Acne VulgarisAcne Vulgaris(Otherwise known as zits, pimples and (Otherwise known as zits, pimples and

blackheads)blackheads)

Conference GoalsConference Goals Review pathogenesis as a way to help Review pathogenesis as a way to help

us understand why we use certain us understand why we use certain medsmeds

Differentiate common types of acneDifferentiate common types of acne Generate a quick differential Generate a quick differential

diagnosisdiagnosis Apply a stepwise approach to Apply a stepwise approach to

treatment treatment prior prior toto referral to referral to dermatologydermatology

EpidemiologyEpidemiology

Onset?Onset? Males 10-17 yrsMales 10-17 yrs Females 14-19 Females 14-19

yrsyrs May persist through 4May persist through 4thth decade or decade or

olderolder

Prevalence?Prevalence? Asians 10%Asians 10% African-American 25%African-American 25% Caucasians 29%Caucasians 29%

Causes?Causes?

Majority of patients have a family Majority of patients have a family history of acnehistory of acne

Emotional stressEmotional stress AndrogensAndrogens Dioxins, lithiumDioxins, lithium Occlusion and pressure “acne Occlusion and pressure “acne

mechanica”mechanica” NOT DUE TO CHOCOLATE OR FATTY NOT DUE TO CHOCOLATE OR FATTY

FOODS!FOODS!

PathogenesisPathogenesis

Plugging of the hair folliclePlugging of the hair follicle

w/ abnormally keratinized w/ abnormally keratinized cellscells

Androgen-induced Androgen-induced sebaceous gland sebaceous gland hyperactivityhyperactivity

Proliferation of bacteriaProliferation of bacteria

- - Propionibacterium acnesPropionibacterium acnes

Inflammation Inflammation

““Doctor my skin is breaking Doctor my skin is breaking out!”out!”

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

HPIHPI When was the onset?When was the onset? AdolescenceAdolescence Where?Where? Face, neck, trunk Face, neck, trunk

&& buttocksbuttocks Does it itch or hurt?Does it itch or hurt? Pustules painfulPustules painful How have the individual lesions changed?How have the individual lesions changed? Triggers? Triggers? Worse in fall/winterWorse in fall/winter Hirsutism? Oligomenorrhea?Hirsutism? Oligomenorrhea?

Differential DiagnosisDifferential Diagnosis FaceFace

Staph aureusStaph aureus folliculitis folliculitis RosaceaRosacea Perioral dermatitisPerioral dermatitis

TrunkTrunk Pityrosporum Pityrosporum folliculitisfolliculitis ““Hot Tub” folliculitisHot Tub” folliculitis

Acne AestivalisAcne Aestivalis Appears after sun exposureAppears after sun exposure

Types of AcneTypes of Acne ComedonalComedonal PapulopustularPapulopustular NodulocysticNodulocystic

Why is this important?Why is this important? Directs treatment optionsDirects treatment options

Comedonal AcneComedonal Acne

Closed comedones (whiteheads)Closed comedones (whiteheads) Sebum accumulation results in a Sebum accumulation results in a

white papule visible at the skin white papule visible at the skin surfacesurface

Open comedones (blackheads)Open comedones (blackheads) Plug protrudes from canal and Plug protrudes from canal and

turns darkturns dark

Non-inflammatoryNon-inflammatory Usually responds to topical Usually responds to topical

keratolytickeratolytic

Papulopustular AcnePapulopustular Acne Papules/PustulesPapules/Pustules

Follicular wall rupturesFollicular wall ruptures Releases sebum and Releases sebum and

bacteria into dermisbacteria into dermis

Topical agents Topical agents alone usually alone usually insufficientinsufficient

Consider topical Consider topical retinoids retinoids plusplus systemic antibioticssystemic antibiotics

Nodulocystic AcneNodulocystic Acne Soft nodules that are Soft nodules that are

secondary comedones secondary comedones from repeated ruptures from repeated ruptures reencapsulations and reencapsulations and abscess formationsabscess formations

Painful and disfiguringPainful and disfiguring Psychological impactPsychological impact

Treatment consists of Treatment consists of topical agents, oral topical agents, oral antibiotics or isotretinoinantibiotics or isotretinoin

