ACNE Overview

Dr Paul Spano

Cosmetic Physician

ACNE Pathology

• Chronic Inflammation - Pilosebaceous Unit

• Abnormal Keratinizaton in Hair Follicle

• Increased Follicular Epithelial Turnover

• High Sebum Production

• Follicle Blockage = Comedone– Non-Inflammatory

• Propionibacterium acnes – Chemical Inflammation

General Factors

• Diet - Unconfirmed • Cosmetics

• Oil

• Irritation

• Summer• UV light

• Salt water

• Stress• Common Association

• Picking

• Endocrine• Androgens

• PCOS

• Pre-menstrual Flare

• Drugs• Steroids

• OCP

• Occupation• Sweating

• Oils

Aims of Treatment

• Unblocking the Comedones

• Reducing Sebaceous Gland activity

• Reducing Bacterial Count

• Reducing Inflammation

• Cosmesis Short Term - Pimples

• Cosmesis Long Term - Scarring

Treatment

• TOPICAL– Keratolytics

• Salicylic Acid

• Azealic Acid

– Retinoids• Tretinoin

• Adapalene

– Anti-Bacterial• Benzoyl peroxide

• Topical Antibiotics

• SYSTEMIC– Antibiotics

• Antibacterial

• Antiinflammatory

• Resistance

• Side Effects

• eg Minocycline (Dizziness, Ataxia, Pigmentation, Headache)

– Hormones• Cyproterone

– Spironolactone• Antiandrogen

Roaccutane

• 4-6 months oral therapy

• 20% need second course

• Teratogenic

• Side Effects ++++++++

• Linked to Teenage Suicide via Depression and Psychoses

Vitamin A

• Group of compounds

• Cellular differentiaion, organ development and pigment production (retina)

• Immune function, Antiinflammatory

• all Trans Retinoic acid (Tretinoin)

Roaccutane - M.O.A.

• Inhibits Vit. A metabolism in skin • Vit A levels increase by 50% in Epidermis

• Sebosuppressive• 90% red. In gland size, proliferation

• Inhibits Keratinocyte numbers• Less follicle blockage• increased water loss - barrier loss

• Inhibits Bacterial Growth• Antiinflammatory

Roaccutane - Precautions

• Contraindicated• Pregnancy and Lactation• Severe Hepatic or Renal Failure

• Relative Contraindications• Hyperlipideamia• Diabetes• Severe Osteoporosis

• Co-medication• Vit A - Incresed Toxicity• Tetracyclines - Cranial Hypertension• Regular Aspirin/NSAIDS - Mucosal damage

Roaccutane - Adverse EffectsDose Dependent, Reversible

• Cheilitis 80%• Facial Dermatitis 40%• Xerosis (Dry Skin) 40%• Photosensitivity 100%• Dry Mucosa 40%• Conjunctivitis 30%• Epistaxis 25%• I.B.D. • Flare / Scarring ++

• Itching 25%• Skin Fragility 20%

• Waxing, Shaving

• Abrasive therapy

• Desquamation 15%• Hair Loss 15%• Retinoid Dermatitis• Depression / Psychosis

Roaccutane - Adverse Effects 2

• Eyes and Pseudotumour cerebri• Dryness / Contact Lenses

• Corneal opacities, Cataract

• Pseud. C. with Tetracycline

• Lipids and Liver• Hypertriglyceridaemia, Hypercholesterolaemia

• Reduced HDL, Hepatic enzyme disruption

• Arthralgia / Myalgia 5%• Young Adults, can be severe

• +/- Ligament calcification

Roaccutane Adverse Effects 3

• Long Term Toxicity - Bone• Vitamin A intoxication

• > 2 yrs treatment

• hyperostosis, periostosis, demineralization

• premature epiphyseal closure

• Irreversible

• Teratogenicity• OPC 1 month before and 3 months after

• Pregnancy Testing

• Monitoring• LFT , ESR, Glucose, Lipids

Roaccutane cont.

• Links to Teenage Suicide

• Jick Study by Roche to dispel concerns• Poorly designed

• Raised more concerns

• Depression 20% incidence • ? Roaccutaanes role

Modern Treatments

• Microdermabrasion• Crystal Abrasion

• Suction / Oxygenation

• Home exfoliation / AHA / BHA

• Chemical Peels• Keratolytic

• Exfoliants

Remember…….

• Emotional Support

• Complex Disease

• Concurrent Multiple Treatments

• Antibiotic Resistance

• Roaccutane not a Panacea