Acne

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DIFFICULTIES IN TREATING ACNE

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Acne

  1. 1. DIFFICULTIES IN TREATING ACNE
  2. 2.  Acne vulgaris is a disorder of pilosebaceous unit characterized by the formation of comedones, papules, pustules, nodules and cysts.  It is the most common disorder encounter in day to day practice by dermatologists  Although generally considered to be a benign, self limiting condition, but it may sometime cause severe psychological upset or disfiguring scars
  3. 3.  Treatment of Acne  Good Responders 85-90%  Poor Responders 10-15%
  4. 4. Poor response despite proper management  Genuine poor responders  Patients with problematic side effects  Patients with Acne variants and cystic acne  Patients with scars  Miscellaneous
  5. 5. Poor responders  To Antibiotics  To Isotretinoin
  6. 6. Poor Responders Antibiotics - Causes  Resistant P. Acnes  Gram (-) folliculitis  Very high SebumExcretion Rate
  7. 7. P. Acnes Resistance  Prevalence of P. Acnes resistance on the skin of acne patients. 10 year surveillance date:  1991 34.5% to one or more used anti-acne  antibiotics  1997 55.5% to one or more used anti-acne  antibiotics  2000 64% to one or more used anti-acne  antibiotics Coates P, Cunliffe W et al. Br J Derm. 146 (5): 840 (2002)
  8. 8. Main reason for increased P. Acnes resistance The extensive use of topical formulations of Erythromycin and Clindamycin Eady E et al. Dermatology 206(1): 54 (2003)
  9. 9. P. Acnes Resistance        Erythromycin ……………………High Clindamycin .……………………High Tetracycline ……………………..Medium Doxycycline ……………………..Medium Trimethoprin …………………….Medium Resistance to Minocycline ……..Very rare Management: Isotretinoin – Minocycline J. Ross, I. Snelling, A Katsambas et al. Br J Derm 148: 467— 478 (2003)
  10. 10. Guidelines to avoid P.Acnes resistance      Limit antibiotics to shorter period Avoid concomitant use of oral and topical dissimilar antibiotics (e.g. Tetra PO, Ery topical) Use topical retinoids to speed up improvement Avoid long-term antibiotics for maintenance If re-treatment is necessary, use the same antibiotic (if it was effective) Gollnick H., Cunliffe W et al. JAAD 49(1): Suppl. July 2003
  11. 11. Guidelines to avoid P.Acnes resistance  Topical antibiotics should not be used as monotherapy  Combine topical antibiotics with B.Peroxide  Topical antibiotic therapy should be discontinued once improvement is seen  If no improvement with 6-8 weeks discontinue Eady E.A. et al. Deramtology 206:54-56; 2003
  12. 12. Gram (-) Folliculitis Sudden onset of many follicular pustules  Sudden deterioration of acne  Localised perioral & perinasal location  Management:  Dicontinuation of current antibiotics  Isotretinoin (1mg/kg)  Ampicilin (250mg qid) 
  13. 13. Very high Sebum Excretion Rate  The excess of sebum dilute the antibiotic and produce lower and ineffective concentration of the antibiotic in the pilosebaceous unit.  Management:  Double dose of antibiotic (Minocycline 200mg/d) (Doxycyclin 200mg/d)  Isotretinoin  Estrogen + Anti-androgens (Diannette)
  14. 14.   Antibiotics Cause Management  Resistant P. Acnes: Isotretinoin-Minocycline  Gram (-) folliculitis : Isotretinoin - Ampicilin  Very high Sebum Excretion Rate Isotretinoin Cypr. Acetate + Estrogens Minocylcin 200mg/d Doxycycline 200mg/d
  15. 15. Treatment of Acne : Poor responders Isotretinoin with many macrocomedones – microcysts  Women with endocrine problems - Polycystic Ovarian Syndrome  Patients who have received total cumulative dose less than 120mg/kgr  Patients
  16. 16. Patients with many macrocomedones –microcysts Management: Gentle excision or cautery under topical anesthesia before isotretinoin treatment Cunliffe W et al. Dermatology 206 (1) 11:6 (2003)
  17. 17. Isotretinoin: Women with endocrine problems       Management: Oral estrogens alone or with antiandrogens given together or after ISO treatment Ethinylestradiol (EE) 35mg + Cyproterone Acetate (CPA) 2mg EE 25mg + CPA 50mg EE + drospirenone Spironolactone 25-50 mg/d Prednisone 2.5-5 mg/d Indefinitely Leyden J et al JAAD 47 (3) 399: 2002 Huber J and Waltz K. Contraception 73(1): 23-9; 2006
