Dr Noori Moti-Joosub Dermatologist Laserderm, Dunkeld/ DGMC

Dr Noori Moti-Joosub
Dermatologist
Laserderm, Dunkeld/ DGMC
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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 selflimiting, the sequelae can be lifelong, with
pitted or hypertrophic scar lifelong.
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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.
Whitehead
Cyst
Blackhead
Papule
Pustule
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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)
Scars
HYPERTROPHIC
ATROPHIC
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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
hormone
◦ Acromegaly due to excessive growth hormone production
◦ Adenoma of the adrenal gland especially prolactinoma
Obesity and the metabolic syndrome
Medication-phenytoin,steroids,barbiturates,OCPills
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Patients with acne often have increased production
of sebum, hence oily skin.
This may be
because of:
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.
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Stress
Diet
High GI diet
ACNE
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Mild: Comedones
Moderate: Papules, pustules
Severe: Nodules, cysts, conglobate lesions
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Grade
Grade
Grade
Grade
1:
2:
3:
4:
Comedones only
Inflammatory papules
Pustules
Nodules, cysts, conglobate lesions
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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
suppurativa,
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Allergic reaction to P. acne
Abrupt onset
Inflammatory and ulcerated nodular acne on
chest and back
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.
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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.
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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
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Acne can be effectively treated, but
response is usually slow
Face washing-rock of management
Where possible, avoid excessively humid
conditions
Ultraviolet light helps
Abrasive skin treatments can aggravate
acne
Try not to scratch or pick the spots
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Important part of acne treatment
Wash face once or twice a day
Gentle cleansers
Foam cleansers best
Exfoliative cleansers can be used
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Often not needed in acne
Do not dry skin out
Mattifying moisturisers
Often extra moisturisers needed with
Isotretinoin treatment
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Not necessary
Use non-alcoholic type
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Often too oily
Use non-comedogenic types
Shade-seeking behaviour
Protective clothing
With Isotretinoin treatment, sun protection
imperative
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Liquid foundation better than powders
Powders block pores
The more you use, the worse it is
Make sure adequately removed
Non-comedogenic
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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.
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Anti-bacterial
Antibiotics
Retinoids
Other
Benzoyl peroxide 2.5-10% wash, gel, cream
Gel: drying
Cream: tolerant
Wash: Chest and Back
 MOA: kill bacteria, dry up oil, slough dead
skin cells
 Problem: dryness, irritation, flakiness
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Erythromycin 4% and Zinc 1,2%
Clindamycin
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MOA: anti-inflammatory, kill bacteria
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Problem: Resistance
folliculitis
Gram negative
Adapalene 0.1%
Photo-stable
Gel: drying
Cream: more tolerant
 Tretinoin 0.1-0.25%
 Isotretinoin 0.05%
 MOA: Promote cell turnover, prevent plugging
of hair follicles
 Problems: dryness, irritation, redness, sunsensitivity
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Oral or topical
 Often in combination
 Safe in pregnancy
 MOA: unknown??
Immune-modulatory
Anti-bacterial, anti-viral?
 Problem: None
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Sulfur compounds: 2% sulfur in UEA
Cost-effective
MOA: anti-bacterial, anti-parasitic, antifungal, anti-inflammatory
Problems: smell
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Gel or cream formulations
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MOA: anti-bacterial, anti-inflammatory
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Problems: Dry skin, irritation
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MOA: keratolytic agent (sloughing of dead
skin cells).
Problems: Irritation
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Used for acne, wounds, infection, fungal
infection
MOA: anti-bacterial, anti-viral, anti-fungal,
anti-inflammatory
Problems: slower onset of action compared to
benzoyl peroxide, sensitivity
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Topical treatment plus Antibiotics
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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
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MOA: bacteriostatic, anti-inflammatory
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First line – Tetracycline (no longer used)
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2nd line- doxycycline (abdominal cramping,
nausea, vomiting), minocycline(causes SLE),
lymecycline (abdominal cramping)
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Take with probiotic
Not to be taken with food
Warn females about vaginal thrush
Can have a flare when commencing treatment
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MOA: bactericidal activity (2 agents).
Most effective due to lack of resistance (2
agents).
Can be effective on those who failed on
tetracycline treatment (different sites of
sebum production, less resistance).
S/E: GIT disturbance, drug reaction.
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Must be a combination OCP (oestrogen and
progesterone)
Often regarded as an adjunctive therapy in
acne
Indicated in PCOS, CAH, idiopathic hirsutism
Often combined with cyproterone acetate
(25-100mg day 5-19)
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MOA: reduces sebum production by an antiandrogenic effect.
Mild Side effects:
 Headaches
 Nausea
 Breast tenderness
 Weight gain
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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
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Smoking
History of thrombosis or cardio-vascular disease
Family history of blood clotting disease or
abnormal clotting
Anti-phospholipid syndrome
Severe migraines
Diabetes
Hypertension, hypercholesterolaemia
History of thromboplebitis
Immobilisation
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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
in Pill users)
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Must be taken every day
Diarrhoea and vomiting decrease
effectiveness
Anti-epileptics, anti-virals may interfere with
it.
No clear evidence that antibiotics interfere
with OCP.
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Takes time to work
Family Planning Association of UK, safe to
take OCP until 50yrs of age.
Weigh up benefits and risk factors
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Many patients will be treated with oral
isotretinoin.
If this is not suitable, the following may be
used:
High dose oral antibiotics for six months or
longer
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
sebaceous gland
 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
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May fall pregnant 1 month after stopping
Isotretinoin
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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
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Sunlight is anti-inflammatory and can help
briefly. Beware of skin cancer.
Cryotherapy
Intralesional steroid injections
Comedones can be expressed by cautery or
diathermy.
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
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Will resolve in 9-12months
Topical depigmenting agents can speed up
recovery
Fractionated lasers can resolve PIH in 3-5
sessions.
Hypertrophic:
I/L steroids
Fractionated laser and rub steroid in
 Atrophic
HA fillers
Fractionated laser
CO2 laser
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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
deformity
Routine referral
 At risk of or are developing scarring despite
management
 have moderate acne that has failed to
respond to treatment which has included
two courses of oral antibiotics, each lasting
three months.
 are suspected of having an underlying
endocrinological cause for the acne (such as
polycystic ovary syndrome) that needs
assessment