This document discusses the management of acne and rosacea. It defines the diseases, their clinical manifestations and risk factors. For acne, treatment involves targeting the four pathological factors with topical retinoids, antibiotics, isotretinoin or hormonal therapies depending on severity. Maintenance therapy typically involves topical retinoids. Rosacea management focuses on subtypes and includes lifestyle changes, topical metronidazole and oral antibiotics. Both conditions require long-term management to control symptoms and prevent scarring. Referral is indicated for severe or refractory cases.

1. ACNE & ROSACEA
MANAGEMENT
DR. T. K.

2. OBJECTIVES
• TO KNOW ACNE & ROSACEA AS A DISEASE
• TO UNDERSTAND HOW TO DEAL WITH PATIENT WHO HAS
THEM
• TO KNOW THE LATEST RECOMMENDATION REGARDING
THOSE DISEASES
• TO UNDERSTAND HOW TO MANAGE & TREAT THEM
• TO KNOW WHEN TO REFER

3. CONTENT
• DEFINITION, EPIDEMIOLOGY & CLINICAL MANIFESTATIONS
• MANAGEMENT
• PATIENT EDUCATION
• NONPHARMACOLOGICAL & PHARMACOLOGICAL
• HORMONAL THERAPY
• LIGHT-BASED, ADJUNCTIVE, AND OTHER THERAPIES FOR ACNE
VULGARIS
• COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM)

4. ACNE VULGARIS

5. • A CHRONIC INFLAMMATORY SKIN DISEASE
• THE MOST COMMON CUTANEOUS DISORDER AFFECTING
ADOLESCENTS AND YOUNG ADULTS.

6. EPIDEMIOLOGY
• WORLD WILD PREVALENCE OF ACNE VULGARIS IN ADOLESCENTS
FROM 35 TO OVER 90 %
• AGE & GENDER ?
• POSTADOLESCENT AFFECTS WOMEN WHILE ADOLESCENT ACNE,
MALE PREDOMINANCE

7. SURVEY OF OVER 1000 ADULTS, SELFREPORTED ACNE IN MEN &
WOMEN :
● 20 TO 29 YEARS: 43 AND 51 %, RESPECTIVELY
● 30 TO 39 YEARS: 20 AND 35 %, RESPECTIVELY
● 40 TO 49 YEARS: 12 AND 26 %, RESPECTIVELY
● AGES 50 AND OLDER: 7 AND 15 %, RESPECTIVELY

8. EPIDEMIOLOGY
311 RESPONDED TO THE QUESTIONNAIRE. 64.5% SUFFERED FROM
ACNE
BOYS > GIRLS
85% ---( 12-24 ) YEARS
8% ---( 25-34 ) YEARS
3% ---( 35- 44) YEARS

9. SAUDI MED J 2005; VOL. 26 (10):
1607-1610
PATTERN OF SKIN DISEASES …
ALAKLOBY SURVEY SAMPLE 1076

10. NON INFLAMMATORY ACNE
(COMEDONAL ACNE):
• CLOSED COMEDONES (WHITEHEADS)
• OPEN COMEDONES (BLACKHEADS)

11. INFLAMMATORY ACNE:
PUSTULES AND NODULES.
• MILD ACNE
• MODERATE ACNE.
• NODULOCYSTIC ACNE.
• ACNE CONGLOBATA
• ACNE FULMINANAS.

17. PATHOGENESIS
DISEASE OF PILOSEBACEOUS FOLLICLES, FOUR FACTORS ARE
INVOLVED:
● FOLLICULAR HYPERKERATINIZATION
● INCREASED SEBUM PRODUCTION
● PROPIONIBACTERIUM ACNES WITHIN THE FOLLICLE
● INFLAMMATION
FOLLICULAR DISTENTION, RUPTURE & INFLAMMATION

19. RISK FACTORS
• AGE 12 TO 24 YEARS
• FAMILY HISTORY
• EXTERNAL FACTORS — SOAPS, DETERGENTS, AND ASTRINGENTS
• DIET ?
• STRESS
• BODY MASS INDEX
• MEDICATIONS

20. CHOCOLATE & ACNE
A RANDOMIZED CROSSOVER STUDY, J AM ACAD DERMATOL
VOLUME 75, NUMBER 1

21. • CHOCOLATE CONSUMPTION GROUP HAD A STATISTICALLY
SIGNIFICANT (P < .0001) INCREASE IN ACNE LESIONS (+14.8
LESIONS) COMPARED WITH THE JELLYBEAN CONSUMPTION
GROUP (-0.7 LESIONS).

