Acne is a bigger problem than injuries, yet as dermatologist our duty is to help people to heal inside and outside from its non permanent scar...

1. Practical guideline for the
management of acne
By: Marwa Abdel Khaliq
Dermatology and venereology specialist

2. What is acne?
Acne is a chronic inflammatory skin disease
that affect approximately 85% of population at
some point in their lives.
Generally straightforward to recognize clinically,
acne has a variable presentation with a group
of lesion types including open and closed
comedones, papules, pustules, nodules, and
cysts.
Face is involved in most cases, and the trunk
is affected in up to 61% of patients.

3. Pathogenesis of acne
Pathogenesis of acne is
multifactorial, involving the
hormonal influence of
androgens along with excess
sebum production, disturbed
keratinization, inflammation,
and stimulation of the innate
immune system by several
pathways including hyper-
colonization by
Propionibacterium acnes.

4. Grading of acne
There is no standardized acne grading or classification system; however, acne is often
categorized by an overall as mild, moderate, and severe in guidelines and clinicians treating
patients.
2016 European evidence-based (S3) Acne Guideline has used the following 4-point
classification system that might help to approach these issues in a practical fashion:
1. Comedonal acne.
2. Mild-moderate papulopustular acne.
3. Severe papulopustular acne, moderate nodular acne.
4. Severe nodular acne, conglobate acne.
Similarly, the The 5-point Investigator's Global Assessment (IGA) scale recommended by the
US Food and Drug Administration (FDA) considers quality of lesions and quantity.

5. The 5-point IGA scale

6. The 5-point IGA scale

7. Comparison of
different acne
assessment
scales

8. Topical agents in the treatment of adult acne and acne
vulgaris in adolescents to adults, including:
➔ Retinoids and retinoid-like drugs
➔ Benzoyl peroxide
➔ Topical antibiotics
➔ Salicylic/azelaic acids
➔ Sulfur and resorcinol
➔ Aluminum chloride
➔ Zinc
➔ Combinations of topical agents
Treatment of acne vulgaris

10. Topical retinoids
Comedolytic and
sometimes anti-
inflammatory
Effects of different agents used to treat acne
Antibiotics
Antimicrobial and anti-
inflammatory
Benzoyl peroxide
Antimicrobial plus
weakly anti-
inflammatory and
comedolytic
Hormonal agents
Sebosuppressive
Oral retinoids
Comedolytic, sebosuppressive, antimicrobial, and anti-inflammatory

11. Topical retinoids
Topical retinoids target multiple aspects of acne
pathophysiology, including:
➔ Normalizing infundibular hyperkeratinization.
➔ Reducing inflammation.
➔ Unique class action in reducing the formation of acne
precursor lesions (microcomedones).
➔ limiting the development of new lesions.
However, although there is considerable evidence supporting
the efficacy of topical retinoid treatments for primary lesions
of acne, it also prove its effectiveness in prevent acne scar.

12. Single agent topical therapy for severe inflammatory
acne
Adapalene 0.3% / benzoyl peroxide 2.5% fixed-dose
combination gel, combines a retinoid with benzoyl peroxide,
which exhibits potent and rapid bactericidal effect.

13. Single agent topical therapy for severe inflammatory
acne
Recently, there have been several
studies of topical combination therapy
that included patients that would be
categorized as severe inflammatory
acne (grade 3 on the European Union
scale or grade 4 on the IGA US FDA
scale).
In 2016, it has been reported that the fixed combination adapalene 0.3%/benzoyl peroxide
2.5% (A/BPO 0.3%) was the “first topical fixed–combination agent therapy developed for
severe inflammatory acne.

14. Adherence to treatment recommendations
Physical and emotional scarring are equally important burdens of acne vulgaris in
patients of any age. Effective therapeutic regimens are readily available, and the
consistent and correct use of these medications results in effective disease
management, reduced risk for scarring, as well as improvement in various factors that
affect quality of life.
Nevertheless, adherence to treatment recommendations generally is
poor.
Clinicians can help improve adherence with a variety of strategies,
including:
➔ Counseling
➔ Education and awareness
➔ Choosing treatment options that are most consistent with a patient’s
lifestyle.

15. Factors Negatively Associated With adherence to treatment
recommendations including:
➔ Younger (vs older) age
➔ Being single (vs married)
➔ Male (vs female)
➔ Alcohol use
➔ Cigarette smoking
➔ Unemployment
➔ Medication cost (adherence drops with increasing costs)
➔ Psychiatric morbidity (anxiety/depression)
Factors Negatively Associated With Adherence

16. Types of acne scar
Two types of scarring are well recognized
Atrophic scars, caused by a loss of tissue.
Atrophic scarring is more common, it has tendency to occur
in certain areas of the skin.
Hypertrophic and keloid scars, caused by an increase in
tissue formation.
Hypertrophic and keloid scars both result from excess
deposition of collagen in response to inflammation and are
seen most commonly in truncal areas. These scars differ in
appearance and histology.

