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Acne vulgaris: overview

Introduction: Definition: Multi-factorial disease characterized by abnormalities in sebum production, follicular desquamation, bacterial proliferation and inflammation. Prevalence:  85% adolescents experience it  Prevalence of comedones (lesions) in adolescents approaches 100%  affects 8% of 25 - 34y yr olds, and 3% of 35-44yr olds

Overview  Acne vulgaris is the most common cutaneous disorder in the U.S.  It affects more than 17 million Americans.

 10 percent of all patient encounters with primary care physicians.  Pts can experience significant psychological morbidity and, rarely, mortality due to suicide.  Important that physicians are familiar with Acne Vulgaris and its treatment.

Overview

affects all races and ethnicities with equal significance

 Darker skinned patients at increased risk for developing post-inflammatory hyper-pigmentation and keloids.

Pathogenesis:

Acne vulgaris is a disease of pilosebaceous follicles. Factors: • Retention hyperkeratosis. • • Increased sebum production. Propionibacterium acnes within the follicle. Inflammation

Initial pathogenesis (reason unknown): follicular hyperkeratinization proliferation + decreased desquamation of keratinocytes hyperkeratotic plug (microcomedone) .

Pathogenesis Sebaceous glands enlarge Sebum production increases Growth medium for P. Acnes plugs provide anaerobic Lipid-rich environment .

Pathogenesis Bacteria thrive Inflammation results Chemotactic factors attract neutrophils Depending on conditions Non-inflammatory open/closed comedones Inflammatory papule/ pustule/nodule .

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Terms/Definitions • Microcomedone: hyperkeratotic plug made of sebum and keratin in follicular canal .

.Closed comedones (whiteheads) • closed comedo (a whitehead): Accumulation of sebum converts a microcomedo into this.

Closed comedones (whiteheads) .

Open comedo (blackhead) • open comedo (a blackhead): when follicular orifice is opened + distended. Melanin + packed keratinocytes + oxidized lipids  dark colour .

Open comedo (blackhead) .

Whitehead and blackheads .

resulting in papule/pustule/nodule.Cysts • Cysts: when follicles rupture into surrounding tissues. .

Cysts .

Pustular .

chest. pruritic and painful .Keloids • Well-demarcated overgrowths of scar tissue • Altered connective tissue response in predisposed individuals (darker skin). • Most commonly on earlobes. shoulders • Can be permanent. upper back. abnormal fibroblast activity.

keloids .

• Other factors can cause increased androgen production • Higher serum levels of DHEA-S are found in pre-pubertal girls with acne • Acne tends to resolve in the third decade as DHEA-S levels decline • Medication induced .Pathogenesis • Most pts with acne likely have glands locally hyperresponsive to androgens.

• Post-adolescent acne predominantly affects women (76%): -hyperandrogenous -family history in half -premenstrual flares in older women • adolescent acne has a male predominance .Pathogenesis • Acne may develop de novo in adulthood.

greases. or dyes in hair products Cosmetics water-based products are less comedogenic Repetitive trauma may worsen inflammation Soaps decrease sebum but do not alter production Humidity perspiration .External factors: • • • • • • • Oils.

External factors: • Role for diet in acne is controversial • A study of 47.natural hormonal components of milk? • A study of 22 university students found in a multivariate analysis some correlation with stress.355 women that used a retrospective data found an association between acne and intake of milk . .

mild scarring Type 3 — Numerous comedones. and upper trunk. severe scarring Note: categories are not rigid. A pt with mainly comedones and papules but notable scarring may be considered to have severe acne . no scarring present Type 2 — Comedones and more numerous papules and pustules (mainly facial). spreading to the back. moderate scarring Type 4 — Numerous large cysts on the face. papules. and pustules.Classification • • • • Classification system generally as follows Type 1 — Mainly comedones with an occasional small inflamed papule or pustule. with an occasional cyst or nodule. chest. and shoulders. neck.

Lesion type .keloid .Location .Diagnosis • Complete history • Pay attention to endocrine function .scarring .Rapid appearance with virilization/menstrual irregularity PCOS and other syndromes • Complete medication list • Physical exam: .pigmentation .

6.Medications that can cause acne • • • • • • ACTH Azathioprine Barbiturates Isoniazid Lithium phenytoin • • • • • • Disulfiram Halogens Iodides Steroids Cyclosporine Vitamins B2.12 .

