ACNECont.

Acne Variants

1. Acne conglobata

2. Acne fulminans

3. Neonatal acne

4. Infantile acne

5. Post-adolescent

acne

6. Acne excoriée

7. Cosmetic / Pomade

acne

8. Acne Detergicans

9. Acne mechanica

10.Premenstrual Acne

11.Occupational acne /

Chloracne

12.Senile (solar)

comedones

13.Drug-induced acne

14.Pyoderma Faciale

15.Solid facial edema

Acne Conglobata

Conglobate: shaped in a rounded mass or ball

Severe form of inflammatory nodulocystic acne characterized by numerous comedones, large abscesses or cysts interconnecting with sinuses, grouped inflammatory nodules but without systemic manifestations.

Suppuration on forehead, cheeks, and neck

Acne Conglobata

Occurs most frequently in young men

Follicular Occlusion Tetrad:I. Acne conglobata, II. Hiradenitis suppurva,III. Dissecting cellulitis of the scalpIV. Pilonidal cysts

Heals with scarring difficult to prevent Treatment; oral isotretinoin for 5 months

Acne Conglobata

The association of 1. Sterile Pyogenic Arthritis, 2. Pyoderma gangrenosum, 3. Acne conglobata

can occur in the context of an autosomal dominant autoinflammatory disorder referred to as PAPA syndrome.

Acne Fulminans

the most severe form of acne characterized bysudden onset of severely inflamed nodulocystic & suppurative acne lesions in association with systemic manifestations.

Rare form of extremely severe Teenage boys, chest, shoulders & back

Patients typically have mild to moderate acne prior to the onset of acne fulminans

Acne Fulminans

Rapid coalescence into painful, oozing, friable plaques with hemorrhagic crusts Rapid degeneration of nodules leaving ulceration can lead to significant scarring.

Fever, arthralgias, myalgias, hepatosplenomegaly, severe malaise. anorexia are common. Osteolytic bone lesions may accompany the cutaneous finding.

Ix: leukocytosis, proteinuria

SAPHO Syndrome

Synovitis, Acne, Pustulosis, Hyperostosis, and Osteomyelitis

Acne fulminans, acne conglobata, pustular psoriasis, and palmoplantar pustulosis

Chest wall is most site of musculoskeletal complaints

Pustules on the sole of the left foot (A) and left palm (B), and radioisotope scan (C) showing intense uptake by the

sternoclavicular and first sternocostal joints.

Treatment of acne fulminans

1. Oral steroids2. Oral isotretinoin often with initiation of the

latter at a low dose and/or after the acute inflammation subsides.

3. Topical or intralesional corticosteroids,4. Oral antibiotics (limited efficacy), 5. TNF-α inhibitors 6. Immunosuppressives (e.g. azathioprine). 7. Dapsone

Pyoderma Faciale (Rosacea fulminans) Postadolescent girls, reddish

cyanotic erythema with abscesses and cysts

Distinguished from acne by absence of comedones, rapid onset, fulminant course and absence of acne on the back and chest

Tx; oral steroids followed by isotretinoin

Preadolescent Acne

Neonatal Infantile Childhood/Juvenile

Neonatal Acne

very common First four weeks of life More than 20% of healthy newborns. Facial papules or pustules typically no

comedones. Arise primarily on the cheeks and nasal

bridge but the forehead, chin, neck and upper trunk can also be involved.

Neonatal Acne

The development related to hormonal activity in utero / An inflammatory response to Malassezia spp. (e.g. furfur) has been proposed as the etiology and will resolve spontaneously 1-3 months after delivery without evidence of scarring.

No treatment is required except reassurance for parents who may be extremely anxious

Tx with topical imidazoles (e.g. ketoconazole 2% cream).

Infantile Acne

Cases that persist beyond 4 weeks or have an onset after

In contrast to neonatal acne, comedo formation is prominent and pitted scarring can develop.

Infantile acne typically resolves within 1–2 years and remains quiescent until around puberty. In unusual cases, however, infantile-onset acne may persist into adolescence.

Infantile Acne Androgen production intrinsic to this stage

of development including elevated levels of LH stimulating testicular production of testosterone in boys during the first 6–12 months of life (with levels transiently equivalent to those during puberty) and elevated levels of DHEA produced by the infantile adrenal gland in both boys and girls. These androgen levels normally decrease substantially by 6-12 months of age and remain at nadir levels until adrenarche.