23. STARTED ON PHENYTOIN FOR HIS
SEIZURE DISORDER.

24. DIAGNOSIS
• IDENTIFICATION OF ACNE
• SKIN LESIONS (FACE, NECK, CHEST, AND BACK )
• NONINFLAMMATORY CLOSED OR OPEN COMEDONE
• INFLAMMATORY COULD BE PAPULES, PUSTULES OR NODULES
• SYSTEMIC COMPLAINTS (ACNE FULMINANS)

25. MANAGEMENT

26. PRETREATMENT ASSESSMENT
●CLINICAL TYPE AND SEVERITY OF ACNE
●SKIN TYPE (EG, DRY, OILY)
●PRESENCE OF ACNE SCARRING
●PRESENCE OF POSTINFLAMMATORY HYPERPIGMENTATION
●MENSTRUAL CYCLE HISTORY AND HISTORY OF SIGNS OF
HYPERANDROGENISM IN WOMEN

27. ●CURRENT SKIN CARE REGIMEN AND ACNE TREATMENT
HISTORY
●HISTORY OF ACNE-PROMOTING COSMETIC PRODUCTS AND
MEDICATIONS
●PSYCHOLOGICAL IMPACT OF ACNE ON THE PATIENT

28. ●FOLLICULAR HYPERPROLIFERATION AND ABNORMAL
DESQUAMATION
•TOPICAL RETINOIDS
•ORAL RETINOIDS
•AZELAIC ACID
•SALICYLIC ACID
•HORMONAL THERAPIES
●INCREASED SEBUM PRODUCTION
•ORAL ISOTRETINOIN
•HORMONAL THERAPIES

29. ●PROPIONIBACTERIUM ACNES PROLIFERATION
•BENZOYL PEROXIDE
•TOPICAL AND ORAL ANTIBIOTICS
•AZELAIC ACID
●INFLAMMATION
•ORAL ISOTRETINOIN
•ORAL TETRACYCLINES
•TOPICAL RETINOIDS
•AZELAIC ACID

31. ●FOR COMEDONAL ACNE USE TOPICAL RETINOIDS AS FIRST-LINE
THERAPY (GRADE 2A). ADAPALENE 0.1 OR 0.3 % GEL OD.
●FOR MILD TO MODERATE INFLAMMATORY ACNE USE TOPICAL
RETINOID, TOPICAL ANTIBIOTIC & BENZOYL PEROXIDE (GRADE 2A).
●FOR MODERATE TO SEVERE INFLAMMATORY ACNE USE TOPICAL
RETINOID, TOPICAL BENZOYL PEROXIDE & ORAL ANTIBIOTIC
(GRADE 2A). DOXYCYCLINE AND MINOCYCLINE 50-100 MG ODBD
UP TO 3-4 MONTHS.

32. ●WOMEN WITH MODERATE TO SEVERE ACNE UNRESPONSIVE TO
TOPICAL THERAPY & ORAL ANTIBIOTICS & WHO DO NOT DESIRE
PREGNANCY USE OF COMBINATION ORAL CONTRACEPTIVES
(GRADE 2A). 3-6 MONTHS DURATION.
●WOMEN WITH MODERATE TO SEVERE ACNE UNRESPONSIVE TO
TOPICAL THERAPY, ORAL ANTIBIOTICS & COC USE
SPIRONOLACTONE (GRADE 2B). 3-6 MONTHS DURATION.
●FOR SEVERE, RECALCITRANT, NODULAR ACNE USE
ORAL ISOTRETINOIN < 0.5 MGKGDAY FOR 20 WEEKS, OR A
CUMULATIVE DOSE OF 120-150 MG PER KG

