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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 Latinos 47% 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
  • Acne

    1. 1. Acne Vulgaris (Otherwise known as zits, pimples and blackheads)
    2. 2. Conference Goals <ul><li>Review pathogenesis as a way to help us understand why we use certain meds </li></ul><ul><li>Differentiate common types of acne </li></ul><ul><li>Generate a quick differential diagnosis </li></ul><ul><li>Apply a stepwise approach to treatment prior to referral to dermatology </li></ul>
    3. 3. Epidemiology <ul><li>Onset? </li></ul><ul><li>Males 10-17 yrs Females 14-19 yrs </li></ul><ul><li>May persist through 4 th decade or older </li></ul><ul><li>Prevalence? </li></ul><ul><li>Asians 10% </li></ul><ul><li>African-American 25% </li></ul><ul><li>Caucasians 29% </li></ul>
    4. 4. Causes? <ul><li>Majority of patients have a family history of acne </li></ul><ul><li>Emotional stress </li></ul><ul><li>Androgens </li></ul><ul><li>Dioxins, lithium </li></ul><ul><li>Occlusion and pressure “acne mechanica” </li></ul><ul><li>NOT DUE TO CHOCOLATE OR FATTY FOODS! </li></ul>
    5. 5. Pathogenesis <ul><li>Plugging of the hair follicle </li></ul><ul><li>w/ abnormally keratinized cells </li></ul><ul><li>Androgen-induced sebaceous gland hyperactivity </li></ul><ul><li>Proliferation of bacteria </li></ul><ul><li>- Propionibacterium acnes </li></ul><ul><li>Inflammation </li></ul>
    6. 6. “ Doctor my skin is breaking out!” <ul><li>34yo Latina comes to your office stating that she has had “bad skin forever” and her face is the worse it’s ever been. Saint Ivy’s scrub is not helping. She’s trying to eat healthy but despite her best efforts keeps gaining weight. She wonders if she is doing the wrong things and asks for your help. </li></ul>
    7. 7. HPI <ul><li>When was the onset? Adolescence </li></ul><ul><li>Where? Face, neck, trunk & buttocks </li></ul><ul><li>Does it itch or hurt? Pustules painful </li></ul><ul><li>How have the individual lesions changed? </li></ul><ul><li>Triggers? Worse in fall/winter </li></ul><ul><li>Hirsutism? Oligomenorrhea? </li></ul>
    8. 8. Differential Diagnosis <ul><li>Face </li></ul><ul><ul><li>Staph aureus folliculitis </li></ul></ul><ul><ul><li>Rosacea </li></ul></ul><ul><ul><li>Perioral dermatitis </li></ul></ul><ul><li>Trunk </li></ul><ul><ul><li>Pityrosporum folliculitis </li></ul></ul><ul><ul><li>“ Hot Tub” folliculitis </li></ul></ul><ul><li>Acne Aestivalis </li></ul><ul><ul><li>Appears after sun exposure </li></ul></ul>
    9. 9. Types of Acne <ul><li>Comedonal </li></ul><ul><li>Papulopustular </li></ul><ul><li>Nodulocystic </li></ul><ul><li>Why is this important? </li></ul><ul><ul><li>Directs treatment options </li></ul></ul>
    10. 10. Comedonal Acne <ul><li>Closed comedones (whiteheads) </li></ul><ul><ul><li>Sebum accumulation results in a white papule visible at the skin surface </li></ul></ul><ul><li>Open comedones (blackheads) </li></ul><ul><ul><li>Plug protrudes from canal and turns dark </li></ul></ul><ul><li>Non-inflammatory </li></ul><ul><li>Usually responds to topical keratolytic </li></ul>
    11. 11. Papulopustular Acne <ul><li>Papules/Pustules </li></ul><ul><ul><li>Follicular wall ruptures </li></ul></ul><ul><ul><li>Releases sebum and bacteria into dermis </li></ul></ul><ul><li>Topical agents alone usually insufficient </li></ul><ul><li>Consider topical retinoids plus systemic antibiotics </li></ul>