Treatment of Infantile acne

Topical retinoids (e.g. tretinoin, adapalene) and benzoyl peroxide are first-line treatments.

Oral antibiotics (e.g. erythromycin, azithromycin) can be helpful for patients with a more severe inflammatory component,

Isotretinoin is occasionally required for recalcitrant or nodulocystic presentations

Post-adolescent acne Inflammatory acne persisting beyond 25

years of age is most common in women, Tends to flare during the week prior to

menstruation, and typically features tender, deep-seated papulonodules on the lower third of the face, jawline and neck.

Approximately one-third of affected women have other signs of hyperandrogenism

Regardless of androgen levels, hormonal therapy is often effective.

Premenstrual Acne

Papulopustular lesions week prior Estrogen-dominant contraceptive pills

will diminish

Excoriated Acne (Acne Excoriée/picker’s acne)

Girls, mild acne minute or trivial primary lesions are made worse by squeezing, scratching, erosions and crusting on individual lesions.

Crusts, scarring, and atrophy Individuals with an anxiety

disorder, obsessive–compulsive disorder or personality disorder are particularly at risk

Treatment of Excoriated Acne

In addition to acne Rx; eliminate magnifying mirror, Rx of depression; Antidepressants or

psychotherapy

Acne mechanica Occurs secondary to repeated

mechanical and frictional obstruction of the pilosebaceous outlet.

Well-described mechanical factors include rubbing by helmets, chin straps, suspenders and collars.

Acne mechanica Fiddler’s neck, where

repetitive trauma from violin placement on the lateral neck results in a well-defined lichenified, hyperpigmented plaque interspersed with comedones. Linear & geometrically distributed areas of involvement should suggest acne mechanica.

Treatment is aimed at eliminating the inciting forces

Acne Detergicans

Patients wash face with comedogenic soaps

Closed comedones Tx; wash only once or twice a day

with non-comedogenic soap

Solid facial edema (Morbihan’s disease).

An unusual and disfiguring complication of AV.

Clinically, there is a distortion of the midline face& cheeks due to soft tissue swelling.

The woody induration may be accompanied by erythema. Impaired lymphatic drainage and fibrosis.

Fluctuations in severity are common, but does not usually resolve spontaneously.

Treatment of Solid facial edema

1. Isotretinoin (0.2–1 mg/kg/day), alone or in combination with;

2. Ketotifen (1–2 mg/day) or;3. Prednisone (10–30 mg/day), for 4–5

months.

Acne Aestivalis (Mallorca acne)

Rare, females 25-40 yrs Starts in spring, resolves by fall Small papules on cheeks, neck, upper body Comedones & pustules are sparse or absent Tx; retinoic acid, abx don’t help

Occupational acne (Acne Venenata)

Exposure to insoluble, follicle-occluding substances in the workplace.

Comedones dominate the clinical picture, with varying numbers of papules, pustules and cystic lesions distributed in exposed as well as typically covered areas.

Offending agents: 1. Cutting oils2. Petroleum-based products3. Chlorinated aromatic hydrocarbons (Chloracne)4. Coal tar derivatives.

Coal-Tar Acne

Appear after prolonged exposure to coal-tar products coal tar oils,

These compounds, forming a black plug mixed with dead skin cells and keratin.

Especially the face and arms. If not treated properly, coal-tar acne can

develop into skin cancer    

Chloracne

Occupational acne caused by exposure to chlorinated aromatic hydrocarbons, develops after several weeks of exposure.

The malar, retroauricular and mandibular regions of the head and neck as well as the axillae and scrotum, are most commonly afflicted with small cystic papules and nodules. The extremities, buttocks and trunk are variably involved.

Chloracne

Cystic lesions can heal with significant scarring, and recurrent outbreaks may occur for many years following exposure.

Chloracnegens, found in electrical conductors and insulators, insecticides, fungicides, herbicides and wood preservatives.

Prevention of exposure is integral to the safety of at-risk employees.

Treatment of Chloracne

Initial management is aimed at vigorous removal of chemical agents at the time of exposure.

Topical or oral retinoids and oral antibiotics may be beneficial therapeutic interventions

Acne Cosmetica

Closed comedones and papulopustules on the chin and cheeks

In areas of skin chronically exposed to follicle-occluding cosmetics

May take months to clear after stopping cosmetic product

Pomade Acne

Blacks, males, due to greases or oils applied to hair.