34. MAINTENANCE THERAPY
• ACNE SYMPTOMS TYPICALLY RECUR OVER YEARS
• ANTIBIOTIC RESISTANCE LIMIT THE USE OF ANTIBIOTICS AS
LONG-TERM THERAPY.
• TOPICAL RETINOIDS IS THE COMPELLING OPTION . (GRADE 2A).
• BENZOYL PEROXIDE CAN BE ADDED TO THE TREATMENT
REGIMEN
• 12 WEEKS IN MODERATE TO SEVERE ACNE
• 16 WEEKS IN SEVERE ACNE

35. • LIGHTBASED THERAPIES NOT BE USED AS 1ST LINE TREATMENT
FOR ACNE VULGARIS (GRADE 2B).
• PRIMARILY COMEDONAL ACNE, DESIRE AN ACCELERATED
RESPONSE USE CHEMICAL PEELS (GRADE 2B).
• NOT USING MICRODERMABRASION FOR THE TREATMENT OF
ACNE
(GRADE 2C).
• INTRALESIONAL GLUCOCORTICOIDS FOR SELECTED NODULAR
INFLAMMATORY ACNE LESIONS IN ORDER TO ACCELERATE THEIR
RESOLUTION (GRADE 2C).

36. POSTINFLAMMATORY
HYPERPIGMENTATION
• TOPICAL RETINOID AS A
COMPONENT OF ACNE
THERAPY (GRADE 2B).

37. ACNE CONGLOBATA:
• LARGE DRAINING
LESIONS, SINUS TRACTS,
AND SEVERE SCARRING
• SYSTEMIC
SYMPTOMS ARE ABSENT.
• LOWER DOSES OF
ISOTRETINOIN (0.5
MG/KG/DAY OR LESS) PLUS
SYSTEMIC GLUCOCORTICOIDS

38. ACNE FULMINANS:
• ULCERATIONS AND
CRUSTS + FEVER &
ARTHRALGIAS
• WBC 17,000
• TREATED WITH SYSTEMIC
GLUCOCORTICOIDS (0.5
TO 1 MG/KG) PLUS ORAL
ISOTRETINOIN (0.5
MG/KG/DAY OR LESS &
GRADUALLY INCREASED)
OR ORAL ANTIBIOTICS

40. ACNE NEONATORUM
• ALSO CALLED NEONATAL CEPHALIC PUSTULOSIS ONSET WITHIN 1ST
FEW WEEKS OF LIFE
• USUALLY RESOLVES WITHIN 4 MONTHS WITHOUT SCARRING
• INFANTILE ACNE (WITH TYPICAL ONSET AT AGE 3-6 MONTHS)
• IN SEVERE CASES, 2.5% BENZOYL PEROXIDE LOTION CAN BE USED TO
HASTEN RESOLUTION.

41. ACNE IN PREGNANCY
• WOMEN WITH SEVERE ACNE, ONLY A FEW TOPICALS ARE
CATEGORY B AND SAFE IN PREGNANCY
• INCLUDING CLINDAMYCIN, ERYTHROMYCIN, AND AZELAIC ACID.

42. PROGNOSIS
• ACNE TYPICALLY IMPROVES AS PATIENTS PROGRESS THROUGH
ADOLESCENCE .
• NO LONG-TERM CONSEQUENCES FROM ACNE BUT SEVER LESIONS
LEAVE RESIDUAL SCARRING .

43. INSTRUCTIONS
• ACNE DIET: AVOID MILK, HIGH GLYCEMIC INDEX & CHOCOLATE
• COMPLIANCE MINIMUM OF 8 WEEKS & MAINTENANCE
• MORNING & EVENING WITH TOPICAL TREATMENT
• ISOTRETINOIN IPLEDEGE & REGULAR LAB TESTS
• MAY FLARE SLIGHTLY AFTER INITIATING TREATMENT
• USE GENTLE CLEANSERS AND SHOULD AVOID IRRITATING SKIN CARE
PRODUCTS. SELECT "NONCOMEDOGENIC" SKIN CARE PRODUCTS
AND COSMETICS.

