ACNE

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ACNE

• Dr. Sandeep Rondla
• South Birmingham VTS

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Introduction

• Acne is a disease of pilosebaceous follicles
  present on the face and the upper trunk and are
  under androgenic control.
• Affects most of the adolescent population, in 20
  of these it is clinically significant
• Both sexes involved, peak at 16 - 20 years
• In chronic disease, it persists till the mid 20s,
  in 7 until 40-50 yrs.
• Rare in infancy

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Aetiology

• 3 types of follicles in the skin hair (beard),
  vellus and sebaceous
• Acne involves sebaceous follicles - seen on face,
  back and chest.
• Factors in acne formation
• increased sebum production
• ductal hyperprolifertaion (comedone formation)
• colonisation of the duct with Propionibacterium
  acnes
• inflammation
• inflamation

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Increased sebum production

• Patients with acne produce more sebum than
  controls
• No evidence of significant hormonal
  abnormalities, hence do not need investigation
• Evidence suggests that acne is an end-organ
  hyper-response of sebaceous glands to circulating
  hormones
• Androgens of adrenal and gonadal origin stimulate
  sebum production

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comedone formation

• Comedone formation is the result of ductal
  corneocytes accumulating in the ductal lumen.
• Comedone present clinically as blackheads and
  whiteheads
• A whitehead is referred as a closed comedone as
  it very small orifice with many proinflammatory
  substances in the duct contents.
• A black head is referred to as a open comedone
  with large orifice.
• Whiteheads are more prone to develop into
  inflammatory lesions than blackheads.
• Treatment should be aimed at reducing
  microcomedones which usually precede these
  lesions.Topical retinoids are the treatment of
  choice.

whitehead Vs blackhead
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comedone formation
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P.acnes

• Normal commensal of the skin, esp in sebum rich
  areas
• Infection occurs when there is colonisation of
  the pilosebaceous duct with p. acne, usually
  early after comedone formation
• Exact mechanism of colonisation is not known
• Evidence suggests role of micro-environment in
  acne prone glands

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inflammation

• Inflammation is type IV cell mediated immune
  reaction
• Specific antigen not identified
• In pustule stage polymorphonuclear leucocytes
• In intense papular stage giant cell response
  with associated duct rupture
• Inflammation leads to scarring due to loss of or
  increase collagen

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clinical features

• Seborrhoea - greasiness
• Comedones
• Superficial inflamed lesions - papules, pustules,
  macules
• Deep inflamed lesions - nodules and deep pustules
• Scars
• Post inflammatory pigmentation

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acne grading

• MILD - Predominantly consists of non-inflammatory
  comedones
• MODERATE - Mixture of non-inflammatory comedones
  and inflammatory papules and pustules
• SEVERE - Presence of nodules and cysts along with
  preponderance of inflammatory papules and
  pustules

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differential diagnosis

• Perioral dermatitis
• Seborrhoeic eczema
• Rosacea
• Pomade acne
• Steroid induced acne

Pomade acne
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investigations

• Rarely needed
• Hormonal investigations to be done if hirsuitism
  or very irregular menses (PCOD)
• Erythromycin resistant P. acne seen in 65 and
  tetracycline resistance seen in 20 - culture
  might be useful
• Patients on minocycline should have blood tests 6
  monthly to check LFTs, ANF and pANCA
• If starting on oral isoretinoin - liver enzymes
  and lipids at baseline / 1 month after starting
  treatment and every 3 months there after
• Pregnancy test - pre therapy and 5 weeks post
  therapy. Monthly pregnancy test recommended.

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treatment principles

• Discussion with patient
• Choice of Topical therapy
• Choice of Oral therapy
• Choice of Physical therapy
• Combined therapy

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discussion with the patient

• Time spent by the general practioner in
  discussing acne with the patient should emphasise
  the following
• Acne is a chronic disease.
• A treatment strategy is needed and it is likely
  that long therapy will be required.
• Acne is a slow responding disorder with little
  improvement in the first 3-5 weeks.
• There is a need for continued compliance
• There is no evidence that fatty foods or
  chocolate adversely affect acne.
• Certain physiological events may influence
  acne,for example stress may make acne worse
• Premenstrual flare is common in 70 of females.
  Sunshine often helps acne but often temporarily.