Favors forehead and temples

ACNEIFORM ERUPTIONS

Acneiform Eruptions

Acneiform eruptions are dermatoses that resemble acne vulgaris.

Lesions may be papulopustular, nodular, or cystic. While acne vulgaris typically consists of comedones, acneiform eruptions (such as acneiform drug eruptions) usually lack comedones clinically.

Location may be outside of the area in which acne vulgaris occurs.

Age outside the range typical of acne vulgaris.

Acneiform Eruptions Acnelike eruptions develop as a result of;

1. Infections.2. Hormonal abnormalities.3. Metabolic abnormalities.4. Genetic disorders. 5. Drug reactions.

Acneiform Eruptions1.Epidermal growth factor receptor inhibitor-induced papulopustular eruption2.Tropical acne3.Radiation acne4.“Pseudoacne” of the transverse nasal crease5.Idiopathic facial aseptic granuloma6.Childhood flexural comedones7.Nevus comedonicus. 8.Eruptive hair cysts.9.Tuberous sclerosis.

10.Chloracne. 11.Acneiform drug eruptions.12.Steroid acne.13.Amineptine acne. 14.Gram-negative folliculitis.15.Eosinophilic pustular

folliculitis.16.Pityrosporum folliculitis.17.Coccidioidomycosis.18.Secondary syphilis.19.Sporotrichosis.20.Rosacea. 21.Perioral dermatitis.22.Senile (solar) comedones

1. Epidermal growth factor receptor inhibitor-induced papulopustular eruption

EGFR inhibitors used for the treatment of solid tumors, including head and neck squamous cell carcinoma and lung, colon and breast carcinoma.

The incidence of acneiform eruptions due to EGFR inhibitors is very high, e.g. up to 95% of patients treated with panitumumab.

Patients present with an eruption of monomorphous follicular pustules and papules involving the face, scalp and upper trunk, usually 1–3 weeks after beginning treatment with an EGFR inhibitor.

No comedonal lesions are seen either microscopically or clinically,

Acneiform eruptions due to epidermal growth factor receptor inhibitors. A,B Numerous

monomorphous follicular pustules and crusted papules on the face of two patients treated with

erlotinib

2. Tropical Acne (Hydration Acne)

Follicular acneiform eruption that results from exposure to extreme heat.

Markedly inflamed nodular, cystic, and pustular lesions on back, buttocks, & thighs

Face is spared Young adult military

stationed in tropics, furnace workers.

Tx; returns to a more moderate climate.

3. Radiation acne

Characterized by comedo-like papules occurring at sites of previous exposure to therapeutic ionizing radiation.

The lesions begin to appear as the acute phase of radiation dermatitis starts to resolve.

The ionizing rays induce epithelial metaplasia within the follicle adherent hyperkeratotic plugs that are resistant to expression.

4. “Pseudoacne” of the transverse nasal crease

The transverse nasal crease is a horizontal anatomical demarcation line found in the lower third of the nosewhich corresponds to theseparation point betweenthe alar cartilage and thetriangular cartilage.

Milia, cysts & comedones can line up along this fold.

These acne-like lesions aren’t hormonally responsive& arise during early childhood prior to puberty.

Tx; consists of surgical expression as needed.

5. Idiopathic facial aseptic granuloma

chronic, painless, usually solitary nodule with an acneiform appearance can develop on the cheeks of young children.

Histopathologic evaluation reveals a granulomatous inflammatory response; dermal lymphohistiocytic infiltrate with foreign body-type giant cells.

They eventually resolve spontaneously after an average of 11 months without treatment

6. Childhood flexural comedones

Discrete, double-orifice comedones localized to the axillae & less commonly, the groin.

The majority of patients have a single lesion and the average age at Dx is 6 years.

A small subset of cases are familial. In most cases, the flexural comedones

are discovered incidentally in patients presenting with other dermatologic concerns.

Date of download: 9/2/2014Copyright © 2014 American Medical Association.

All rights reserved.

From: Childhood Flexural Comedones:  A New Entity

Arch Dermatol. 2007;143(7):909-911. doi:10.1001/archderm.143.7.909

The left axilla showing 3 double-orifice comedones in a 4-year-old boy.

Figure Legend:

Date of download: 9/2/2014Copyright © 2014 American Medical Association.

