Edith Hanna/Dania Shakaron

WHAT IS THE MOST COMMON SKIN DISORDER?
OBJECTIVES
 Describe the MORPHOLOGY of acne
 Explain the basic PRINCIPLES of treatment for acne
 Recommend an initial treatment PLAN for a patient with acne
 Practice providing patient EDUCATION on acne treatment
 Determine when to REFER a patient with acne to a dermatologist
EPIDEMIOLOGY
 Acne vulgaris, or simply ACNE, is a disorder of the pilosebaceous follicles
 Typically:
-
presents at ages 8-12
-
peaks at ages 15-18
-
resolves by age 25
 Affects 40-50 million persons; ~90% of adolescents
CLINICAL PRESENTATION
 Face, neck, upper trunk, upper arms
 Starts with a “clogged pore” aka COMEDONE
CASE ONE
Karim is an 18 year-old healthy teenager presenting to the OPD with “pimples” on his
face for the past 2 years. He notes scrubbing his face with Le Chat soap on a
daily basis during his morning shower.
PMHx/PSHx: -ve
Allergies: NKDA
Meds: none
FMHx: father had acne as a teenager
Social Hx: lives at home with parents, high school student
ROS: -ve
SKIN EXAM FINDINGS
CLASSIFICATION OF ACNE
Based on:
Comedonal
1. Severity
Inflammatory
2. Presence of scarring
3. Morphology
Nodulocystic
HOW WOULD YOU DESCRIBE
KARIM’S ACNE?
ANSWER: C
A. Mild comedonal acne without scarring
B. Mild inflammatory acne without comedones
C. Moderate mixed comedonal & inflammatory
acne with scarring
D. Moderate mixed comedonal & inflammatory
acne without scarring
HOW WOULD YOU DESCRIBE THIS PATIENT’S ACNE?
 Moderate comedonal acne
without evidence of scarring
HOW WOULD YOU DESCRIBE THIS PATIENT’S ACNE?
 Severe nodulocystic acne
with presence of scarring
Diagnosis
 Treatment ???
PATHOGENESIS
 Presence of androgenic hormones
 Sebaceous gland activity
 Plugging of hair follicle as result of abnormal keratinization of upper portion
 Propionibacterium acnes in the hair follicle
 IGF-1 signaling?
WHICH AGENTS
ARE EFFECTIVE
FOR TREATING ACNE?
TOPICAL RETINOIDS
 Vitamin A derivatives
 Used for acne, fine wrinkles, photodamaged skin, &
hyperpigmentation
 Common side-effects: dryness, pruritus, erythema,
scaling, PHOTOSENSITIVTY
BENZOYL PEROXIDE
 Both antibacterial & comedolytic properties
 Available in combinations with topical AntiB
 Common side-effects: bleaching of hair, skin irritation
• Cutacnyl 5%/10% gel
• Eclaran 5%/10% gel
TOPICAL ANTIBIOTICS
 Reduce the number of P. acnes & reduce inflammation
 Do not use as monotherapy
 Erythromycin 2% [solution, gel] vs Clindamycin 1% [lotion, solution, gel,
foam]
•
•
•
•
Erycine 4% gel
Eryfluid 4% solution
Erythromycin 1.5%/4% solution
Zineryt lotion
•
•
•
•
Cliniderm 1% gel
Clinimycin T gel
Medacin T 1% gel
Zindaclin gel
ORAL ANTIBIOTICS
 Tetracycline, Doxycycline, Minocycline
 Often combined with BP to prevent antibiotic resistance
 If NO RESPONSE after 3 months of therapy, consider:
•
Increasing the dose
•
Changing the treatment
•
Referring to a dermatologist
Side-effects: GI upset and photosensitivity
 Contraindicated in ?
Doxy 50
Granudoxy 100 mg
Retadox 100 mg
Tolexine 100 mg
WHICH ANTIBIOTIC CAUSES THIS?
A.
B.
C.
D.
Tetracycline
Doxycycline
Minocycline
All of the above
WHICH ANTIBIOTIC CAUSES THIS?
ANSWER: C
A.
B.
C.
D.