45. WHEN TO REFER
• SCARS FORMATION
• NO RESOLUTION OF THE LESIONS AFTER 8 WEEKS
• PSYCHOLOGICAL COMORBIDITY
• SIGNIFICANT SCARRING

46. ROSACEA

48. EPIDEMIOLOGY
• AFFECT OVER 14 MILLION PEOPLE IN US .
• (AROUND 5 %- 10 % OF THE POPULATION )
• MOSTLY AFFECTS FAIR-SKINNED WHITE PEOPLE .
• FEMALE > MALE

49. CAUSES
THE UNDERLYING CAUSE IS CURRENTLY UNKNOWN .

50. RISK FACTORS
STRONG
LIGHTER SKIN TYPE
HOT BATHS/SHOWERS
TEMPERATURE EXTREMES
SUNLIGHT
EMOTIONAL STRESS
HOT DRINKS
EXERCISE
WEAK
(SPICY FOODS – ALCOHOL - MEDICATIONS )

51. DIAGNOSIS
• PRESENCE OF RISK FACTORS
• FLUSHING/ERYTHEMA
• PAPULES AND PUSTULES
• TELANGIECTASES
• OCULAR MANIFESTATIONS
• FACIAL DISTRIBUTION
• PHYMATOUS CHANGES
• BURNING OR STINGING PAIN
• ACNE VULGARIS

53. SUBTYPES
• SUBTYPE 1: ERYTHEMATOTELANGIECTATIC
• SUBTYPE 2: PAPULOPUSTULAR
• SUBTYPE 3:PHYMATOUS
• SUBTYPE 4:OCULAR MANIFESTATIONS

54. SUBTYPES

55. SKIN CONDITIONS THAT SHARE
SIMILAR FEATURES WITH ROSACEA
Distinguishing featuresCondition
Comedone formation No ocular
symptoms
Acne vulgaris
Associated with itching and often
improves over time when causative
agent is removed
Contact dermatitis
Rash appears on multiple body parts
with sunlight exposure
Photodermatitis
Has distinct distribution pattern
involving the scalp, eyebrows, and
nasolabial folds
Seborrheic dermatitis
Rarely has pustulesSystemic lupus erythematosus

56. ROSACEA TREATMENT

57. MANAGEMENT
GENERAL MEASURES:
- AVOIDING FLUSHING.
- SKIN CARE.
- SUN PROTECTION.
- COSMETIC CAMOUFLAGE.
SPECIFIC TYPE MANAGEMENT:
- ERYTHEMATOTELANGECTATIC ROSACEA.
- PAPULOPUSTULAR ROSACEA
- PHYMATOUS ROSACEA
- OCULAR ROSACEA.

58. Treatment
Topical antibiotic(metronidazole) /
anti-inflammatory and / or oral
antibioticand / or brimonidine
oral minocycline, azithromycin,
clarithromycin.
T line
1st
Patient group
1st subtype
1(erythematotelangiectati
c
2-(papulopustular)
3-mild form subtype 3
Benzoyl preoxideadjunct
Laser treatment ±tacrolimus for
telangiectases and erythema
adjunct
(electrosurgery/laser/cryotherapy )
Oral isotretinoin
1st
2nd
4-severe subtype 3
Artificial tears and warm water rinses
Topical metronidazole / topical
ciclosporin
1st
adjunct
5-subtype 4(ocular

59. PROGNOSIS
• THERE IS NO CURE .
• MANY PEOPLE ARE UNAWARE.
• MILD FORMS CONTROL BY AVOID TRIGGERS .
• OTHER PATIENTS NO IMPROVEMENT WITH VARIETY OF TREATMENT
MODALITIES .

60. INSTRUCTIONS
• AVOIDANCE TRIGGERS
• DAILY APPLICATION OF A SUNSCREEN PROTECTION
• AVOIDANCE OF MIDDAY SUN
• GENTLE SOAP-FREE CLEANSER .
• EMOLLIENT.

61. WHEN TO REFER
• OCULAR ROSACEA
• REFRACTORY CASES OR PHYMATOUS CHANGES
• ORAL ISOTRETINOIN ABLATIVE/PULSED DYE THERAPY –
ELECTROSURGERY

62. REFERENCES