All rights reserved.

From: Childhood Flexural Comedones:  A New Entity

Arch Dermatol. 2007;143(7):909-911. doi:10.1001/archderm.143.7.909

Axillary double-orifice comedo with a visible content underlying the epidermal bridge in an 8-year-old boy.

Figure Legend:

7. Gram Negative Folliculitis

Occurs in prolonged treatment with antibiotics for acne vulgaris or rosacea.

E. coli, Enterobactor, Klebsiella, Proteus. Anterior nares colonized Persistent papulopustular eruption, These gram-negative organisms are

typically spread to the skin of the upper lip, chin, and jawline.

Tx; isotretinoin is considered standard of care.

8. Perioral Dermatitis Papulopustules with erythematous base Characteristically; Clear zone around vermillion

border. It may also include the perinasal and periorbital areas (periocular dermatitis).

Young ♀ (23-35yrs) Has a superficial resemblance to rosacea

8. Perioral Dermatitis Etiology;

1. Topical steroids 2. Demodex mites3. Contact irritants or allergens4. Moisturizers 5. Cleansers6. Fluorinated compounds e.g. fluorinated

toothpaste Tx; d/c topical steroids or other offending agent- oral tetracycline 1g/d or doxycycline - topical pimecrolimus cream, - azelaic acid

9. Drug-induced acne (Acne Medicamentosa)

An abrupt, monomorphous eruption of inflammatory papules and pustules

Steroid-induced acne High-dose IV or oral corticosteroids commonly

induce characteristic acneiform eruptions with a concentration of lesions on the chest and back

Steroid-induced acne (and rosacea) can also result from the inappropriate use of topical corticosteroids on the face. Inflamed papules and pustules develop on a background of erythema that favors the distribution of corticosteroid application.

Lesions eventually resolve following discontinuation of the steroid, although “steroid dependency” can lead to prolonged & severe flares post-withdrawal

Common causes of drug-induced acne

1. Anabolic steroids (danazol, testosterone)2. Bromides3. Corticosteroids4. Corticotropin5. EGFR inhibitors 6. Iodides7. Isoniazid8. Lithium9. Phenytoin10.Progestins

Uncommon Medications that can cause acne

1. Azathioprine2. Barbiturates3. Disulfiram4. Halogens, other5. Cyclosporine6. Vitamins B2,6,127. Psoralen + ultraviolet A (PUVA)

10. Malassezia folliculitis (previously called pityrosporum folliculitis)

Itchy, acne-like eruption and most often affects the trunk.

Tiny dome-shaped pink papules and small superficial pustules arise in crops on the upper back, shoulders & chest. It can occasionally affect other areas including neck, face & upper arms.

The spots may appear more prominent when scratched.

A KOH preparation of follicular contents reveals abundant yeast forms.

10. Malassezia folliculitis AGGRAVATING FACTORS;I. External factors 1. Hot, humid, sweaty environment yeast overgrowth2. Wearing occlusive clothing. 3. Sunscreens and greasy emollients.

II. Host factors 1. Oily skin.2. Obesity. 3. Pregnancy. 4. Stress or fatigue. 5. Diabetes mellitus.

Tx; 1. Correct as far as possible any of the predisposing factors

2. Treat yeast overgrowth (like PVC)3. Isotretinoin

6. Immune deficiency. 7. Medications, such as: Broad

spectrum oral antibiotics, which suppress skin bacteria allowing yeasts to proliferate. Oral steroids (steroid acne) OCP.

11. Senile (solar) comedones Arise on the face of the middle-

aged and elderly. They affect areas that have been exposed to sunlight over a long period of time, particularly the cheeks, which may become yellow and leathery (solar elastosis).

Occur in 6% of adults older than 50 years especially males.

The comedones may be open or closed may also be larger cysts.

Solar comedones are not related to acne vulgaris and do not usually become inflamed. They are however very persistent.

11. Senile (solar) comedones Favre-Racouchot syndrome; usually bilaterally

symmetrical, Solar comedones in association with elastosis (yellowish thickening and furrows) atrophy, wrinkles. It may affect the skin around the eyes, the temples and rarely the neck. It is thought to be due to a combination of sun exposure and heavy smoking.

