DIFFICULTIES IN TREATING ACNE

1. DIFFICULTIES IN
TREATING ACNE

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.  Treatment
of Acne
 Good Responders 85-90%
 Poor Responders 10-15%

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. Poor responders
 To Antibiotics
 To Isotretinoin

6. Poor Responders
Antibiotics - Causes
 Resistant P. Acnes
 Gram (-) folliculitis
 Very high SebumExcretion Rate

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. 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. P. Acnes Resistance
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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. Guidelines to avoid P.Acnes
resistance
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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. 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. 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. 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. 

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. 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. 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. Isotretinoin: Women with
endocrine problems
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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. Patients who have received total
cumulative dose less than
120mg/kg
Repeat the treatment with
the proper dose

19. Patients with problematic side
effects
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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. 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. 

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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.  Drug:
Isotretinoin
 Side effects:
 Dermatitis&Cheilitis
 Arthralgia
&Myalgia
 S. Aureous Boils
 Depression
Management:
Moisturizers&HC
Cream
Lower dose NSAID
Erythromycin
Discontinuation

23. Acne Variant
 Acne
conglobata
 Pyoderma faciale
 Acne Fulminans
 Cystic Acne

24. Acne conglobata
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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. Pyoderma faciale
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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. Acne Fulminans
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,
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. Cystic Acne

Giant whiteheads

Inflammatory cysts
Extraction & light cautery
Isotretinoin 1mg/d
TriamcinoloneAc.(I/L)
or
Liq. Nitrogen
(more than 3 week
duration)

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. Keloid Scars
 Treatment:
1. Potent topical steroids
2. Triamcinolone AC injections
3. Liq. Nitrogen + Triamcinolone Ac
injections

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. Treatment of hyperpigmented scars
 Topical Retinoids
 Hydroquinone
 Kojic Acid
 Azelaic Acid
 Chemical peels
 Lasers

32. Miscellaneous
 Acne
Excoriee
 Over expectant patients (Over-concerned
about Appearance)
 Dysmorphobic patients (Over-complaining
about a few spots)

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. THANKS