ManagementManagement Acne often spontaneously clearsAcne often spontaneously clears Flares may occur in the winter & Flares may occur in the winter &

w/mensesw/menses Scarring can be avoided by proper Scarring can be avoided by proper

treatment treatment earlyearly in the course of in the course of diseasedisease

Assess the psychological impact of Assess the psychological impact of cosmetic disfigurementcosmetic disfigurement

Four Major Goals of TreatmentFour Major Goals of Treatment Correct the abnormal follicular keratinizationCorrect the abnormal follicular keratinization Decrease sebaceous gland activityDecrease sebaceous gland activity Decrease follicular bacteriaDecrease follicular bacteria Inhibit the production of extracellularInhibit the production of extracellular

inflammationinflammation

Take home points:Take home points:

Retinoids, abx, hormonal treatments target Retinoids, abx, hormonal treatments target different areas responsible for acnedifferent areas responsible for acne

RetinoidsRetinoidsCostCost

Tretinoin (Retin-A)Tretinoin (Retin-A) $42 (20g)$42 (20g) Adapalene (Differin) Adapalene (Differin) $42 (15g)$42 (15g) Tazarotene (Tazarotene) Tazarotene (Tazarotene) $74 (30g)$74 (30g)

Acts as a keratolytic and anti-Acts as a keratolytic and anti-inflammatoryinflammatory

Inactivated by UV lightInactivated by UV light SE: Dryness, scaling, erythema, burning, SE: Dryness, scaling, erythema, burning,

irritation, and photosensitivityirritation, and photosensitivity

Topical AntibioticsTopical Antibiotics

CostCost Clindamycin Gel (Cleocin) Clindamycin Gel (Cleocin) $32 $32

(30 g)(30 g) Erythromycin Gel (Akne-Mycin) Erythromycin Gel (Akne-Mycin) $18 $18

(30 g)(30 g)

Kills Kills propionibacterium acnespropionibacterium acnes SE: Irritating; stains clothes SE: Irritating; stains clothes

OtherOtherCostCost

Benzoyl peroxide gelBenzoyl peroxide gel $24 (90g)$24 (90g)

Reduces antibiotic resistanceReduces antibiotic resistance SE: erythema, dryness SE: erythema, dryness

Ortho-TricyclinOrtho-Tricyclin $38 (pack)$38 (pack) Ortho-CyclenOrtho-Cyclen DesogenDesogen

Anti-androgenicAnti-androgenic 2-4 months before improvement is seen2-4 months before improvement is seen

Comedonal AcneComedonal AcneTretinoin Tretinoin 0.025% cream 0.025% cream oror 0.01% gel 0.01% gel qhs qhs

0.05% cream 0.05% cream oror 0.025% gel 0.025% gel

0.1% cream0.1% cream

PLUSPLUS benzoyl peroxide 5% benzoyl peroxide 5% gel qamgel qam

-Gels have a drying effect-Gels have a drying effect-Creams/lotions tend to be -Creams/lotions tend to be moisturizingmoisturizing

Papulopustular AcnePapulopustular Acne

Tretinoin Tretinoin 0.025% cream 0.025% cream oror 0.01% gel qhs 0.01% gel qhs

0.05% cream 0.05% cream oror 0.025% gel 0.025% gel

0.1% cream0.1% cream

PLUSPLUS clindamycin 1% gel clindamycin 1% gel ororerythromycin 2% gelerythromycin 2% gel

PLUSPLUS benzoyl peroxide 5% gelbenzoyl peroxide 5% gel

Oral antibioticsOral antibioticsCostCost

TetracyclineTetracycline $8 (30caps)$8 (30caps) Least efficacious but cheapLeast efficacious but cheap Decreases efficacy of OCP’s; need backupDecreases efficacy of OCP’s; need backup Must take 1hr before meals; wait 2hrs after takingMust take 1hr before meals; wait 2hrs after taking

Doxycycline Doxycycline $75 (30caps)$75 (30caps) SE: Dyspepsia, nausea, emesisSE: Dyspepsia, nausea, emesis

diarrhea, photosensitivity, esophagitisdiarrhea, photosensitivity, esophagitis

MinocyclineMinocycline $117 (30caps)$117 (30caps) Most effective but also most expensiveMost effective but also most expensive Can take with food unlike other tetracylinesCan take with food unlike other tetracylines Infrequently causes photosenstivityInfrequently causes photosenstivity SE: SE: vertigovertigo, mouth & shin hyperpigmentation, mouth & shin hyperpigmentation