    12. 12. Nodulocystic Acne <ul><li>Soft nodules that are secondary comedones from repeated ruptures reencapsulations and abscess formations </li></ul><ul><li>Painful and disfiguring </li></ul><ul><li>Psychological impact </li></ul><ul><li>Treatment consists of topical agents, oral antibiotics or isotretinoin </li></ul>
    13. 13. Management <ul><ul><li>Acne often spontaneously clears </li></ul></ul><ul><ul><li>Flares may occur in the winter & w/menses </li></ul></ul><ul><ul><li>Scarring can be avoided by proper treatment early in the course of disease </li></ul></ul><ul><ul><li>Assess the psychological impact of cosmetic disfigurement </li></ul></ul>
    14. 14. Four Major Goals of Treatment <ul><li>Correct the abnormal follicular keratinization </li></ul><ul><li>Decrease sebaceous gland activity </li></ul><ul><li>Decrease follicular bacteria </li></ul><ul><li>Inhibit the production of extracellular </li></ul><ul><li>inflammation </li></ul><ul><li>Take home points: </li></ul><ul><li>Retinoids, abx, hormonal treatments target different areas responsible for acne </li></ul>
    15. 15. Retinoids <ul><ul><li>Cost </li></ul></ul><ul><ul><li>Tretinoin (Retin-A) $42 (20g) </li></ul></ul><ul><ul><li>Adapalene (Differin) $42 (15g) </li></ul></ul><ul><ul><li>Tazarotene (Tazarotene) $74 (30g) </li></ul></ul><ul><ul><li>Acts as a keratolytic and anti-inflammatory </li></ul></ul><ul><ul><li>Inactivated by UV light </li></ul></ul><ul><ul><li>SE: Dryness, scaling, erythema, burning, irritation, and photosensitivity </li></ul></ul>
    16. 16. Topical Antibiotics <ul><ul><li>Cost </li></ul></ul><ul><li>Clindamycin Gel (Cleocin) $32 (30 g) </li></ul><ul><li>Erythromycin Gel (Akne-Mycin) $18 (30 g) </li></ul><ul><ul><li>Kills propionibacterium acnes </li></ul></ul><ul><ul><li>SE: Irritating; stains clothes </li></ul></ul>
    17. 17. Other <ul><ul><li>Cost </li></ul></ul><ul><li>Benzoyl peroxide gel $24 (90g) </li></ul><ul><ul><li>Reduces antibiotic resistance </li></ul></ul><ul><ul><li>SE: erythema, dryness </li></ul></ul><ul><li>Ortho-Tricyclin $38 (pack) </li></ul><ul><li>Ortho-Cyclen </li></ul><ul><li>Desogen </li></ul><ul><ul><li>Anti-androgenic </li></ul></ul><ul><ul><li>2-4 months before improvement is seen </li></ul></ul>
    18. 18. Comedonal Acne <ul><li>Tretinoin 0.025% cream or 0.01% gel qhs </li></ul><ul><ul><ul><li> </li></ul></ul></ul><ul><ul><ul><li>0.05% cream or 0.025% gel </li></ul></ul></ul><ul><ul><ul><li> 0.1% cream </li></ul></ul></ul><ul><ul><ul><li>PLUS benzoyl peroxide 5% gel qam </li></ul></ul></ul><ul><ul><ul><li>-Gels have a drying effect </li></ul></ul></ul><ul><ul><ul><li>-Creams/lotions tend to be moisturizing </li></ul></ul></ul>
    19. 19. Papulopustular Acne <ul><li>Tretinoin 0.025% cream or 0.01% gel qhs </li></ul><ul><ul><ul><li> </li></ul></ul></ul><ul><ul><ul><li>0.05% cream or 0.025% gel </li></ul></ul></ul><ul><ul><ul><li> 0.1% cream </li></ul></ul></ul><ul><li>PLUS clindamycin 1% gel or </li></ul><ul><ul><ul><li>erythromycin 2% gel </li></ul></ul></ul><ul><li>PLUS benzoyl peroxide 5% gel </li></ul>