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topical therapy

• Mild disease
• Combination with oral antibiotics in moderate
  disease
• Combination with hormonal therapy in females
• Maintenance therapy after oral therapy has been
  discontinued

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topical therapy
Anti-comedonal therapies benzoyl peroxide (mild impact)
Anti-comedonal therapies azelaic acid (mild impact)
Anti-comedonal therapies topical retinoids (significant impact)
Anti-inflammatory agents topical retinoids such as adapalene
Anti-inflammatory agents topical retinoids such as all-trans retinoic acid
Anti-inflammatory agents topical retinoids such as isotretinoin
Anti-inflammatory agents non-antibiotic antimicrobials such as benzoyl peroxide
Anti-inflammatory agents non-antibiotic antimicrobials such as azelaic acid
Anti-inflammatory agents antibiotics such as clindamycin
Anti-inflammatory agents antibiotics such as erythromycin
Anti-inflammatory agents antibiotics such as tetracycline
Anti-inflammatory agents combination therapy such as zinc erythromycin
Anti-inflammatory agents combination therapy such as benzoyl peroxide erythromycin (Benzamycin)
Anti-inflammatory agents combination therapy such as adapalene benzoyl peroxide Epiduo
Clindamycin and benzoyl peroxide (DUAC) isotretinion and erythromycin (isotrex)
Miscellaneous Nicotinamide
Miscellaneous Potent steroids for 4-5 days
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oral therapy
Drug Dosage Comments regarding usage Incidence of P. acne resistance Adverse effects
Oxytetracycline 500 mg BD inexpensive, taken 30 mins pre-food and not with milk moderate rare onycholysis, photosensitivity, BIH
Erythromycin 500 mg BD inexpensive, take on empty stomach high GI upset, nausea diarrhoea
Minocycline 100-200 mg daily expensive moderate and increasing headaches (dose related) pigmentary changes autoimmune hepatitis LE like syndrome
Doxycycline 100-200 mg daily moderate moderate photosensitivity (dose related)
Lymecycline 300-600 mg daily moderate as tetracycline less than minocycline
Trimethoprim 200-300 mg BD inexpensive moderate or low rarely hepatic or renal toxicity, aganulocytosis
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DIANETTE

• Dianette has a product license for severe acne
  but is not licensed as an oral contraceptive in
  the UK.
• It achieves improvement in 75 - 90 of female
  patients.
• Relative risk of VTE is slightly higher compared
  to other COC pills
• Should be withdrawn 3 to 4 cycles after the acne
  is clear
• Once Acne is clear - low androgenic effect pill
  like Marvelon , Cilest or Yasmin prescribed for
  contraception rrequired

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treatment failure

• Wrong Diagnosis
• Compliance Problems - common problem. Must be
  stressed to patient
• P.acnes Resistance - increasing problem. Commonly
  seen with Erythromycin Clindamycin

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referral guidelines to secondary care - NICE

• Patients who have severe physical disease.
• Patients who have moderate disease but have
  failed to respond to 6 months of adequate oral
  and topical therapy.
• Patients in whom there are significant
  psycho-social problems from acne.
• Patients with significant problems with scarring
  / who may be at risk of scarring.
• Patients suspected of significant hormonal
  disease.

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treatment algorithm
Acne grade
Choice of treatment
Maintenance therapy
Topical retinoids /- Benzoyl peroxide / Topical
antibiotics
Mild acne (Comedones /- inflammatory lesions
Success
Failure
Combination therapy Oral Antibiotic Topical
retinoid /- Benzoyl peroxide
Success
Moderate acne (mild to moderate papular /
pustular)
Topical retinoids /- Benzoyl peroxide
Failure
Systemic isoretinoin /- Hormonal therapy
(females)
Success
Severe acne (severe nodulocystic)
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Thank You

• Questions