Whats New and Whats Not in Acne and Rosacea

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Whats New (and Whats Not) in Acne and Rosacea

• Adam O. Goldstein, MD
• Assistant Professor
• Department of Family Medicine
• University of North Carolina at Chapel Hill
• Email aog_at_med.unc.edu

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Objectives

• 1. Know differential diagnosis acne/rosacea
• 2. Increased knowledge treatment strategies
• 3. Increased familiarity new products
• 4. Learn 2 new patient education tips
• GOAL Improved therapeutic outcomes

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Acne

• Most common dermatologic disease
• Onset usually adolescence but anytime
• More frequent and severe in males
• 70 women premenstrual flares

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Acne Quiz (T/F)

• 1. Certain foods make acne worse...
• 2. Dirty skin makes acne worse...
• 3. Acne worsens with sexual activity...
• 4. Acne improves within 24 hours of tx...
• 5. Sweating may make acne worse...
• 6. Humidity may exacerbate acne...
• 7. Acne may worsen during menstruation...
• 8. Stress may make acne worse...

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Art of acne treatment

• Negotiating long-term treatment
• Increasing compliance by using fewer medications
• Contracting with adolescents
• Thorough explanation of natural history of
  disease
• Patience with acnes emotional toil
• Combining drugs _at_ different mechanisms

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Art of acne treatment

• Quality of Life scale
• 0 1 2 3
• 1. Feeling self-conscious
• 2. Decrease in socialization
• 3. Difficulties in relationships
• (partner, friends, family)
• 4. Feeling like an outcast
• 5. People making fun of you
• 6. Feeling rejected (romance, friends)

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Common pitfalls in acne treatment

• Using more than two medications
• Insufficient patient education or unrealistic
  expectations
• Frustration all around

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Acne Etiology

• Combination hormonal (androgen), bacterial
  (Proprionibacterium acnes) and follicular
  (hyperkeratosis)causing debris and occlusion
• Bacteria multiply and inflammatory response
• Comedones Blackheads and Whiteheads
• Blackheads open comedones
• Whiteheads closed comedones

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Acne Morphology

• Comedones
• Papules
• Pustules

• Nodules
• Cysts

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Acne Differential Diagnosis

• Rosacea No comedones, erythema striking,
  central face
• Hidradenitis Axilla inguinal, nodules cysts,
  scarring
• Keratosis Pilaris Upper arms trunks,
  follicular- based papules
• Perioral Derm. Papulovesicles erythema,
  perioral, topical steroid use
• Senile Comed. Face neck, comedones and cysts
  in damaged skin
• Topical steroids Lesions same stage, no comedones

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Rosacea
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Hidradenitis
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Keratosis Pilaris
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Keratosis Pilaris
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Perioral Dermatitis
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Perioral Dermatitis
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Senile Comedones
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Topical Steroids
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Acne Keloidalis
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Acne Keloidalis
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Acne Treatment

• Treatment goal is to prevent new lesions/scarring
• Treatment will not improve outcomes for 4-6 weeks
• (Acne exacerbated by iodides, bromides,
  hydantoin, chlorinated hydrocarbons,
  occluding topical preparations, vigorous washing,
  and mechanical occlusion)

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Acne and Iodides
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Acne and Dilantin
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Acne and Topical Steroids
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Acne and Topical Steroids
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Mechanical occlusion
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Mild acne

• Apply one agent thinly to entire face
• If two agents selected, use at separate times
• Apply after washing with water or mild soap
• Choices
• Benzoyl peroxide Topical antibiotics
• Tretinoin Birth Control Pills
• Azelaic acid Salicylic acid
• Use for 6-8 weeks before judging if effective

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Mild acne

• Benzoyl peroxide ()
• Antibacterial, drying and peeling actions
• Rx 2.5-10 gel/cream/wash
• OTC 2.5-10 gel/lotion/cream
• Usually start with 2.5-5, thin layer QD-BID

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Mild acne

• Benzoyl peroxide
• Water based preps are milder and less drying
• Alcohol/acetone preps useful in oily skin
• Washes and soaps are good for acne on the chest,
  back and shoulders (5-10)
• Benzamycin gel- 23.3 grm- benzoyl peroxide and
  erythromycin- must be kept refrigerated