Management of Senile comedones

Medical: 1. Use sun protection and

apply oil-free sunscreen to exposed skin

2. Stop smoking 3. Wash affected areas

twice daily with mild soap or cleanser and water

4. Apply retinoid cream to affected areas at night

5. Apply light moisturisers if the skin is dry

Surgical: require further treatment from time to time.

1. Comedo extraction. If these measures are unhelpful, the comedones can often be removed by: 2. Cautery, diathermy,3. Chemical peels 4. Dermabrasion 5. Laser (CO2)

DDx of Acne

TREATMENT OF ACNE VULGARIS

Therapeutic Goals

1. To prevent the formation of new lesions. 2. To heal existing lesions.3. To prevent or minimize scarring.4. Decrease psychological stress.

General Principles of Acne Management

The clinical subtype, severity, prior treatment, psychological impact, and presence of scarring should be considered for all patients with acne.

The treatment of acne usually involves initial therapy followed by long-term maintenance therapy.

Treatment should target as many pathophysiological causes as possible.

Use of topical or systemic antibiotic monotherapy may give rise to antibiotic-resistance which may leads to acne treatment failure & colonizing bacteria on skin and at remote sites, including streptococcal colonization of the throat.

General Principles of Acne Management

Use of combination therapy is more effective for the treatment of acne.

Topical retinoids used alone or as part of a combination therapy is considered first-line in the initial treatment and maintenance of all types of acne except for severe nodular disease, which requires systemic retinoid therapy.

Severe disease–especially scarring or trunk involvement–requires systemic therapy.

Some female patients may benefit greatly from hormonally targeted treatment.

It is essential to align the treatment regimen with the patient’s goals � and preferences for treatment: systemic versus topical, complexity of regimen.

Medical Tx of Acne

Topical Treatments Systemic therapy

1. Benzoyl peroxide2. Retinoids3. Antibiotics– Clindamycin– Erythromycin– Sodium sulfacetamide/sulfur4. Azelaic acid5. Salicylic acid6. Topical Dapsone

1. Oral minocycline 2. Oral doxycycline 3. Oral tetracycline 4. Oral erythromycin5. Oral azithromycin6. Oral Clindamycin 7. Oral Sulfanomides8. Oral contraceptives 9. Oral spironolactone 10.Oral isotretinoin 

Topical Treatment of acne

Topical Treatment

1. Benzoyl peroxide2. Topical retinoids3. Topical antibacterials4. Azelaic acid5. Sodium sulfacetamide6. Salicyclic acid7. Topical dapsone

1. Benzoyl Peroxide Available as gels, creams, lotions,

foams, washes, pads and soaps alone as well as in combination.

2.5% to 10%. Potent antibacterial effect also has

mild comedolytic properties Is to introduce oxygen to the clogged parts of the

skin pores more oxygen is more fatal environment for the anaerobic bacteria.

Microbial resistance to benzoyl peroxide has not been reported.

It is on the World Health Organization's List of Essential Medicines, a list of the most important medication needed in a basic health system.

Contact dermatitis (irritant > allergic) frequency of application.

Whitening of clothing and bedding

1. Benzoyl Peroxide

2. Topical Retinoids Creams, gels, liquids 0.01%, 0.025%, 0.04%, 0.05%

and 0.1% Cream base may be less

irritaiting 1st-line therapy for mild to

moderate inflammatory acne , comedonal acne, maintenance therapy, enhance penetration of other drugs.

2. Topical Retinoids MOA;1. Normalize follicular keratinization2. Comedolytic the numbers of microcomedones,

comedones & inflammatory lesions.3. FFA in the microcomedons.4. Anti-inflammatory; downregulating of TLR, cytokines5. penetration of the other medications into the

sebaceous follicle.6. It reduces the signs of aging by stimulating collagen

production. 7. Tretinoin also may help prevent more serious effects

of ultraviolet radiation

2. Topical Retinoids Tretinoin is photolabile so night-time application

is recommended to prevent early degradation. Adapalene to have milder comedolytic

properties than tretinoin, it is also less irritating & unlike tretinoin, it is light-stable and resistant to oxidation by benzoyl peroxide.

Tazarotene synthetic retinoid, once applied, is converted into its active metabolite, tazarotenic acid. Both daily overnight application of tazarotene and short contact therapy regimens have been used and shown to be effective in the treatment of comedonal and inflammatory acne.

2. Topical Retinoids Side effects;

1. Local irritation 2. Erythema, 3. Dryness, 4. Peeling 5. Scaling. 6. Pustular flare of acne occasionally occurs

during the initial 3–4 weeks of Tx 7. pt.’s susceptibility to sunburn.

