Chester Clinic

Acne

Dr Noori Moti-Joosub Laserderm, Dunkeld/ DGMC

 Acne vulgaris is a self-limited disorder of the pilosebaceous unit that is seen primarily in adolescents. Most cases of acne present with a pleomorphic variety of lesions, consisting of comedones, papules, pustules and nodules. Although the course of acne may be self- limiting, the sequelae can be lifelong, with pitted or hypertrophic scar lifelong.

 Almost every teenager can experience acne to a certain degree during adolescent years.  Boys>girls  Tend to "grow out of it" in early 20s  Females can continue until post-menopausal

Hair follicle has a hair and sebaceous gland. The gland produces too much oil which becomes clogged with keratin, bacteria and cells.

 Excoriations (picked or scratched spots)  Erythematous macules (red marks from recently healed spots, mostly in fair skin)  Pigmented macules (dark marks from old spots, mostly in dark skin)  Normal physiological reaction in puberty  Disease of the ovaries ◦ Polycystic ovarian syndrome ◦ Benign or malignant ovarian tumors  Disease of the adrenal gland ◦ Partial deficiency of the adrenal enzyme 21 Hydroxylase ◦ Benign or malignant adrenal tumors  Disease of the pituitary gland ◦ Cushing's syndrome due to excessive adrenocorticotrophic ◦ Acromegaly due to excessive growth hormone production ◦ Adenoma of the adrenal gland especially prolactinoma  Obesity and the metabolic syndrome  Medication-phenytoin,steroids,barbiturates,OCPills  Patients with acne often have increased production of sebum, hence oily skin. This may be  High overall levels of sex hormones (mainly the androgen, testosterone).  Hyperandrogenism in females  Increased free testosterone because of low levels of circulating sex-hormone-binding-globulin (SHBG).  More active conversion of weaker androgens to stronger androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin.  Higher sensitivity of the skin to DHT.  Mild: Comedones  Moderate: Papules, pustules  Severe: Nodules, cysts, conglobate lesions  Grade 1: Comedones only  Grade 2: Inflammatory papules  Grade 3: Pustules  Grade 4: Nodules, cysts, conglobate lesions  Unpleasant form of nodulocystic acne  Interconnecting abscesses and sinuses, which result in unsightly hypertrophic (thick) and atrophic (thin) scars.  There are groups of large macrocomedones and cysts that are filled with smelly pus.  It is occasionally associated with hidradenitis  Allergic reaction to P. acne  Abrupt onset  Inflammatory and ulcerated nodular acne on  Severe acne scarring  Fluctuating fever  Painful joints  Malaise (i.e. the patient feels unwell)  Loss of appetite and weight loss  Raised white blood cell count.  Infantile acne  Generally affects the cheeks, and sometimes the forehead and chin, of children aged six months to three years.  More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months.  The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.  The cause of infantile acne is unknown.  It is thought to be genetic in origin.  Hormone abnormalities in older children with acne may be associated with the following conditions:  Congenital adrenal hyperplasia  Cushing's Disease  21-Hydroxylase deficiency  Precocious puberty  Androgen-secreting tumors  Acne can be effectively treated, but response is usually slow  Face washing-rock of management  Where possible, avoid excessively humid  Ultraviolet light helps  Abrasive skin treatments can aggravate  Try not to scratch or pick the spots  Important part of acne treatment  Wash face once or twice a day  Gentle cleansers  Foam cleansers best  Exfoliative cleansers can be used  Often not needed in acne  Do not dry skin out  Mattifying moisturisers  Often extra moisturisers needed with Isotretinoin treatment  Not necessary  Use non-alcoholic type  Often too oily  Use non-comedogenic types  Shade-seeking behaviour  Protective clothing  With Isotretinoin treatment, sun protection  Liquid foundation better than powders  Powders block pores  The more you use, the worse it is  Make sure adequately removed  Non-comedogenic  Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.  Acne products should be applied to all areas affected by acne, rather than just put on individual spots.  They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this.  Apply an oil-free moisturizer only if the affected skin is obviously peeling.  Anti-bacterial  Benzoyl peroxide 2.5-10% wash, gel, cream Gel: drying Cream: tolerant Wash: Chest and Back  MOA: kill bacteria, dry up oil, slough dead  Problem: dryness, irritation, flakiness  Erythromycin 4% and Zinc 1,2%  MOA: anti-inflammatory, kill bacteria  Problem: Resistance Gram negative  Adapalene 0.1% Cream: more tolerant  Tretinoin 0.1-0.25%  Isotretinoin 0.05%  MOA: Promote cell turnover, prevent plugging of hair follicles  Problems: dryness, irritation, redness, sun-  Oral or topical  Often in combination  Safe in pregnancy  MOA: unknown?? Immune-modulatory Anti-bacterial, anti-viral?  