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Mild acne Benzoyl peroxide

• Side Effects
• Occasional hypersensitivity reactions (1-5)
• Oxidating agent will bleach clothes and hair

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Mild acne

• Topical antibiotics (all Px) ()
• Erythromycin 2- pledgettes, pads, gel (oily
  skin), solution, ointment (dry skin)
• Clindamycin 1- solution, gel, lotion
• (e.g. Cleocin T)
• Meclocycline- cream useful in patient with very
  dry skin
• (e.g. Meclan)

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Mild acne Topical antibiotics

• Sodium sulfacetamide 10, Sulfur 5, Sodium
  thiosulfate 10
• Numerous keratolytic/astringent agents
• Useful if lotion preparation preferred and other
  topical antibiotics not working or tolerated
• Sulfacet R- tinted (can cover redness)
• Novacet- untinted
• Bacterial resistance may develop after 6-12
  months of use

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Mild acne Topical Retinoids

• Especially good for comedonal or papular acne
• Modulates keratinization
• Use pea size amount to entire face
• Apply 3x week for 2 weeks, then nightly
• Increases photosensitivity
• Flare reaction frequent
• Web Sites http//www.healthsquare.com/pdrfg/pd/
  monos/retin-a.htm

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Topical Retinoids

• Retin A (Renova)
  ()
• Vehicles0.025, 0.05, 0.1 cream 0.01, 0.025
  gel
• Start with 0.025 strength
• Apply at bedtime 30 minutes after washing
• Avita
• Vehicles 0.025 cream/gel
• Slow release polymer may be less irritating
• Retin A Micro
• Vehicle 0.1 gel Thick and yellow
• Slow release may be less irritating

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Retinoid-Like

• Adapalene (Differin) ()
• Vehicles 0.1 gel, solution
• May apply right after washing at bedtime
• Tazarotene (Tazorac)
• Vehicles 0.05, 0.1 gel
• Irritating initially
• May be useful with oily skin
• Short contact therapy

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Retinoids-Comparisons

• Adapalene 0.1 gel vs. Tretinoin 0.025 gel,
  meta-analysis of 5 RCTs (BMJ, 139S 1998)
• equivalent efficacy reducing total lesions
• Adapalene with significant difference in
  reduction of inflammatory and total lesions at
  week 1
• Adapalene with greater local tolerability
• Adapalene 0.1 gel vs. Tretinoin 0.05 gel,
  Split-face clinical and bio-instrumental
  comparison (Dermatology. 198(2)218-22, 1999)
• Tretinoin with better comedolysis and clinical
  improvement than adapalene
• Erythema transiently more pronounced with
  tretinoin

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Salicylic acid 2

• OTC ()
• Keratolytic
• Many preparations
• Useful in combo with tretinoin or topical
  antibiotics

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20 Azelaic acid (Px)

• Mechanism unknown ()
• Useful for patients intolerant to tretinoin or
  benzoyl peroxide
• Avoid on broken skin
• Use qd-bid, usually in combination with other
  topicals

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Acne and Birth Control Pills

• Lowers hormonal factors exacerbating acne
• Use pill with low androgenic potential
• Know side effects and contraindications
• Acne often improves
  during pregnancy

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Moderate acne
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Moderate acne

• Mild treatment
• Add oral antibiotics
• Tetracycline- 500 mg bid or doxycycline 50-100
  mg/day
• Erythromycin- 500 mg bid
• Minocycline- 50-100 mg/day
• Trimethoprim/Sulfamethoxazole 1 DS qd-bid
• Comedo removal

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Minocycline has fewer GI side effects, but it is
more expensive
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Severe acne

• Moderate regimen X 3 months
• Isotretinoin for severe nodulocystic acne
• Steroid injections
• TAC acetonide 10 mg/ml diluted to 3 mg/ml
• Inject 0.1 ml into fresh cyst
• Prednisone rarely
• Consultation

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Isotretinoin (Accutane)

