acne dr. jerald e. hurdle kennebec medical consultants

Acne

Dr. Jerald E. Hurdle

Kennebec Medical Consultants

Learning Objectives

To manage the patient with acne vulgaris,

To review the clinical presentation and management of Acne Rosacea, and

To recognize acneiform rashes & folliculitis.

Case Study 1

• 28 yr old ♀

• Always had dandruff

• Using over the counter cream for facial rash

Attends Primary Care

• PCP prescribes 2.5% HC Cream

• Initially improves then returns

• PCP stops HC and rash gets much worse

• Pt demands referral to dermatology

Diagnosis: peri-oral dermatitis

Acne Vulgaris

• Common

• Puberty onwards

• Disease of pilosebaceous unit

• Gets better with time

Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo

(whitehead); (D) papule; (E) pustule.

Acne Vulgaris: pathogenesis

4 factors• Presence of hormones (androgens)

• Sebaceous gland activity (due to #1)

• P. acnes (bacteria) in the hair follicle (it lives on the oil and breaks it down to free fatty acids which cause inflammation)

• Plugging of the hair follicle (abnormal keratinization of the upper portion)

Acne Vulgaris: classification

• By severity

• By type of lesions

• By distribution

Mild Moderate Severe

Acne Vulgaris: classification

• By severity

• By type of lesions

• By distribution

Papules & Pustules

Nodules & Cysts

OpenComedones

ClosedComedones

Acne Vulgaris: classification

• By severity

• By type of lesions

• By distribution

Acne Vulgaris: Rx

Patient Education • Diet

• Cleanliness

• Cosmetics

• Picking

• UV light

Acne Vulgaris: Rx

Patient EducationTreatment Response & Time

Course

• Prognosis excellent

• All treatments take up to 3 months to see improvement

• No one ever becomes zit free for the rest of their life

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Gel, wash or cream• 5-10%• 1-2 x daily

Side effects: redness, dryness & bleaching

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Tretinoin (Retin-A)

0.025- 0.1% • 1 x Daily @ night

Adapalene (Differin)

0.1% gel or cream

1-2 x daily

SEs: dryness, redness & sun sensitivity

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Tretinoin (Retin-A)

0.025- 0.1% • 1 x Daily @ night

Adapalene (Differin)

0.1% gel or cream

1-2 x daily

SEs: dryness, redness & sun sensitivity

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Acne Vulgaris: Rx Mild Disease

Topicals• Benzoyl Peroxide

• Tretinoin & adapalene

• Topical Antibiotics

Clindamycin

1% Gel, lotion & solution

2x Daily

Erythromycin

2% gel or sol, 2x daily

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Tetracycline• 250mg 2x daily• Empty stomach

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Tetracycline• 250mg 2x daily• Empty stomach

Erythromycin• 250mg 2x daily• GI upset

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Tetracycline• 250mg 2x daily• Empty stomach

Erythromycin• 250mg 2x daily• GI upset

Minocycline• 50-100mg 1-2x daily• Hyperpigmentation

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Tetracycline• 250mg 2x daily• Empty stomach

Erythromycin• 250mg 2x daily• GI upset

Minocycline• 50-100mg 1-2x daily• Hyperpigmentation

Doxycycline• 50-100mg 1-2x daily• Photosensitivity

Acne Vulgaris: Rx Moderate Disease

Systemics• Oral Antibiotics

• Oral Contraceptive Pills

• Spironolactone

Acne Vulgaris: Rx Severe Disease

Acne Vulgaris: Rx Severe Disease

Isotretinoin• Refer to Dermatology• Women of childbearing potential need

adequate contraception• Check LFTS & fasting lipids• I-Pledge process bureaucratic: warn patient• Likely to require 6 months of Rx• Dry skin, cracked lips : inevitable side effects

Acne Vulgaris: Rx Severe Disease

Photography

Useful for treatment monitoring

Acne Variants: acne excoriee

• Predominantly in young women

• Comedones & papules excoriated +++

• Often underlying psych component (anxiety, OCD or personality disorder)

Acne Variants: peri-oral dermatitis

• Commoner in women• Eczematous patches

and papules around mouth

• Occasionally around eyes

• Exacerbated by topical steroids

• Treat as acne vulgaris & stop steroids

Case 2

• 33-year-old female complains of red cheeks

• Homeless, chronic alcoholic

Case 2: Physical Exam

• Red Cheeks

• Papules and pustules on the central face and nose

• NO Comedones

Case 2: Diagnosis?

• A. Systemic Lupus Erythematosus

• B. Bacterial Folliculitis with cellulitis

• C. Acne Rosacea

• D. Pellagra from nutritional deficiency

Case 2: Diagnosis?

• A. Systemic Lupus Erythematosus (no pustules)

• B. Bacterial Folliculitis with cellulitis(acute and systemic symptoms)

• C. Acne Rosacea

• D. Pellagra from nutritional deficiency (scale, diarrhea, but no pustules)

Case 2: Acne Rosacea

• Chronic inflammatory condition of the “flush” areas of the face (nose, cheeks > brow, chin)

• F > M

• Middle age (30-50)

• Affected persons blush easily

Case 2: Question 2

• Which of the following might trigger this patient’s rosacea? A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above

Case 2: Question 2

• Which of the following might trigger this patient’s rosacea?

A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above

Acne Rosacea: triggers

• Alcohol

• Sunlight

• Hot Beverages (heat)

• Hot, Spicy food

• If it makes you flush it can flare rosacea

• Rosacea is NOT related to androgens!!

Acne Rosacea: clinical features

• Erythema and Telangiectasias

• Papules and Pustules (NO COMEDONES!)

• Rhinophyma (W.C. Fields nose)

• Ocular Rosacea (keratitis, blepharitis, conjunctivitis)

Acne Rosacea

Acne Rosacea

Acne Rosacea

Acne Rosacea

Acne Rosacea

Acne Rosacea Treatment

• Medical treatment only effective for the papular and pustular component

• Topical Antibiotics (metronidazole)

• Topical Sulfur

• Oral Antibiotics (tetracyclines)

• Therapy is suppressive and may be required lifelong

Acne Rosacea: Surgical Treatment

• Laser therapy can help the telangiectasias and the rhinophyma, once the papulopustular component is controlled.

Steroid Rosacea

• Topical Steroids may exacerbate or induce an acneiform eruption resembling rosacea

• Treatment: Stop the topical steroids; give oral tetracyclines.

• Never treat central facial papular eruptions with topical steroids. It may be rosacea which will flare severely when the topical steroids are stopped

Case 3

Acneiform Eruptions: Drugs

• Systemic/topical steroids

• Anabolic steroids

• Lithium

• Phenytoin (Dilantin®)

• Epidermal growth factor receptor inhibitors

Acneiform Eruptions: Acne Keloidalis Nuchae & Pseudofolliculitis Barbae

• Predominantly affects men of African descent

• Due to ingrowing hairs

• Avoid shaving

• Treat as acne

Folliculitis

• Confined to hair follicles• No comedones• Lesions tend to

monomorphic• Often itchy• Common causes Staph,

Pityriasporum

• If HIV positive, consider eosinophilic folliculitis

Learning Objectives

To manage the patient with acne vulgaris,

To review the clinical presentation and management of Acne Rosacea, and

To recognize acneiform rashes & folliculitis.