  18. 18. Patients who have received total cumulative dose less than 120mg/kg Repeat the treatment with the proper dose
  19. 19. Patients with problematic side effects        Drug: Topical (Retinoids – Benzoyl Peroxide) Side effects: Irritant Dermatitis Temporary exacerbation of acne Management: Inform patient about temporary nature of side effects Use on alternate evenings Use moisturizers and even hydrocortisone cream in the morning Use less irritant topical retinoid (Adapalene – tretinoin gel microsphere) Nighland M et al. Cutis 77(5): 313-6; 2006
  20. 20. Adapalene gel is equally effective and significantly better tolerated than tretinoin cream and tretinoin microsphere gel in the treatment of acne. Katsambas A, Papakonstantinou C. Clinics in Derm. 22:439444; 2004 Thiboutot DM et al. Arch Derm 142(5): 597-602; 2006
  21. 21.    Drug: Minocycline Side effects: Benign intra-cranial hypertension  (Dizziness – headache)  Hyperpigmentation Management: Lower dose Change to Doxycycline Discontinuation Change toDoxycycline Katsambas A. et al. Clinics in Derm. 22:412-418; 2004
  22. 22.  Drug: Isotretinoin  Side effects:  Dermatitis&Cheilitis  Arthralgia &Myalgia  S. Aureous Boils  Depression Management: Moisturizers&HC Cream Lower dose NSAID Erythromycin Discontinuation
  23. 23. Acne Variant  Acne conglobata  Pyoderma faciale  Acne Fulminans  Cystic Acne
  24. 24. Acne conglobata      Most commonly in adult males with no or little systemic upset. Lesions usually occur on the trunk and upper limbs and frequently extend to the buttocks. facial lesions are not common. Long-term highdose antibiotics, dapsone, ciclosporin and/or colchicine in conjunction with topical retinoids and antimicrobial therapy . Oral isotretinoin (1 mg/kg/day) for 4–6 months is the treatment of choice.
  25. 25. Pyoderma faciale       Women 25-40 yr Sudden development of inflammatory pustules and nodules Management: Treatment with prednisolone at 1 mg/kg/day, before Adding isotretinoin 0.2–0.5 mg/kg/day. The steroid was tapered off over 2–3 weeks and the isotretinoin continued for 3–4 months
  26. 26. Acne Fulminans        , Severe truncal acne in males Fever and polyarthropathy Management: Oral prednisolone therapy should be commenced first line (0.5– 1.0 mg/kg/day) and decreased slowly over 2–3 months oral salicylates or NSAID Low-dose oral isotretinoin (0.25–0.5 mg/kg/day) should be cautiously introduced after 3–4 weeks of steroids and gradually increased as tolerated according to clinical response.
  27. 27. Cystic Acne  Giant whiteheads  Inflammatory cysts Extraction & light cautery Isotretinoin 1mg/d TriamcinoloneAc.(I/L) or Liq. Nitrogen (more than 3 week duration)
  28. 28. Patients with Scars Atrophic scar Treatment: 1. Laser resurfacing (CO2 – Er-Yag) 2. Chemical Peel 3. Dermabrasion 4. Excision of the scar 5. Injection of fillers
  29. 29. Keloid Scars  Treatment: 1. Potent topical steroids 2. Triamcinolone AC injections 3. Liq. Nitrogen + Triamcinolone Ac injections
  30. 30. Hyperpigmented Acne scars  Management: a. Prevention b. Treatment  Prevention of Hyperpigmented scars :  Initiation of the proper treatment as soon as possible in order to minimize the risk of inflammation and the subsequent hyperpigmentation.  Photo-protection, especially during the periods of treatment when inflammation exists  Minimization of the inflammation caused by potent anti-acne drugs.
  31. 31. Treatment of hyperpigmented scars  Topical Retinoids  Hydroquinone  Kojic Acid  Azelaic Acid  Chemical peels  Lasers
  32. 32. Miscellaneous  Acne Excoriee  Over expectant patients (Over-concerned about Appearance)  Dysmorphobic patients (Over-complaining about a few spots)
  33. 33. FINAL REMARK All acne cases can be adequately controlled if the relationship between doctor and patient has been built on trust and confidence
  34. 34. THANKS

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