan take with food unlike other tetracylines  Infrequently causes photosenstivityInfrequently causes photosenstivity  SE:SE: vertigovertigo, mouth & shin hyperpigmentation, mouth & shin hyperpigmentation
    21. 21. Papulopustular AcnePapulopustular Acne  Tetracycline 500mg po tid-qid x 3 monthsTetracycline 500mg po tid-qid x 3 months  Doxycycline 100mg po bid x 3 monthsDoxycycline 100mg po bid x 3 months  Minocycline 100mg daily thenMinocycline 100mg daily then  to 100mg bidto 100mg bid x 3 monthsx 3 months
    22. 22. ConsiderConsider  Hormone TherapyHormone Therapy  Ortho-Tricyclen, Desogen, Ortho-CyclenOrtho-Tricyclen, Desogen, Ortho-Cyclen  Spironolactone 100mg dailySpironolactone 100mg daily
    23. 23. Nodulocystic AcneNodulocystic Acne  Only indication to use AcutaneOnly indication to use Acutane  Acts against the four pathogenic factors thatActs against the four pathogenic factors that contribute to acnecontribute to acne  It is the only med w/ the potential to suppressIt is the only med w/ the potential to suppress acne over the long termacne over the long term  To prescribe this med the physician must be aTo prescribe this med the physician must be a registered member of System to Manageregistered member of System to Manage Accutane-Related Teratogenicity (SMART)Accutane-Related Teratogenicity (SMART) program to educate patients about the possibleprogram to educate patients about the possible severe adverse effects and teratogenicity ofsevere adverse effects and teratogenicity of isotretinoinisotretinoin
    24. 24. EducationEducation  Improvement occurs over 2-5 monthsImprovement occurs over 2-5 months  Face, upper arms and legs tend to respondFace, upper arms and legs tend to respond more quickly than those on the trunkmore quickly than those on the trunk  Retinoids should be applied at bedtimeRetinoids should be applied at bedtime  Clinda/Erythro/BP are applied in the morningClinda/Erythro/BP are applied in the morning  Combination therapy is BEST!Combination therapy is BEST!  Avoid using topical antibiotic aloneAvoid using topical antibiotic alone  Should combine with antibacterial agent such asShould combine with antibacterial agent such as benzoyl peroxide or oral antibioticbenzoyl peroxide or oral antibiotic  No improvement? Change topical or add oralNo improvement? Change topical or add oral antibioticantibiotic
    25. 25.  Soaps, detergents, and astringentsSoaps, detergents, and astringents remove sebum from the skin surface butremove sebum from the skin surface but do not alter sebum productiondo not alter sebum production  Avoid repetitive mechanical traumaAvoid repetitive mechanical trauma  Avoid occlusive clothing and refrain fromAvoid occlusive clothing and refrain from rubbing their faces or picking their skinrubbing their faces or picking their skin  Water-based cosmetics and hair productsWater-based cosmetics and hair products are less comedogenic than oil-basedare less comedogenic than oil-based productsproducts
    26. 26. Completing TherapyCompleting Therapy  Once acne cleared you can attempt toOnce acne cleared you can attempt to wean meds. Typically wean down from bidwean meds. Typically wean down from bid to daily dosing for 2-3 months then offto daily dosing for 2-3 months then off completely. Some will have completecompletely. Some will have complete remission while others made need repeatremission while others made need repeat treatment.treatment.
    27. 27. Follow-up on PatientFollow-up on Patient  Sent labs for PCOS – all negativeSent labs for PCOS – all negative  Concern for early metabolic syndromeConcern for early metabolic syndrome  Started on topical tretinoin cream andStarted on topical tretinoin cream and benzoyl peroxide and spironolactonebenzoyl peroxide and spironolactone  Advised to apply tretinoin on acanthosisAdvised to apply tretinoin on acanthosis nigracansnigracans  Referred for PMDReferred for PMD
    28. 28. ConclusionsConclusions  KeratinizationKeratinization  androgensandrogens  bacteriabacteria  inflammationinflammation  Comedonal, Papulopustular, NodulocysticComedonal, Papulopustular, Nodulocystic  11stst Line: Topical Retinoids!Line: Topical Retinoids!  Minimum use of 3 months prior to labelingMinimum use of 3 months prior to labeling treatment as a failuretreatment as a failure  Intervene early to prevent scarringIntervene early to prevent scarring
    29. 29. SourcesSources  AAFPAAFP  UptodateUptodate  Fitzpatrick, et al Color Atlas & Synopsis ofFitzpatrick, et al Color Atlas & Synopsis of Clinical DermatologyClinical Dermatology  Brian Swan’s Foom HandoutBrian Swan’s Foom Handout

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