Acne Vulgaris Otherwise known as zits, pimples and blackheads

1
Acne Vulgaris(Otherwise known as zits, pimples
and blackheads)

• Cynthia Salinas, M.D.
• PGY-3 Patient Conference
• February 2, 2005

2
Conference Goals

• Review pathogenesis as a way to help us
  understand why we use certain meds
• Differentiate common types of acne
• Generate a quick differential diagnosis
• Apply a stepwise approach to treatment prior to
  referral to dermatology

3
Epidemiology

• Onset?
• Males 10-17 yrs Females 14-19 yrs
• May persist through 4th decade or older
• Prevalence?
• Asians 10
• African-American 25
• Caucasians 29

4
Causes?

• Majority of patients have a family history of
  acne
• Emotional stress
• Androgens
• Dioxins, lithium
• Occlusion and pressure acne mechanica
• NOT DUE TO CHOCOLATE OR FATTY FOODS!

5
Pathogenesis

• Plugging of the hair follicle
• w/ abnormally keratinized cells
• Androgen-induced sebaceous gland hyperactivity
• Proliferation of bacteria
• - Propionibacterium acnes
• Inflammation

6
Doctor my skin is breaking out!

• 34yo Latina comes to your office stating that she
  has had bad skin forever and her face is the
  worse its ever been. Saint Ivys scrub is not
  helping. Shes trying to eat healthy but despite
  her best efforts keeps gaining weight. She
  wonders if she is doing the wrong things and asks
  for your help.

7
HPI

• When was the onset? Adolescence
• Where? Face, neck, trunk buttocks
• Does it itch or hurt? Pustules painful
• How have the individual lesions changed?
• Triggers? Worse in fall/winter
• Hirsutism? Oligomenorrhea?

8
Differential Diagnosis

• Face
• Staph aureus folliculitis
• Rosacea
• Perioral dermatitis
• Trunk
• Pityrosporum folliculitis
• Hot Tub folliculitis
• Acne Aestivalis
• Appears after sun exposure

9
Types of Acne

• Comedonal
• Papulopustular
• Nodulocystic
• Why is this important?
• Directs treatment options

10
Comedonal Acne

• Closed comedones (whiteheads)
• Sebum accumulation results in a white papule
  visible at the skin surface
• Open comedones (blackheads)
• Plug protrudes from canal and turns dark
• Non-inflammatory
• Usually responds to topical keratolytic

11
Papulopustular Acne

• Papules/Pustules
• Follicular wall ruptures
• Releases sebum and bacteria into dermis
• Topical agents alone usually insufficient
• Consider topical retinoids plus systemic
  antibiotics

12
Nodulocystic Acne

• Soft nodules that are secondary comedones from
  repeated ruptures reencapsulations and abscess
  formations
• Painful and disfiguring
• Psychological impact
• Treatment consists of topical agents, oral
  antibiotics or isotretinoin

13
Management

• Acne often spontaneously clears
• Flares may occur in the winter w/menses
• Scarring can be avoided by proper treatment early
  in the course of disease
• Assess the psychological impact of cosmetic
  disfigurement

14
Four Major Goals of Treatment

• Correct the abnormal follicular keratinization
• Decrease sebaceous gland activity
• Decrease follicular bacteria
• Inhibit the production of extracellular
• inflammation
• Take home points
• Retinoids, abx, hormonal treatments target
  different areas responsible for acne

15
Retinoids

• Cost
• Tretinoin (Retin-A) 42 (20g)
• Adapalene (Differin) 42 (15g)
• Tazarotene (Tazarotene) 74 (30g)
• Acts as a keratolytic and anti-inflammatory
• Inactivated by UV light
• SE Dryness, scaling, erythema, burning,
  irritation, and photosensitivity

16
Topical Antibiotics

• Cost
• Clindamycin Gel (Cleocin) 32 (30 g)
• Erythromycin Gel (Akne-Mycin) 18 (30 g)
• Kills propionibacterium acnes
• SE Irritating stains clothes