3. Topical Antibacterials

For their role against P. acnes. creams and gels to solutions and

pledgets Erythromycin 2-3% Clindamycin 1% effective

against pustules and small papulopustular lesions

Both equally effective, combined with bezoyl peroxide can decrease resistance

4. Azelaic Acid

Naturally occurring compound found in cereal grains.

Cream and gel-twice daily. Anti-inflammatory/ Inhibiting the

growth of P. acnes/comedolytic low adverse reactions than topical

retinoids. In addition, it may help to lighten

postinflammatory hyperpigmentation.

5. Sodium sulfacetamide

is a well-tolerated topical antibiotic that is thought to restrict the growth of P. acnes.

It is formulated in a 10% lotion, suspension, foam and cleanser, either alone or in combination with 5% sulfur.

Tinted formulations are also available.

6. Salicylic acid Comedolytic and mild anti-inflammatory

agent. It is also a mild chemical irritant that works

in part by drying up active lesions. Available over the counter in concentrations

of up to 2% in numerous delivery formulations, including gels, creams, lotions, foams, solutions and washes.

Side effects; include erythema and scaling.

7. Topical dapsone

Gel 5% is effective and safe as monotherapy and in combination with other topical agents in mild-to-moderate acne vulgaris, direct inhibition of leukocyte.

Of note, a temporary yellow–orange staining of the skin and hair occasionally occurs with concomitant use of topical dapsone and BPO.

Systemic Treatment of acne

Systemic Antibiotics

Use for 6m. or until lesions resolve. MOA;

1. Antimicrobial against P. acnes.2. chemotaxis of polymorphonuclear

leukocytes.3. lipase production in P. acnes.

1. Tetracycline

Tetracycline since 1951 Safest and cheapest choice & good first

choice 250 to 500mg QD to QID for 4 weeks or

until lesions respond. Gradual reduction in dose Take on empty stomach Calcium and iron decrease absorption Constant or intermittent tx months to years

1. Tetracycline

Tetracycline as sole treatment will give a positive response in 70%

May take 4-6 weeks for response Effects of tetracycline are obtained by the

reduction of FFA Vaginitis and perianal itching in 5% due to

Candida albicans Staining of growing teeth precludes use in

pregnancy and children < 9 or 10 y.

2. Doxycyline

100-200mg/d P. ances resistant to

erythromycin, photosensitivity can occur

Gastro-Intestinal adverse effects

Photosensitivity from doxycycline

3. Minocycline

More effective than tetracycline in AV.

Lipophilic derivative of tetracycline, greater penetration into the sebaceous follicle.

50 to 100mg QD or BID Absorption less affected by

milk and food SE; minocycline-induced hypersensitivity

syndrome and autoimmune reactions.

4. Macrolides

Erythromycin; 500mg t.i.d.

Azithromycin; 250-500mg/d for 3days

consider in young and pregnant who cannot use tetracycline.

5. Clindamycin

150-300mg t.i.d works well, but can

cause pseudomembranous colitis

6. Sulfonamides

Trimethoprim/Sulfamethoxazole SE; Phototoxicity, drug reactions, BM

suppression, Scalded skin

Bacterial Resistance

Worsening clinical condition correlates with a high minimum inhibitory concentration for erythromycin and tetracycline for P. acnes

Resistance lost after 2 months after withdrawal of antibiotic.

Avoid use of different oral and topical antibiotics at the same time

Hormonal therapy Hormonal therapy is an established second-line

treatment for female patients with acne. work best in adult women with premenstrual

acne. Block both ovarian and adrenal production of

androgens Hormonal therapy include;

1. Oral contraceptives2. Cyproterone acetate (CPA)3. Oral spironolactone

1. Oral Contraceptives Estradiol suppresses the uptake of testosterone by

the sebaceous glands Oral contraceptives containing androgenic

progesterones may exacerbate acne. Three oral contraceptives are currently FDA-

approved for the treatment of acne, (Ortho Tri-cyclen, Estrostep, Yaz, Loryna and Beyaz)

Clinical data to support use Yasmin & Diane-35. From 5th to 25th day of menstruation.

Yasmin (Ethinyl estradiol 30/drospirenone 3000)

Drospirenone is an analog of spironolactone (equivalent to 25 mg) and has antiandrogenic

and antimineralocorticoid properties.

