Managing Acne & Acne   Scarring An Hands-On Approach Dr Philippa McCaffery Cosmetic Physician Sydney
Declaration <ul><li>I am a Director of Clearskincare which makes creams and medical devices for treating the skin </li></ul>
Understanding Acne <ul><li>Affects 80% of adolescents and adults between the ages of 11 and  30 </li></ul><ul><li>Targets ...
Factors causing Acne <ul><li>In normal follicles, follicular keratinocytes are shed as single cells. The process of replen...
Factors causing Acne <ul><li>The microcomedo starts the acne cycle ( a microscopic lesion made up of abnormal follicular k...
Pathogenesis of Acne Androgens Sebocyte  Keratinocyte Seborrhea Abnormal desquamation Alteration of follicular  micro-envi...
Comedogenesis Microcomedo Sebocytes Follicular keratinocytes Inflammatory Lesons Closed comedo Open comedo Sebum accumulat...
Effective treatment targets Pathophysiologic Processes  Seborrhea Abnormal keratinocyte desquamation Formation of Microcom...
Treating Acne <ul><li>Normalise the pilosebaceous glands - the role of tretinoin and isotretinoin </li></ul><ul><li>Contro...
Tretinoin – Dermatology’s best kept secret <ul><li>Inhibits the formation of and number of microcomedones </li></ul><ul><l...
Treating Acne – A step by step Guide <ul><li>Take a history – age of onset, severity, previous treatments, menstral histor...
Classify Acne – Mild, Moderate or Severe
Acne skincare protocol <ul><li>Take some time to explain why they have acne and why using this protocol will stop their br...
Treatment Programme <ul><li>Always start patients on 0.025% tretinoin to avoid retinoid dermatitis. Even on this low start...
A word on Androgens <ul><li>Androgens are the primary driver of Acne but exactly why they cause Acne is unclear </li></ul>...
Control and Maintenance <ul><li>Review patients every 3-4 weeks until all breakouts are controlled </li></ul><ul><li>Incre...
Treating Resistant Acne / Non Responders/ Sun Lovers & Sportsmen <ul><li>Approximately 20% of patients with mild to modera...
Treating Resistant Acne/ Non Responders <ul><li>In my practice we add light therapy at this stage ( IPL or LED) which is q...
Treating Acne Scarring <ul><li>Do not treat acne scarring until active acne is under control </li></ul><ul><li>Use tretini...
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Managing Acne & Acne Scarring - Clearskincare

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Acne is the result of overactive sebaceous glands and excessive keratin production, leading to excessively oily skin that is prone to blackheads and pimples. You cannot change your skin type you cannot stop this process permanently. However, you can control this process and minimise your acne breakout reoccurrence by....

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Managing Acne & Acne Scarring - Clearskincare

  1. 1. Managing Acne & Acne Scarring An Hands-On Approach Dr Philippa McCaffery Cosmetic Physician Sydney
  2. 2. Declaration <ul><li>I am a Director of Clearskincare which makes creams and medical devices for treating the skin </li></ul>
  3. 3. Understanding Acne <ul><li>Affects 80% of adolescents and adults between the ages of 11 and 30 </li></ul><ul><li>Targets the Pilosebaceous unit </li></ul><ul><li>Commonest on face, chest and back </li></ul><ul><li>( areas with greatest number of pilosebaceous glands ) </li></ul><ul><li>Acne has a multifactorial aetiology with androgens playing a major role </li></ul><ul><li>Sebaceous glands enlarge at age 7-8 </li></ul><ul><li>( adrenache ) with resultant increase in sebum production </li></ul><ul><li>Acne results from the abnormal response of some sebaceous glands to normal physiologic processes that govern sebum production and the replenishment of cells within the pilosebeous unit. </li></ul>
  4. 4. Factors causing Acne <ul><li>In normal follicles, follicular keratinocytes are shed as single cells. The process of replenishment of the epidermis ( and the pilosebeous unit is essentially an extension of the epidermis into the dermis ) is a continuous process where basal cells divide and push up to the surface of the skin, dying and flattening as they go and eventually exfoliating at the surface. In Acne affected follicles – follicular keratinocytes hyperproliferate and become densely packed along the follicle wall, along with sebum - comedogenesis </li></ul><ul><li>We know androgens drive changes in sebocytes and follicular keratinocytes leading to microcomedo formation, we don’t know why some pilosebeous units are affected and others not. </li></ul><ul><li>Individual sebaceous gland hyper-responsiveness is likely – again we are not sure of the exact pathophysiology of this. </li></ul>
