Acne and rosaceaDr Daniel HewittDermatologistSkin and Cancer Foundation Westmead
ObjectivesUnderstand that acne and rosacea are extremely common and have a significant burden on patientsTo understand the most common clinical findingsTo be able to list the management options
AcneAcne is extremely common, affecting approximately 85% of people at some stage.It most commonly presents in teenagers but can occur at any age.It has a profound psychological and social impact. Acne may have a big impact even when there are few lesions in the skin.
PathogenesisThere is no single cause.Acne tends to run in families as there is a genetic basis.The main aetiological factors are1 Blocking of the follicle or “pilosebaceous unit”– this occurs most commonly on the face and trunk2 Increased production of sebum by the sebaceous glands which are connected to the follicle3 Inflammation in the follicle – this seems to occur after rupture of the follicle or sebaceous duct4 Bacteria such as Propionobacterium acnes – these probably have a role in stimulating inflammation5 Hormonal stimulation of sebaceous glands, although the majority of patients with acne have normal hormone levels.
Myths abound regarding acneIt is not strongly related to any lifestyle factors. Dietary modification is not generally helpful in its management.It is not caused by dirt or poor hygeine.Like many dermatoses, it can flare during stressful times, but stress is not a common cause.
Clinical featuresAcne is a clinical diagnosis and usually obviousThe hallmarks are papules – small red, raised lesions pustules – yellow papules, often on an erythematous base comedones – a plug in the follicle seen as black dots (blackheads) or small white lumps (whiteheads)There are usually combinations of these
Classic acne with the combination of papules, pustules and comedones
TreatmentTreatment can be divided into two main categories - topical treatments and systemic treatments.All treatments require at least 6-8 weeks to work. Generally patients are asked to stay on treatment regimes for at least 3 months.Various light and laser treatments have been used, but they are not commonly helpful for active acne.
Topical treatmentsRetinoids These are vitamin A derivatives. They normalize keratinization to decrease follicular occlusion in addition to decreasing sebaceous gland secretion. Examples are tretinoin 0.025%, 0.05% or 0.1% adapalene 0.1% isotretinoin 0.05%Antibiotics and antiseptics These aim to kill bacteria in the follicles and decrease inflammation. Examples include erythromycin 2% gel benzoyl peroxide 5% lotion clindamycin 1% lotion or gel
Keratolytics These can be prescribed in larger quantities and may be useful for truncal acne. An example is 3% salicylic acid in 70% ethanolCombination products are also available eg benzoyl peroxide 5% + clindamycin 1% benzoyl peroxide 5% + adapalene 0.1%All of these products have the potential to produce dryness or irritation
Systemic treatmentsAntibioticsThese can be used with or without topical products. They control inflammatory or pustular acne most effectively.Tetracyclines are most commonly used. These kill bacteria in hair follicles but probably also have an anti- inflammatory effect on the skin eg doxycycline 50mg bd minocycline 50mg bd Other antibiotics are also used eg erythromycin ethyl succinate 400mg bd this is safe in pregnancy cotrimoxazole one tablet od or bd
IsotretinoinThis is a very useful medication for severe, cystic acne.It can only be prescribed on the PBS by dermatologists.Female patients must have absolutely no risk of becoming pregnant while on oral isotretinoin as it causes birth defects.Most people on it get dryness of their mucosal surfaces and skin. Possible other side effects include – muscle aches and pains, stiffness, photosensitivity, headaches, hair thinning, nail brittleness, tiredness, liver enzyme elevation, elevated cholesterol and decreased visual acuity.Patients are given detailed information prior to commencing and blood counts, liver function, lipids and a pregnancy test must be checked prior to commencing.The usual dose is 40-60mg per dayA cumulative total dose of 100 to 150mg /kg is aimed for.
RosaceaRosacea is a chronic inflammatory condition of the face, usually seen in older adults.It is difficult to understand as it has many different characteristics.
Clinical featuresRosacea has different forms. It does not necessarily progress from one form to the next1 Telangiectatic – often there is a history of flushing and blushing or heat in the face. This can then develop into fixed erythema and telangiectasia in this form of rosacea.2 Inflammatory – papules and pustules, centred on the follicles characterise this type. Comedones are not seen, unlike in acne3 Proliferative – Sebaceous hyperplasia, chronic oedema and connective tissue proliferation lead to this form seen most commonly in men. The nose is most frequently affected – “rhinophyma.”The eyes are sometimes involved, most commonly as a blepharitis.
TriggersThe fundamental causes are not well understood but there are a number of triggersAlcohol – although this is not an important causeHot food and drinksSpicy foodHeatSun exposureIrritating products eg soaps and cleansersStress
Strong topical steroids are often problematic on the face.They can produce a rosacea-like eruption known as perioral dermatitis. This comprises monomorphic papules and small pustules and can occur around the mouth, nose or eyes.It flares on cessation of topical steroids. It settles slightly with their use but patients can become dependent on them and they must be avoided.Tetracyclines (eg minocycline 50mg po bd) are used for 2-3 months to control this condition. They must be warned that there will be an initial flare.
ManagementThere are four main areas1 General measures2 Topical therapy3 Systemic therapy4 Surgery and physical modalities
General measuresPatients should avoid normal soaps and drying products to their face. Daily use of a gentle soap free wash (eg QV soap free wash) and low irritant sunscreens are appropriate.Known triggers are to be avoided – eg sunlight, heat, hot and spicy food and drinks.Sympathetic explanation of the chronicity of the condition and the need to adapt to it is essential.All treatments require perseverence – often no response is seen until 6 to 8 weeks and often maintainence therapy is required.
Topical therapyThe two most commonly used products are metronidazole 0.75% gel or cream azaleic acid 15% gelOther options include Erythromycin 2% gel Extemperaneous preparations eg 1% sulfur + 2% salicylic acid in aqueous creamTopical treatments are used twice a day initially but can be reduced to once a day once a response has been achieved. They can be used for long term maintainence, if required.Topical steroids are to be avoided as the condition often flares on their withdrawal.
Systemic therapyThis is used in more severe cases, or when inadequate control is achieved topically.Antibiotics are used, as in acne eg doxycycline 50 to 100mg daily minocycline 50 to 100mg daily erythromycin ethyl succinate 400mg bdIsotretinoin is sometimes used in very difficult cases.
Surgery and physical modalititesVascular laser or intense pulsed light therapy is effective for the erythema and telangiectasia of rosacea. Improvement is usually only partial and several treatment sessions may be required.Shave excison and laser ablation procedures may be appropriate for the more proliferative forms of rosacea (eg rhinophyma) once it is more resistant to medical treatment.
ConclusionAcne and rosacea are very common skin conditions that impair patients’ quality of life.Treatments are numeorus but can de divided into topical and systemic treatments. They need to be used for at least several weeks to obtain an optimal response.