17
Other

• Cost
• Benzoyl peroxide gel 24 (90g)
• Reduces antibiotic resistance
• SE erythema, dryness
• Ortho-Tricyclin 38 (pack)
• Ortho-Cyclen
• Desogen
• Anti-androgenic
• 2-4 months before improvement is seen

18
Comedonal Acne

• Tretinoin 0.025 cream or 0.01 gel qhs
• 0.05 cream or 0.025 gel
• 0.1 cream

PLUS benzoyl peroxide 5 gel qam -Gels
have a drying effect -Creams/lotions tend to be
moisturizing
19
Papulopustular Acne

• Tretinoin 0.025 cream or 0.01 gel qhs
• 0.05 cream or 0.025 gel
• 0.1 cream
• PLUS clindamycin 1 gel or
• erythromycin 2 gel
• PLUS benzoyl peroxide 5 gel

20
Oral antibiotics

• Cost
• Tetracycline 8 (30caps)
• Least efficacious but cheap
• Decreases efficacy of OCPs need backup
• Must take 1hr before meals wait 2hrs after
  taking
• Doxycycline 75 (30caps)
• SE Dyspepsia, nausea, emesis
• diarrhea, photosensitivity, esophagitis
• Minocycline 117 (30caps)
• Most effective but also most expensive
• Can take with food unlike other tetracylines
• Infrequently causes photosenstivity
• SE vertigo, mouth shin hyperpigmentation

21
Papulopustular Acne

• Tetracycline 500mg po tid-qid x 3 months
• Doxycycline 100mg po bid x 3 months
• Minocycline 100mg daily then ? to 100mg bid
  x 3 months

22
Consider

• Hormone Therapy
• Ortho-Tricyclen, Desogen, Ortho-Cyclen
• Spironolactone 100mg daily

23
Nodulocystic Acne

• Only indication to use Acutane
• Acts against the four pathogenic factors that
  contribute to acne
• It is the only med w/ the potential to suppress
  acne over the long term
• To prescribe this med the physician must be a
  registered member of System to Manage
  Accutane-Related Teratogenicity (SMART) program
  to educate patients about the possible severe
  adverse effects and teratogenicity of isotretinoin

24
Education

• Improvement occurs over 2-5 months
• Face, upper arms and legs tend to respond more
  quickly than those on the trunk
• Retinoids should be applied at bedtime
• Clinda/Erythro/BP are applied in the morning
• Combination therapy is BEST!
• Avoid using topical antibiotic alone
• Should combine with antibacterial agent such as
  benzoyl peroxide or oral antibiotic
• No improvement? Change topical or add oral
  antibiotic

25

• Soaps, detergents, and astringents remove sebum
  from the skin surface but do not alter sebum
  production
• Avoid repetitive mechanical trauma
• Avoid occlusive clothing and refrain from rubbing
  their faces or picking their skin
• Water-based cosmetics and hair products are less
  comedogenic than oil-based products

26
Completing Therapy

• Once acne cleared you can attempt to wean meds.
  Typically wean down from bid to daily dosing for
  2-3 months then off completely. Some will have
  complete remission while others made need repeat
  treatment.

27
Follow-up on Patient

• Sent labs for PCOS all negative
• Concern for early metabolic syndrome
• Started on topical tretinoin cream and benzoyl
  peroxide and spironolactone
• Advised to apply tretinoin on acanthosis
  nigracans
• Referred for PMD

28
Conclusions

• Keratinization ? androgens ? bacteria
• ? inflammation
• Comedonal, Papulopustular, Nodulocystic
• 1st Line Topical Retinoids!
• Minimum use of 3 months prior to labeling
  treatment as a failure
• Intervene early to prevent scarring

29
Sources

• AAFP
• Uptodate
• Fitzpatrick, et al Color Atlas Synopsis of
  Clinical Dermatology
• Brian Swans Foom Handout