  5. 5. Factors causing Acne <ul><li>The microcomedo starts the acne cycle ( a microscopic lesion made up of abnormal follicular keratinocytes and sebum ). This lesion grows as further cells, sebum and bacteria fill the follicle leading to a clinically apparent lesion which can be inflammatory ( pustule or pimple ) or non- inflammatory ( blackhead or whitehead ( milia ) </li></ul><ul><li>Role of P acnes – normal skin flora, non infective but changes to follicular microenvironment in the acne affected pilosebeous unit stimulates colonisation of the follicle and subsequent inflammation </li></ul><ul><li>Diagrams courtesy of NIAMS website </li></ul>
  6. 6. Pathogenesis of Acne Androgens Sebocyte Keratinocyte Seborrhea Abnormal desquamation Alteration of follicular micro-environment Colonisation with P acnes Inflammation
  7. 7. Comedogenesis Microcomedo Sebocytes Follicular keratinocytes Inflammatory Lesons Closed comedo Open comedo Sebum accumulates Follicle enlarges Keratinous material builds up Sebum and fatty acids Hyperproliferation Abnormal desquamation +/- Rupture of follicle wall P acnes Immune Reactions
  8. 8. Effective treatment targets Pathophysiologic Processes Seborrhea Abnormal keratinocyte desquamation Formation of Microcomedo P acnes colonisation Pilosebaceous hyper -responsiveness excess circulating Androgens
  9. 9. Treating Acne <ul><li>Normalise the pilosebaceous glands - the role of tretinoin and isotretinoin </li></ul><ul><li>Controlling androgen hyper-responsiveness - the role of oestrogen and anti-androgens </li></ul><ul><li>Cleansing, extraction and exfoliation </li></ul><ul><li>Options for treating scarring </li></ul>
  10. 10. Tretinoin – Dermatology’s best kept secret <ul><li>Inhibits the formation of and number of microcomedones </li></ul><ul><li>Reduces mature comedones </li></ul><ul><li>Reduces inflammatory lesions </li></ul><ul><li>Promotes normal follicular desquamation </li></ul><ul><li>Enhances the penetraton of other drugs </li></ul><ul><li>Maintains remission of acne by inhibiting microcomedo formation </li></ul><ul><li>Does not lead to resistance </li></ul><ul><li>Effective in controlling acne in 80% of patients with mild to moderate acne </li></ul><ul><li>Promotes collagen synthesis and skin healing </li></ul><ul><li>CHEAP </li></ul><ul><li>Causes increased sun sensitivity due to melanocyte suppression </li></ul><ul><li>Causes an initial dermatitis, dose and formulation related </li></ul><ul><li>Cannot be used during pregnancy due to theoretical risk of teratogenesis </li></ul><ul><li>Poorly marketed in comparison to less effective prescription acne treatments </li></ul>
  11. 11. Treating Acne – A step by step Guide <ul><li>Take a history – age of onset, severity, previous treatments, menstral history, family history, the patients’ main concerns </li></ul><ul><li>Examine the skin -You cannot assess acne severity from the other side of the desk, you need to examine every patient’s skin under a good magnifying lamp </li></ul><ul><li>Assess acne severity -I use a blackhead extractor to measure the degree of active acne, a similar looking macule can reveal a minimal lesion or a significant cyst </li></ul><ul><li>Clean out blocked and inflammed follicles – a positive accelerant for acne control </li></ul>
  12. 12. Classify Acne – Mild, Moderate or Severe
  13. 13. Acne skincare protocol <ul><li>Take some time to explain why they have acne and why using this protocol will stop their breakouts </li></ul><ul><li>Run through the protocol, then give them an instruction sheet to take home </li></ul><ul><li>AM Cleanse with low ph non soap cleanser </li></ul><ul><li>Apply ½ gram of 8% glycolic cream over whole face (avoid the eye area ) </li></ul><ul><li>Apply ½ gram oil free Sunscreen every day ( no moisturisers ) </li></ul><ul><li>PM Cleanse with low ph non soap cleanser </li></ul><ul><li>Apply ½ gram of tretinoin 0.025% mixed with 2%/4% hydroquinone cream ( in aqueous base ) to whole face and other affected areas </li></ul><ul><li>They may extract blackheads and pustules with a blackhead extractor – no fingers </li></ul>
  14. 14. Treatment Programme <ul><li>Always start patients on 0.025% tretinoin to avoid retinoid dermatitis. Even on this low starter dose, warn patients to expect some dryness and flaking. If it is too much for them, use 0.025% tretinoin every 2 nd night until the dryness subsides, then resume using it every night. </li></ul><ul><li>Review patients’ every 3-4 weeks after commencing the treatment programme. Expect significant improvement with 0.025% tretinoin. Move them up to higher doses ( 0.05% and 0.1% ) depending on their skins’ tolerance ( minimal redness and peeling ) and the degree of breakout. </li></ul>