Tetracycline
Doxycycline
Minocycline
All of the above
ORAL ISOTRETINOIN
 Retinoic acid derivative
Isotroin $
Curacne
Acnogen
Roaccutane $$$
 Single course of therapy: 0.5-1 mg/kg/d for 15-20 weeks
 Teratogenic:
•
Pregnancy testing before, during, & 5 weeks after a course of therapy [monthly]
•
Two forms of contraception must be used
Uncommon side-effect: headache 2o pseudotumor cerebri
ORAL ISOTRETINOIN
Common side-effects:
 Dry skin
 Chapped lips
 Elevated LFTs
 Hypertriglyceridemia
 Order pre-treatment & f/u tests at weekly or biweekly
intervals until response to Accutane is established
COMMON FIRST-LINE TREATMENTS
 Mild comedonal: topical retinoid +/- topical benzoyl
peroxide
Price: 5,721 L.L.
Locacid (0.05%)
+/-
Cutacnyl (5%)
Price: 4,473 L.L.
------------------------------Total= 10,194 L.L.
COMMON FIRST-LINE TREATMENTS
 Mild papular/pustular: topical retinoid +/- topical benzoyl
peroxide +/- topical antibiotics
Locacid (0.05%)
Price: 5,721 L.L.
+/-
Cutacnyl (5%)
Price: 4,473 L.L.
+/-
Eryfluid (4%)
Price: 10,300 L.L.
------------------------------Total= 20,494 L.L.
COMMON FIRST-LINE TREATMENTS
 Moderate papular/pustular: topical retinoid +/- topical benzoyl
peroxide +/- ORAL antibiotics
Locacid (0.05%)
Price: 5,721 L.L.
+/-
Cutacnyl (5%)
Price: 4,473 L.L.
+/-
Granudoxy 100-200 mg QD
Price: 8,175 L.L.
------------------------------Total= 18,369 L.L.
 Severe nodular: refer to a dermatologist for oral isotretinoin
 Scarring and keloids: refer to a dermatologist for oral isotretinoin
“Acne scarring is difficult to treat, therefore aggressive prevention is
imperative”
PATIENT EDUCATION
When using retinoids or BP, begin on ALTERNATE days.
MOISTURIZE to reduce irritation.
Take antibiotics with FULL GLASS of WATER to avoid esophagitis
Be PATIENT, topical agents take 2-3 months for effect
Do NOT DISCONTINUE treatment due to “red, flakey” skin
PATIENT EDUCATION
 Set EXPECTATIONS:
“Acne treatment is only treating new lesions, not the ones already there”
 AVOID:
drying OTC products
Overaggressive washing
Abrasive scrubs
 Check your cosmetics for:
“Non-comedogenic” or “Oil-free”
DIFFERENTIAL DIAGNOSIS OF ACNE
Bacterial Folliculitis
DIFFERENTIAL DIAGNOSIS OF ACNE
Rosacea
DIFFERENTIAL DIAGNOSIS OF ACNE
Seborrheic Dermatitis
DIFFERENTIAL DIAGNOSIS OF ACNE
Pseudofolliculitis barbae [barber’s itch]
DIFFERENTIAL DIAGNOSIS OF ACNE
Perioral dermatitis
DIFFERENTIAL DIAGNOSIS OF ACNE
Drug-induced acne
CASE TWO
Jamilé is a 23 year-old woman presenting to the OPD for recent onset acne. She
notes a 20 kgs weight gain over ~4 years despite a healthy diet & exercise habits.
PMHx: negative
Allergies: NKDA
Meds: none
FMHx: negative
Social Hx: lives at home with parents, AUB student
ROS: new upper lip and chin hair growth, irregular menstrual cycle since menarche,
last period 3 months ago
PHYSICAL EXAM FINDINGS
 Moderate comedonal and
inflammatory acne of
cheeks and jaw line
PCOS
2/3 criteria:
1. olio- and/or anovulation
2. Hyperandrogenism
3. Polycystic ovaries on US
 Lab Tests?
 Total/Free testosterone, DHEAS, LH, FSH
 Antiandrogen therapy can improve acne
 Spironolactone 50 mg-100 mg daily
 OCPs: Yaz 3 mg/30 mcg
 Hormonal acne lesions are often perioral and along the jaw line
HORMONAL ACNE
FUN FACTS
 Chocolate & fries might be causing your breakout.
"What I tell patients with acne is that for some,
chocolate plays a role, and for others it does not,” AAD President
Dr. Moy
 Outside triggers can make breakouts worse.
Dirty cell phone, pillowcase, HANDS etc
 Zaatar is more effective in treating acne than medicated
creams.
REFERENCES
THANK YOU