    20. 20. Oral antibiotics <ul><ul><li>Cost </li></ul></ul><ul><li>Tetracycline $8 (30caps) </li></ul><ul><ul><li>Least efficacious but cheap </li></ul></ul><ul><ul><li>Decreases efficacy of OCP’s; need backup </li></ul></ul><ul><ul><li>Must take 1hr before meals; wait 2hrs after taking </li></ul></ul><ul><li>Doxycycline $75 (30caps) </li></ul><ul><ul><li>SE: Dyspepsia, nausea, emesis </li></ul></ul><ul><ul><li>diarrhea, photosensitivity, esophagitis </li></ul></ul><ul><li>Minocycline $117 (30caps) </li></ul><ul><ul><li>Most effective but also most expensive </li></ul></ul><ul><ul><li>Can take with food unlike other tetracylines </li></ul></ul><ul><ul><li>Infrequently causes photosenstivity </li></ul></ul><ul><ul><li>SE: vertigo , mouth & shin hyperpigmentation </li></ul></ul>
    21. 21. Papulopustular Acne <ul><li>Tetracycline 500mg po tid-qid x 3 months </li></ul><ul><li>Doxycycline 100mg po bid x 3 months </li></ul><ul><li>Minocycline 100mg daily then  to 100mg bid x 3 months </li></ul>
    22. 22. Consider <ul><li>Hormone Therapy </li></ul><ul><ul><li>Ortho-Tricyclen, Desogen, Ortho-Cyclen </li></ul></ul><ul><ul><li>Spironolactone 100mg daily </li></ul></ul>
    23. 23. Nodulocystic Acne <ul><li>Only indication to use Acutane </li></ul><ul><li>Acts against the four pathogenic factors that contribute to acne </li></ul><ul><li>It is the only med w/ the potential to suppress acne over the long term </li></ul><ul><li>To prescribe this med the physician must be a registered member of System to Manage Accutane-Related Teratogenicity (SMART) program to educate patients about the possible severe adverse effects and teratogenicity of isotretinoin </li></ul>
    24. 24. Education <ul><li>Improvement occurs over 2-5 months </li></ul><ul><li>Face, upper arms and legs tend to respond more quickly than those on the trunk </li></ul><ul><li>Retinoids should be applied at bedtime </li></ul><ul><li>Clinda/Erythro/BP are applied in the morning </li></ul><ul><li>Combination therapy is BEST! </li></ul><ul><ul><li>Avoid using topical antibiotic alone </li></ul></ul><ul><ul><li>Should combine with antibacterial agent such as benzoyl peroxide or oral antibiotic </li></ul></ul><ul><li>No improvement? Change topical or add oral antibiotic </li></ul>
    25. 25. <ul><li>Soaps, detergents, and astringents remove sebum from the skin surface but do not alter sebum production </li></ul><ul><li>Avoid repetitive mechanical trauma </li></ul><ul><li>Avoid occlusive clothing and refrain from rubbing their faces or picking their skin </li></ul><ul><li>Water-based cosmetics and hair products are less comedogenic than oil-based products </li></ul>
    26. 26. Completing Therapy <ul><li>Once acne cleared you can attempt to wean meds. Typically wean down from bid to daily dosing for 2-3 months then off completely. Some will have complete remission while others made need repeat treatment. </li></ul>
    27. 27. Follow-up on Patient <ul><li>Sent labs for PCOS – all negative </li></ul><ul><li>Concern for early metabolic syndrome </li></ul><ul><li>Started on topical tretinoin cream and benzoyl peroxide and spironolactone </li></ul><ul><li>Advised to apply tretinoin on acanthosis nigracans </li></ul><ul><li>Referred for PMD </li></ul>
    28. 28. Conclusions <ul><li>Keratinization  androgens  bacteria </li></ul><ul><ul><li> inflammation </li></ul></ul><ul><li>Comedonal, Papulopustular, Nodulocystic </li></ul><ul><li>1 st Line: Topical Retinoids! </li></ul><ul><li>Minimum use of 3 months prior to labeling treatment as a failure </li></ul><ul><li>Intervene early to prevent scarring </li></ul>
    29. 29. Sources <ul><li>AAFP </li></ul><ul><li>Uptodate </li></ul><ul><li>Fitzpatrick, et al Color Atlas & Synopsis of Clinical Dermatology </li></ul><ul><li>Brian Swan’s Foom Handout </li></ul>