  15. 15. A word on Androgens <ul><li>Androgens are the primary driver of Acne but exactly why they cause Acne is unclear </li></ul><ul><li>Severe nodulocystic disease involving the face, neck, chest and back is usually only seen in young males - refer all these patients for Isotretinoin </li></ul><ul><li>Screening females with Acne and irregular menstration/hirsuitism/weight gain will frequently reveal abnormal biochemistry – depressed SHBG and elevated FAI- is this PCOS or Androgen/ Hirsuitism/ Acne syndrome? It doesn’t really matter from a clinical viewpoint but counsel as PCOS </li></ul><ul><li>Many patients with PCOS/ abnormal biochemistry are hirsuite but have no acne and the reverse is also common </li></ul><ul><li>Antiandrogen therapy can be quite effective for controlling acne in females with normal biochemistry </li></ul><ul><li>OCPs like Diane 35 ED ( ethinyloestrodiol/cyproterone ) are often effective in controlling acne in females </li></ul><ul><li>Tretinoin plus Diane 35 ED plus a little extra cyproterone ( titrate dose against breakout ) is very effective for resistant acne in females </li></ul><ul><li>Look for cessation of OCP as a common cause of breakout in adult females ( can occur up to 6 months after stopping OCP ) </li></ul>
  16. 16. Control and Maintenance <ul><li>Review patients every 3-4 weeks until all breakouts are controlled </li></ul><ul><li>Increase dose of tretinoin incrementally as the skin tolerates it: alternating dosing can be very effective </li></ul><ul><li>Use a short course of antibiotics for significant inflammatory acne </li></ul><ul><li>Encourage frequent exfoliation – we use a Microdermabrasion cream which has a combination of 8% glycolic acid and aluminium oxide crystals </li></ul><ul><li>Have a look at their skin under the magnifying light each time they represent - it ‘s the only way you can really assess their degree of breakout </li></ul><ul><li>Most patients will see a significant improvement in their breakout even on tretinoin 0.025%, which encourages them to continue the programme </li></ul><ul><li>Once all breakouts are controlled patients should continue their programme to prevent reoccurrence of Acne </li></ul>
  17. 17. Treating Resistant Acne / Non Responders/ Sun Lovers & Sportsmen <ul><li>Approximately 20% of patients with mild to moderate acne will not be completely controlled with tretinoin. In my experience, a small number of patients cannot use tretinoin at all due to persistent dryness and worsening of acne </li></ul><ul><li>Patients who relapse after treatment with Isotretinoin often respond very well to tretinoin and, as for the pictured patient, achieve ongoing remission </li></ul><ul><li>Female patients can be offered hormonal therapy, either OCP or anti- androgen alone, or a combination if particularly resistant to treatment. </li></ul><ul><li>For people who cannot control sun exposure I recommend adapalene but I generally do not get as good results as with tretinoin </li></ul>
  18. 18. Treating Resistant Acne/ Non Responders <ul><li>In my practice we add light therapy at this stage ( IPL or LED) which is quite effective when it works ( around 50% of patients respond ) These therapies are rarely effective alone and should only be offered as adjunctive treatment. </li></ul><ul><li>In males I may add oral antibiotics usually doxycycline, which again can be very effective ( around 50% of patients respond). Resistance is a problem and usually ( but no always ) develops within 6-12 months </li></ul><ul><li>For some patients antibiotics do work quite effectively to control not just inflammation but also comedogensis. Logically they don’t act on either the sebocytes or the follicular keratinocytes, so how are they stopping comedogensis??? </li></ul><ul><li>If cystic acne is persistent in males, refer for Isotretinoin </li></ul>
  19. 19. Treating Acne Scarring <ul><li>Do not treat acne scarring until active acne is under control </li></ul><ul><li>Use tretinion/hydroquinone combination to treat active acne and to fade pigmented scarring </li></ul><ul><li>Depressed acne scarring can be treated with a combination of skin needling, subscission and spot 100% TCA peeling </li></ul><ul><li>Give patients realistic expectations – under promise and over deliver </li></ul><ul><li>All patients will need repeated treatments to achieve improvement in their scarring </li></ul>

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