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1. Whats New (and Whats Not) in Acne and Rosacea Adam O. Goldstein, MD
Assistant Professor
Department of Family Medicine
University of North Carolina at Chapel Hill
Email: aog@med.unc.edu
3. Objectives 1. Know differential diagnosis acne/rosacea
2. Increased knowledge treatment strategies
3. Increased familiarity new products
4. Learn 2 new patient education tips
GOAL: Improved therapeutic outcomes
5. Acne Most common dermatologic disease
Onset usually adolescence but anytime
More frequent and severe in males
70% women premenstrual flares
6. Acne Quiz (T/F) 1. Certain foods make acne worse...
2. Dirty skin makes acne worse...
3. Acne worsens with sexual activity...
4. Acne improves within 24 hours of tx...
5. Sweating may make acne worse...
6. Humidity may exacerbate acne...
7. Acne may worsen during menstruation...
8. Stress may make acne worse...
7. Art of acne treatment: Negotiating long-term treatment
Increasing compliance by using fewer medications
Contracting with adolescents
Thorough explanation of natural history of disease
Patience with acnes emotional toil
Combining drugs @ different mechanisms
8. Art of acne treatment: Quality of Life scale
0 1 2 3
1. Feeling self-conscious
2. Decrease in socialization
3. Difficulties in relationships
(partner, friends, family)
4. Feeling like an outcast
5. People making fun of you
6. Feeling rejected (romance, friends)
9. Common pitfalls in acne treatment Using more than two medications
Insufficient patient education or unrealistic expectations
Frustration all around
10. Acne: Etiology Combination hormonal (androgen), bacterial (Proprionibacterium acnes) and follicular (hyperkeratosis)causing debris and occlusion
Bacteria multiply and inflammatory response
Comedones: Blackheads and Whiteheads
Blackheads = open comedones
Whiteheads = closed comedones
12. Acne: Morphology Comedones
Papules
Pustules Nodules
Cysts
17. Acne: Differential Diagnosis Rosacea: No comedones, erythema striking, central face
Hidradenitis: Axilla & inguinal, nodules & cysts, scarring
Keratosis Pilaris: Upper arms & trunks, follicular- based papules
Perioral Derm.: Papulovesicles & erythema, perioral, topical steroid use
Senile Comed.: Face & neck, comedones and cysts in damaged skin
Topical steroids: Lesions same stage, no comedones
28. Acne: Treatment Treatment goal is to prevent new lesions/scarring
Treatment will not improve outcomes for 4-6 weeks
(Acne exacerbated by iodides, bromides, hydantoin, chlorinated hydrocarbons, occluding topical preparations, vigorous washing, and mechanical occlusion)
35. Mild acne: Apply one agent thinly to entire face
If two agents selected, use at separate times
Apply after washing with water or mild soap
Choices:
Benzoyl peroxide Topical antibiotics
Tretinoin Birth Control Pills
Azelaic acid Salicylic acid
Use for 6-8 weeks before judging if effective
36. Mild acne Benzoyl peroxide ($)
Antibacterial, drying and peeling actions
Rx: 2.5-10% gel/cream/wash
OTC: 2.5-10% gel/lotion/cream
Usually start with 2.5-5%, thin layer QD-BID
37. Mild acne Benzoyl peroxide
Water based preps are milder and less drying
Alcohol/acetone preps useful in oily skin
Washes and soaps are good for acne on the chest, back and shoulders (5-10%)
Benzamycin gel- 23.3 grm- benzoyl peroxide and erythromycin- must be kept refrigerated
38. Mild acne: Benzoyl peroxide Side Effects
Occasional hypersensitivity reactions (1-5%)
Oxidating agent: will bleach clothes and hair
39. Mild acne Topical antibiotics (all Px) ($$)
Erythromycin 2%- pledgettes, pads, gel (oily skin), solution, ointment (dry skin)
Clindamycin 1%- solution, gel, lotion
(e.g. Cleocin T)
Meclocycline- cream; useful in patient with very dry skin
(e.g. Meclan)
40. Mild acne: Topical antibiotics Sodium sulfacetamide 10%, Sulfur 5%, Sodium thiosulfate 10%
Numerous keratolytic/astringent agents
Useful if lotion preparation preferred and other topical antibiotics not working or tolerated
Sulfacet R- tinted (can cover redness)
Novacet- untinted
Bacterial resistance may develop after 6-12 months of use
41. Mild acne: Topical Retinoids Especially good for comedonal or papular acne
Modulates keratinization
Use pea size amount to entire face
Apply 3x week for 2 weeks, then nightly
Increases photosensitivity
Flare reaction frequent
Web Sites: http://www.healthsquare.com/pdrfg/pd/ monos/retin-a.htm
42. Topical Retinoids Retin A (Renova) ($$$)
Vehicles:0.025%, 0.05%, 0.1% cream; 0.01%, 0.025% gel
Start with 0.025% strength
Apply at bedtime 30 minutes after washing
Avita
Vehicles: 0.025% cream/gel
Slow release polymer may be less irritating
Retin A Micro