Diane-35 (Ethinyl estradiol 35/cyproterone acetate 2000)

1. Oral Contraceptives Side effects;

1. Nausea, 2. Vomiting, 3. Abnormal menses, 4. Weight gain 5. Breast tenderness.6. Hypertension 7. Thromboembolism (e.g. deep venous

thrombosis, pulmonary embolism).8. Hepatotoxicity

2. Cyproterone acetate Progestational antiandrogen. Alone or in combination with EED. Anti-acne effects are mediated

primarily through androgen receptor blockade.

50–100 mg daily higher dosesmay be helpful in ♀ with severe hyperandrogenism.

SE; 1. inhibition of ovulation & spermatogenesis2. Wt. gain3. Congenital deformities in male fetus.

3. Oral spironolactone synthetic corticosteroid Initiated with a low dose

(25–50 mg/day)to Side effects. Effective maintenance doses range from 25 to 200 mg/day divided into 2 doses.

Antiandrogenic; androgen receptor blocker and an inhibitor of 5α-reductase.

for severe inflammatory acne

3. Oral spironolactone

Side effects; are dose-related and include;

1. Potential hyperkalemia rare in young healthy patients.

2. Irregular menstrual periods.3. Breast tenderness.4. Headache.5. Fatigue. 6. Risk of feminization of a male fetus.

Isotretinoin A systemic retinoid 0.5 to 1 mg/kg/day

qd or bid for 15 to 20 wks(taken with a fatty mealto gastrointestinal absorption)

Total cumulative dose is 120-150 mg/kg to reduce the risk of relapse.

Leads to a remission that may last months to years

Isotretinoin

Retinoids exert their physiologic effects through two distinct families of nuclear receptors; RARs and retinoid X receptors (RXRs).

Systemic retinoids act as:1. Comedolytic2. follicular keritization3. Anti-inflammatory4. Suppress sebum production5. Indirectly antimicrobial

Indications of Isotretinoin FOR PATIENTS WITH ACNE; 1. Nodular or nodulocystic acne 2. Acne conglobata 3. Acne fulminans 4. Severe disfiguring inflammatory acne vulgaris 5. Acne which is resulting in scarring 6. Moderate acne which has failed to respond to topical

agents with oral Abc, or in ♀, hormonal Tx.7. Acne which relapses rapidly on discontinuing Tx.8. Acne which has persisted for several years, or arises

in an individual over 25 years old 9. When the acne has a significant adverse

occupational, social or psychological effect.

Indications of Isotretinoin FOR PATIENTS SEVERELY AFFECTED BY OTHER

FOLLICULAR CONDITIONS. THESE INCLUDE:1. Acne keloidalis nuchae 2. Occupational acne/Chloracne 3. Gram negative folliculitis 4. Hidradenitis suppurativa 5. Pityrosporum folliculitis 6. Pseudofolliculitis barbae 7. Pyoderma faciale 8. Solid facial edema 9. Rosacea and rhinophyma 10. Scalp folliculitis 11. Sebaceous hyperplasia 12. Seborrhoea 13. Steatocystoma multiplex

Indications of Isotretinoin TREATMENT FOR SCALY AND OTHER

INFLAMMATORY SKIN CONDITIONS:1. Darier disease 2. Discoid lupus erythematosus (DLE) 3. Epidermal naevi 4. Folliculitis decalvans 5. Granuloma annulare 6. Grover disease 7. Ichthyosis 8. Sarcoidosis 9. Skin cancers especially when they arise in

those with organ transplants or xeroderma pigmentosa

Isotretinoin

Nasal colonization with S.aureus in 90% Paradoxical worsening of acne commonly

occur, an acne fulminans-like flare occasionally develops during the first few weeks of isotretinoin therapy for acne.

Monitoring isotretinoin Most patients are advised to have blood tests before

and four weeks after treatment begins or more occasions during isotretinoin treatment.

1.Pregnancy test (beta-HCG) for women and girls of child-bearing potential.

2.Lipid profile (cholesterol & triglyceride levels). 3.Liver function tests. Occasionally, isotretinoin

may disturb liver function; this requires monitoring but if the reaction is mild the drug can usually be continued. Rarely, it causes a symptomatic hepatitis: the drug must then be discontinued.