(gel for oily. • Microcomedone matures in 8 weeks • Therapy must continue beyond this time frame • considerable heterogeneity in the acne literature.Treatment of Acne Vulgaris • depends on type of clinical lesions • Choose vehicle for topical rx acc to pt’s skin type. and no clear evidence-based guidelines are available . cream for dry skin).

Comedonal acne: Process -increased sebum + abnormal desquamation. • To reduce sebum production no other effective rx apart from hormonal therapies or oral isotretinoin • Hence Rx of abnormal keratinization is most effective .

 Adapalene gel (no studies for pregnancy)  Isotretinoin (tazoretene) : keratolytic.Comedonal acne Topical retinoids: • Normalize keratinization • only agents that affect terminal differentiation of follicular epithelium. • initial drugs of choice  All transretinoic acid (tretinoin): C/I in pregnancy. C/I in pregnancy .

Issues with topical retinoids • Photosensitivity – use in pm. sunscreen • Local irritation – start lowest strength. • Pustular flare during first few wks of Rx sign of accelerated resolution. .

reduces hyperpigminetation) Gycolic acid Sulfur in OTC rx (keratolytic) .Comedonal acne • Other topical agents: • Useful when topical retinoids not tolerated     Salicylic acid (promotes desquamation) Azelaic acid (antimicrobial.

Comedonal acne Mechanical removal of comedones • useful adjunct to topical rx .

. anticomedonal. pregnancy risk C) • Topical antibiotic • Combination of both • Combination rx more effective than mono in increased inflammatory lesions.Mild to moderate inflammatory acne • Benzoyl peroxide: (antimicrobial.

Acne • Reduce inflammation      Clindamycin Erythromycin Tetracycline Metronidazole Azelaic acid .Mild to moderate inflammatory acne • Topical antibiotics • Eliminate P.

Moderate to severe acne: • If topical Rx not effective  oral isotretinoin  oral antibiotics  hormonal rx • • • • • Oral isotretinoin Reduces sebaceous gland size/sebum production regulates cell proliferation and differentiation Effect last 1 yr after cessation Only med altering course of A. Vulgaris .

top 10 drugs for suicide/depression reports.) . (manufacturer—must commit to 2 contracept. • FDA practice rules: 2 negative pregnancy tests before rx Pregnancy test each month (bring pt in) physicians need authorization before prescribing Pregnancy risk pts must use 2 contraceptive for at least 1 mo prior to rx. teratogenic. bone marrow suppression.Moderate to severe acne: oral isotretinoin • Adverse effects can be severe: • Inc TG. hepatotoxicity.

LFT. . then regular intervals.• Monitoring parameters: CBC w/ diff. glucose. TG. CPK • Obtain baseline. ESR. Chol. • LFT 1-2 x week until response to rx • Lipids 1-2 x week until response to rx.

Moderate to severe acne: • Oral antibiotics -Tetracycline .erythromycin . with taper.doxycycline .minocycline .clindamycin • Given daily over 4-6 mo. .TMP-SMX .

prescribe the same abx . may reduce resistance • If abx are stopped and need to be restarted.P.Moderate to severe acne: • Practices to reduce resistance • Use abx if absolutely necessary • Concomitant use of B.

flutamide. PCOS (hirsutism. acne. Consider adult onset congenital adrenal hyperplasia. Cushing’s dz /syndrome. irregular menses. acanthosis nigrans. insulin resistance) • Anti-androgens (spironolactone. ketoconazole. cimetidine) • estrogen • Min 3-6 mo of rx .Moderate to severe acne: • • • • Hormone rx Unresponsive acne Send for Gyn eval if hirsutism/menstrual irregularities. ovarian/adrenal tumour.

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eight treatments generally cost the patient $800 to $1600 • Further data needed to recommend it .Blue light therapy • moderate inflammatory acne • FDA approved • small uncontrolled trial of biweekly rx for 5 wks showed 64% lesion reduction • expensive.

• Second randomized trial (June 04) of similar laser rx comparing sham to laser on either side of face showed no such benefit.Laser therapy • Conflicting data on pulsed dye laser rx • Randomized of 41 assigned to sham or laser showed sig improvement after 12 wks. . • Further data needed.

65-57 (19-28$/mo qd) .99 to $160 • Benzoyl peroxide 5% gel 90 gm : $22 (3-11$/mo for qd) • Erythromycin 2% gel 60 mg: $38.Costs • Minocycline 100 mg (30): $21.

Patient FAQs • Soaps. detergents remove sebum but do not alter production • Avoid occlusive clothing • Water based cosmetic better than oil based • Diet modification no role in rx .