17. Ice pick scars
Which are narrow, punctiform, deep scars (0.5 to 1.5 mm),
which are wider at the surface, suggesting a V shape.
V
Types of acne scar

18. Rolling scars
Measuring at least 4 to 5 mm in width and characterized by an
M-shaped, wavy appearance that results from subdermal,
fibrotic tethering.
M
Types of acne scar

19. Boxcar scars
which are round or oval with well-defined, vertical edges,
suggesting a U shape.
U
Types of acne scar

20. Hypertrophic scars
Usually are pink in color and firm to the touch, and are limited to
the borders of the original wound. In contrast, keloids appear as
reddish-purple papular and nodular scars that typically extend
beyond the borders of the original acne lesion.
Types of acne scar

21. Adjunctive
Treatment

22. Role of combination therapy in atrophic scar
A combination of
therapeutic modalities often
is necessary to achieve
optimal cosmetic outcomes
in the treatment of both
atrophic and hypertrophic
acne scars.

23. Role of combination therapy in atrophic scar
A combination of
therapeutic modalities often
is necessary to achieve
optimal cosmetic outcomes
in the treatment of both
atrophic and hypertrophic
acne scars.

24. American academy
of dermatologist
DOs and DON’Ts
How to control oily skin
10

25. American academy of dermatologist
DO wash your face every morning, evening, and
after exercise.
While washing, resist the temptation to scrub your skin –
even to remove makeup. Scrubbing irritates your skin,
which can make it look worse.
DO choose skin care products that are labeled
“oil free” and “noncomedogenic.”
This means that products that have these labels:
➔ including cleansers, moisturizers and makeup.
➔ won’t clog your pores or cause acne.
2
1

26. American academy of dermatologist
DO use a gentle, foaming face wash.
Many people believe that they need to use a strong face
wash for oily skin in order to dry out their skin. However,
using a face wash that is too harsh can irritate your skin
and trigger increased oil production. Instead, look for a
mild, gentle face wash.
DON’T use oil-based or alcohol-based
cleansers.
These can irritate your skin.
3
4

27. American academy of dermatologist
DO apply moisturizer daily.
Although you have oily skin, it is still important to apply
moisturizer to keep your skin hydrated.
To save time and protect your skin from the sun’s
harmful ultraviolet rays, look for a moisturizer that also
contains a broad-spectrum sunscreen with an SPF of
30 or higher.
5

28. American academy of dermatologist
DO wear sunscreen outdoors.
Sunscreen helps prevent sun damage that could lead to wrinkles, age spots
and even skin cancer. To prevent acne breakouts, look for sunscreens that
contain zinc oxide and titanium dioxide, and do not use sunscreens that
contain fragrance or oils.
6

29. American academy of dermatologist
DO choose oil-free, water-based
makeup.
7

30. American academy of dermatologist
8
DON’T sleep in your makeup.
Always remove all makeup before going
to sleep.
9
DO use blotting papers throughout the day. Gently
press the paper against your face and leave it on for a few
seconds to absorb the oil. Don’t rub the paper on your face, as
this will spread the oil to other areas.
DON’T touch your face
throughout the day.
10

31. Clinical pearls for
ACNE and PIH

32. ★ Oftentimes, identifying the patient who requires PIH management involves
discussing how bothersome the problem is for the individual person, but the
presence of visible PIH merits a discussion with the patient.
★ A score of ≥4 on the Visual Analog Scale of 1-10 may be an indicator of need for
treatment.
★ Most patients want to know how long it will take before dark spots resolve
★ For these patients, it is important to emphasize the need for effective treatment of
acne, regular use of photoprotection, and avoidance of lesion excoriation
Clinical pearls for acne and PIH

33. ★ Cosmeceuticals including antioxidants or exfoliants, chemical peels, intense
pulsed light, lasers, may be useful.
★ Treating hormonal pathologies can help mitigate underlying factors.
★ Early treatment with retinoids can diminish the risk of PIH by inhibiting
tyrosinase and blocking pigment transfer from melanocytes to keratinocytes.
Clinical pearls for acne and PIH

34. ★ When taking history, ask about prior experience with any hormonal or birth control
therapies; women often have performed opinions that should be taken into account
when designing a regimen.
★ Work with the patient to evaluate existing skin care and makeup regimen,
substituting products as needed to minimize potential negative impact on acne and
maximize positive impact.
★ When possible, use simple regimens that allien with the patient's existing daily
routines.
Clinical pearls for acne in women

35. ★ Adding pulsed dye laser to intralesional steroid injections helps reduce erythema
associated with hypertrophic scars and reduces steroid-induced telangiectasias on
the face
★ Use a silicone sheet after intralesional steroids
★ Intralesional bleomycin might be useful
Pearls for hypertrophic or keloidal scars
★ For disseminated lesions, off-label use of oral pentoxifylline plus
steroid injection may be considered
★ Avoid trauma and surgical intervention
★ There is rarely a quick fix; successful treatment might take
multiple treatments and modalities

36. Take home message
Acne is a bigger
problem than injuries,
yet as dermatologist our
duty is to help people to
heal inside and outside
from its non permanent
scar...

37. THANK YOU