4. Blood count: this is to check for anaemia and to monitor white cell count and platelets.

1-Dryness of skin, conjunctiva and mucosa of the genitals, chapped lips (cheilitis), dry Eyes, Epistaxis 2- Arthralgias, myalgias3- Mood changes, Depression & suicidal behavior4- Elevated lipids (serum triglyceride)5- Hepatotoxicity6- Abortion or Teratogenicity 7- Nails dystrophy, paronychia, palmoplantar desquamation,8- Pseudotumor cerebri (benign intracranial HTN)9- Fulminans-like flare, 10- Pyogenic granuloma 11- Premature epiphyseal closure in children < 13 y.

Adverse effects of Isotretinoin

Isotretinoin

Women of childbearing age are urged to use 2 methods of contraception for 1 month before treatment, during treatment and at least 1 month after stopping treatment.

Pregnancy test should be done before beginning therapy and monthly until therapy stops.

Drug interaction with isotretinoin

Tetracyclines

Vitamin-A & its

derivatives

Surgical Treatments for Acne LESIONS SCARS

1. Extraction of comedones

2. Drainage of pustules and cysts

3. Intralesional injection of corticosteroids in nodules & cysts

4. Excision and unroofing of sinus tracts and cysts

1. Dermabrasion

2. Laser abrasion

3. Chemical peels

4. Injection of filling materials

5. Excision

6. Punch autografts

1. Comedo extraction Comedone extractor brings about

quick resolution of comedones improve cosmetic appearance Especially beneficial for deep, inspissated and persistent comedon

In Isotretinoin pts macrocomedones present at week 10 to 15 of therapy

Nicking the surface of a closed comedo with an 18-gauge needle or a #11 blade allows easier expression.

2. Intralesional Corticosteroids

Effective in reducing inflammatory papules, pustules, & smaller cysts & nodule

Acne conglobata & acne fulminans Kenalog-10 (triamcinolone 10mg/ml) Diluted with NS to 5 or 2.5mg/ml The maximal amount used per lesion

should not exceed 0.1 ml. The risks of corticosteroid injections;

1. Hypopigmentation 2. Atrophy, 3. Telangiectasias, 4. Needle tract scarring.

3. Chemical peels Low-concentration are beneficial

for the reduction of comedones. The α-hydroxy acids (including

glycolic acid), salicylic acid and trichloroacetic acid are the most common peeling agents.

These lipid-soluble comedolytic agents act by corneocyte cohesion at the follicular opening and assist in plug extrusion.

Risks of chemical peels include; 1. irritation, 2. pigmentary alteration3. scarring.

New treatments for Acne:

Red, Green, or Blue light: inflammatory acne ,absorbed by P. acnes porphyrins.

IPL: trigger the destruction of the P. acnes. PDT (photodynamic therapy) using ALA : induces

partial destruction of the sebaceous glands along with the destruction of P. acnes.

Lasers: pulsed dye, the 1320 nm neodymium:YAG and especially the 1450 nm diode may be of therapeutic benefit for inflammatory acne

Acne vaccine Metformin

Treatment of acne scar

Surgical Treatments of acne scar

1. Microdermabrasion/Dermabrasion2. Laser abrasion3. Subcision 4. Punch autografts5. Injection of filling materials6. Chemical peels7. Dermaroller 8. Full thickness surgical excision

1. Microdermabrasion & Dermabarsion (sanding of skin).

2. Fractional Laser resurfacing

a) CO2 laser b) Erbium-Yag laser.

3. Subcision of acne scars.

commonly used technique in the management of acne scars.

4. Punch excision of acne scars

Is an option for patients with “ice-pick” scarring.

5. Filler injection under acne scars

For discrete depressed scarscan be temporarily beneficial. Filler substances used include;1. Hyaluronic acid,2. Poly-l-lactic acid, 3. Calcium hydroxylapatite 4. Autologous fat.

6. Chemical peels/CROSS technique by 65%-100% TCA

7. Dermaroller technique

Dermaroller is a cylindrical shaped drum with very fine needles.

It is a medical device used to stimulate skin cells to proliferate.

NEEDLE LENGTH: 1-2mm

8. Full thickness surgical excision

For;1. Larger hypertrophic scars, 2. Aggregated pitted scars 3. Sinus tracts.

References

Jessica San Juan Microbiology Prof. Dr. Wafaa Afify Bolognia 3rd ed.