• 0.5-1 mg/kg/day 16-20 weeks
• 80 success rate
• Indications wider than previous thought
• Improvement continues after treatment stops
• Very teratogenic (2 forms birth control for one
  month beforehand)
• Laboratory monitoring (HCG before monthly,
  CBC, LFT, TG, LDH, TGs, Cholesterol, Q 2 weeks,
  then monthly)
• Use moisturizers, lip balms and artificial tears
• Monthly costs 200-400

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Acne Myths

• NO relation to junk foods
• NO relation to hygiene
• NO relation to masturbation or other sexual
  activity
• NO way to make acne go away overnight

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Acne Truths

• YES acne may worsen premenstrual
• YES sweating may worsen acne
• YES humid environments may worsen acne
• YES stress can exacerbate acne

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Acne Patient Education

• 6-8 week response
• Avoid scrubbing
• Keep regimen simple
• Compliance is key to FTIP Have
  patient bring medications to office

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Acne Patient Education

• Use water-based makeup
• Oil-free moisturizers
• Web Sites
• http//www.pslgroup.com/ACNE.htm
  Useful general information for clinicians
• http//www.derm-infonet.com/acnenet/toc.html
  Comprehensive site
• http//www.m2w3.com/acne/
  Patient support group

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Acne Rosacea

• Rosy dilatation of the central face
• eyes, nose, chin, cheek, forehead
• Diverse spectrum of disease-
  (papules, pustules, nodules, cysts)
• Rhinophyma -hyperplasia of the
  nose in middle aged men

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Acne Rosacea

• Look for periodic facial flushing after
  temperature increase, spicy food ingestion or
  alcohol
• Absence of comedones
• Disease is chronic Treatment goal is control

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Acne Rosacea Differential Diagnosis

• Acne Vulgaris comedones, younger patient,
  lack of flushing, less erythema
• Seb. dermatitis no acneiform lesions
• Lupus no papules and pustules
• Carcinoid flushing is transient

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Acne Rosacea Treatment

• Topical
• Antibiotics, Benzoyl peroxide, Tretinoin
• Oral antibiotics
• Isotretinoin for severe, recalcitrant cases
• Referral for surgery, dermabrasion, laser
• Potent topical steroids often worsen disease

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Acne Rosacea Topical Therapy

• Preferred topical antibiotic
• Metronidazole
• 0.1 cream (Noritate) qday
• 0.75 cream or gel bid
• Alternatives
• Sodium sulfacetamide 10/sulfur 5 lotion
• Clindamycin 1 lotion, gel or solution
• Erythromycin 2 solution

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Acne Rosacea Topical Therapy

• Benzoyl peroxide at 2.5 up to 10 if tolerated
• Tretinoin 0.025, 0.05 0.1 cream
• Start with lowest dose
• May be used in combination with other products

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Acne Rosacea Oral antibiotics

• Useful for nodular lesions
• Doxycycline 50-100 mg/day or tetracycline
  500-1000 mg/day
• Minocycline 50-100 mg at bedtime
• Treat until improvement occurs, then taper for
  control

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Acne Rosacea Patient Education

• Control vs cure
• Avoid excessive sunlight, alcohol, temperature
  extremes and precipitating foods
• Flares may require higher pulse treatment
• Good web sites
• National Rosacea Society
• http//www.rosacea.org/home.html
• Patient education brochure
• http//www.aad.org/pamphlets/rosacea.html

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On the Horizon.

• New retinoids
• Combination products retinoids and topical
  antibiotics
• Glycolic acid, salicylic acid peels
• Hormonal treatments
• Antibiotic alternatives

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Cases

• 14, Sports PE whiteheads- incidental
• 16, with comedones and mild inflammation
• 16, before the prom
• 20, with sensitive skin, papular lesions and skin
  irritation
• 21, moderate acne on 0.1 Retina cream and 5
  Benz. Peroxide, wanting referral to dermatologist
• 22, with extensive cystic acne for 5 years

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Conclusion

• Be confident
• Use 1-2 agents if at all possible
• Define expectations
• Think about acne rosacea in adults