Papulopustular AcnePapulopustular Acne Tetracycline 500mg po tid-qid x 3 monthsTetracycline 500mg po tid-qid x 3 months

Doxycycline 100mg po bid x 3 monthsDoxycycline 100mg po bid x 3 months

Minocycline 100mg daily then Minocycline 100mg daily then to to 100mg bid 100mg bid x x 3 months3 months

ConsiderConsider

Hormone TherapyHormone Therapy Ortho-Tricyclen, Desogen, Ortho-CyclenOrtho-Tricyclen, Desogen, Ortho-Cyclen Spironolactone 100mg dailySpironolactone 100mg daily

Nodulocystic AcneNodulocystic Acne Only indication to use AcutaneOnly indication to use Acutane Acts against the four pathogenic factors Acts against the four pathogenic factors

that contribute to acnethat contribute to acne It is the only med w/ the potential to It is the only med w/ the potential to

suppress acne over the long termsuppress acne over the long term To prescribe this med the physician must To prescribe this med the physician must

be a registered member of System to be a registered member of System to Manage Accutane-Related Teratogenicity Manage Accutane-Related Teratogenicity (SMART) program to educate patients (SMART) program to educate patients about the possible severe adverse effects about the possible severe adverse effects and teratogenicity of isotretinoinand teratogenicity of isotretinoin

EducationEducation Improvement occurs over 2-5 monthsImprovement occurs over 2-5 months Face, upper arms and legs tend to respond Face, upper arms and legs tend to respond

more quickly than those on the trunkmore quickly than those on the trunk Retinoids should be applied at bedtimeRetinoids should be applied at bedtime Clinda/Erythro/BP are applied in the morningClinda/Erythro/BP are applied in the morning Combination therapy is BEST! Combination therapy is BEST!

Avoid using topical antibiotic aloneAvoid using topical antibiotic alone Should combine with antibacterial agent such as Should combine with antibacterial agent such as

benzoyl peroxide or oral antibioticbenzoyl peroxide or oral antibiotic No improvement? Change topical or add No improvement? Change topical or add

oral antibioticoral antibiotic

Soaps, detergents, and astringents Soaps, detergents, and astringents remove sebum from the skin surface remove sebum from the skin surface but do not alter sebum productionbut do not alter sebum production

Avoid repetitive mechanical traumaAvoid repetitive mechanical trauma Avoid occlusive clothing and refrain Avoid occlusive clothing and refrain

from rubbing their faces or picking from rubbing their faces or picking their skintheir skin

Water-based cosmetics and hair Water-based cosmetics and hair products are less comedogenic than products are less comedogenic than oil-based productsoil-based products

Completing TherapyCompleting Therapy

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

Follow-up on PatientFollow-up on Patient Sent labs for PCOS – all negativeSent labs for PCOS – all negative Concern for early metabolic Concern for early metabolic

syndromesyndrome Started on topical tretinoin cream Started on topical tretinoin cream

and benzoyl peroxide and and benzoyl peroxide and spironolactonespironolactone

Advised to apply tretinoin on Advised to apply tretinoin on acanthosis nigracansacanthosis nigracans

Referred for PMDReferred for PMD

ConclusionsConclusions Keratinization Keratinization androgens androgens bacteria bacteria

inflammationinflammation Comedonal, Papulopustular, Comedonal, Papulopustular,

NodulocysticNodulocystic 11stst Line: Topical Retinoids! Line: Topical Retinoids! Minimum use of 3 months prior to Minimum use of 3 months prior to

labeling treatment as a failurelabeling treatment as a failure Intervene early to prevent scarringIntervene early to prevent scarring

SourcesSources

AAFPAAFP UptodateUptodate Fitzpatrick, et al Color Atlas & Fitzpatrick, et al Color Atlas &

Synopsis of Clinical DermatologySynopsis of Clinical Dermatology Brian Swan’s Foom HandoutBrian Swan’s Foom Handout