Problem: None  Sulfur compounds: 2% sulfur in UEA  Cost-effective  MOA: anti-bacterial, anti-parasitic, anti- fungal, anti-inflammatory  Problems: smell  Gel or cream formulations  MOA: anti-bacterial, anti-inflammatory  Problems: Dry skin, irritation  MOA: keratolytic agent (sloughing of dead  Problems: Irritation  Used for acne, wounds, infection, fungal  MOA: anti-bacterial, anti-viral, anti-fungal, anti-inflammatory  Problems: slower onset of action compared to benzoyl peroxide, sensitivity  Topical treatment plus Antibiotics  an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond  after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred(pt assessment)  Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen  Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted  MOA: bacteriostatic, anti-inflammatory  First line – Tetracycline (no longer used)  2nd line- doxycycline (abdominal cramping, nausea, vomiting), minocycline(causes SLE), lymecycline (abdominal cramping)  Take with probiotic  Not to be taken with food  Warn females about vaginal thrush  Can have a flare when commencing treatment  MOA: bactericidal activity (2 agents).  Most effective due to lack of resistance (2  Can be effective on those who failed on tetracycline treatment (different sites of sebum production, less resistance).  S/E: GIT disturbance, drug reaction.  Must be a combination OCP (oestrogen and  Often regarded as an adjunctive therapy in  Indicated in PCOS, CAH, idiopathic hirsutism  Often combined with cyproterone acetate (25-100mg day 5-19)  MOA: reduces sebum production by an anti- androgenic effect. Mild Side effects:  Headaches  Breast tenderness  Often pass in a few months Severe side effects:  Thrombosis (minimally raised with the progesterone drospironone) Risk greatest in first year and as you get older. Over 35 years use a low oestrogen pill  Strokes  Heart attacks  History of thrombosis or cardio-vascular disease  Family history of blood clotting disease or abnormal clotting  Anti-phospholipid syndrome  Severe migraines  Hypertension, hypercholesterolaemia  History of thromboplebitis  Immobilisation  Results have not been consistent  hepatic and endometrial cancer  breast cancer in younger users, returns to normal 10yrs after stopping it  cervical cancer (? Increased sexual activity  Must be taken every day  Diarrhoea and vomiting decrease  Anti-epileptics, anti-virals may interfere with  No clear evidence that antibiotics interfere  Takes time to work  Family Planning Association of UK, safe to take OCP until 50yrs of age.  Weigh up benefits and risk factors  Many patients will be treated with oral  If this is not suitable, the following may be  High dose oral antibiotics for six months or  In females, especially those with polycystic ovary syndrome, oral antiandrogens such as OCP or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect.  Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not licensed MOA:  Reduces sebum secretion and shrinks  Anti-bacterial  Promotes normal keratinisation of hair follicle  Anti-inflammatory Side effects  Teratogenic  Dryness, nosebleeds, dry lips  Body aches and pains  Hair falling out  Staph carriage increased: boils etc  ?? Depression, mood changes  May fall pregnant 1 month after stopping  Blood tests: βHCG. LFTs (ALT, AST), Lipogram (Total cholesterol, triglycerides)  Repeat at 3 months  Dose: 0,5-1mg/kg/day  Cumulative dose: 120-150mg/kg  Low dose?  Take with biggest meal of the day  For greater efficacy bd dosing should be used  Cortisone on commencement  Sunlight is anti-inflammatory and can help briefly. Beware of skin cancer.  Cryotherapy  Intralesional steroid injections  Comedones can be expressed by cautery or  Microdermabrasion can help mild acne.  Lasers and light systems (blue light)  X-ray treatment-no longer recommended for acne as it may cause skin cancer.  Photo-dynamic therapy Topicals  Zinc and Erythromycin  Sulfur Oral meds  Erythromycin  Will resolve in 9-12months  Topical depigmenting agents can speed up  Fractionated lasers can resolve PIH in 3-5  Hypertrophic: I/L steroids Fractionated laser and rub steroid in  Atrophic HA fillers Fractionated laser CO2 laser Immediate referral indicated (within a day):  have a severe variant of acne such as acne fulminans or gram-negative folliculitis Urgent referral  have severe or nodulocystic acne and could benefit from oral isotretinoin  have severe social or psychological problems, including a morbid fear of Routine referral  At risk of or are developing scarring despite  have moderate acne that has failed to respond to treatment which has included two courses of oral antibiotics, each lasting  are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs

Source: http://www.blackignition.co.za/download/files_27/Galderma_Acne.pdf