Vehicle: 0.1% gel; Thick and yellow
Slow release may be less irritating
43. Retinoid-Like Adapalene (Differin) ($$$)
Vehicles: 0.1% gel, solution
May apply right after washing at bedtime
Tazarotene (Tazorac)
Vehicles: 0.05, 0.1% gel
Irritating initially
May be useful with oily skin
Short contact therapy
44. Retinoids-Comparisons Adapalene 0.1% gel vs. Tretinoin 0.025% gel, meta-analysis of 5 RCTs (BMJ, 139S 1998)
equivalent efficacy reducing total lesions
Adapalene with significant difference in reduction of inflammatory and total lesions at week 1
Adapalene with greater local tolerability
Adapalene 0.1% gel vs. Tretinoin 0.05% gel, Split-face clinical and bio-instrumental comparison (Dermatology. 198(2):218-22, 1999)
Tretinoin with better comedolysis and clinical improvement than adapalene
Erythema transiently more pronounced with tretinoin
45. Salicylic acid: 2% OTC ($)
Keratolytic
Many preparations
Useful in combo with tretinoin or topical antibiotics
46. 20% Azelaic acid (Px) Mechanism unknown ($$)
Useful for patients intolerant to tretinoin or benzoyl peroxide
Avoid on broken skin
Use qd-bid, usually in combination with other topicals
47. Acne and Birth Control Pills Lowers hormonal factors exacerbating acne
Use pill with low androgenic potential
Know side effects and contraindications
Acne often improves during pregnancy
48. Moderate acne
49. Moderate acne Mild treatment +
Add oral antibiotics
Tetracycline- 500 mg bid or doxycycline 50-100 mg/day
Erythromycin- 500 mg bid
Minocycline- 50-100 mg/day
Trimethoprim/Sulfamethoxazole 1 DS qd-bid
Comedo removal
52. Severe acne Moderate regimen X 3 months
Isotretinoin for severe nodulocystic acne
Steroid injections
TAC acetonide 10 mg/ml diluted to 3 mg/ml
Inject 0.1 ml into fresh cyst
Prednisone rarely
Consultation
57. Isotretinoin (Accutane) 0.5-1 mg/kg/day 16-20 weeks
80% success rate
Indications wider than previous thought
Improvement continues after treatment stops
Very teratogenic: (2 forms birth control for one month beforehand)
Laboratory monitoring: (HCG before & monthly, CBC, LFT, TG, LDH, TGs, Cholesterol, Q 2 weeks, then monthly)
Use moisturizers, lip balms and artificial tears
Monthly costs $200-400
58. Acne: Myths NO relation to junk foods
NO relation to hygiene
NO relation to masturbation or other sexual activity
NO way to make acne go away overnight
59. Acne: Truths YES acne may worsen premenstrual
YES sweating may worsen acne
YES humid environments may worsen acne
YES stress can exacerbate acne
60. Acne: Patient Education 6-8 week response
Avoid scrubbing
Keep regimen simple
Compliance is key to FTIP; Have patient bring medications to office
61. Acne: Patient Education Use water-based makeup
Oil-free moisturizers
Web Sites:
http://www.pslgroup.com/ACNE.htm Useful general information for clinicians
http://www.derm-infonet.com/acnenet/toc.html Comprehensive site
http://www.m2w3.com/acne/ Patient support group
62. Acne Rosacea Rosy dilatation of the central face:
eyes, nose, chin, cheek, forehead
Diverse spectrum of disease- (papules, pustules, nodules, cysts)
Rhinophyma -hyperplasia of the nose in middle aged men
75. Acne Rosacea Look for periodic facial flushing after temperature increase, spicy food ingestion or alcohol
Absence of comedones
Disease is chronic: Treatment goal is control
76. Acne Rosacea: Differential Diagnosis Acne Vulgaris: comedones, younger patient, lack of flushing, less erythema
Seb. dermatitis: no acneiform lesions
Lupus: no papules and pustules
Carcinoid: flushing is transient
77. Acne Rosacea: Treatment Topical
Antibiotics, Benzoyl peroxide, Tretinoin
Oral antibiotics
Isotretinoin for severe, recalcitrant cases
Referral for surgery, dermabrasion, laser
Potent topical steroids often worsen disease
78. Acne Rosacea: Topical Therapy Preferred topical antibiotic:
Metronidazole
0.1% cream (Noritate): qday
0.75% cream or gel: bid
Alternatives:
Sodium sulfacetamide 10%/sulfur 5% lotion
Clindamycin 1% lotion, gel or solution
Erythromycin 2% solution
79. Acne Rosacea: Topical Therapy Benzoyl peroxide at 2.5% & up to 10% if tolerated
Tretinoin 0.025%, 0.05% 0.1% cream
Start with lowest dose
May be used in combination with other products
80. Acne Rosacea: Oral antibiotics Useful for nodular lesions
Doxycycline 50-100 mg/day or tetracycline 500-1000 mg/day
Minocycline 50-100 mg at bedtime
Treat until improvement occurs, then taper for control
81. Acne Rosacea: Patient Education Control vs cure
Avoid excessive sunlight, alcohol, temperature extremes and precipitating foods
Flares may require higher pulse treatment
Good web sites:
National Rosacea Society
http://www.rosacea.org/home.html
Patient education brochure
http://www.aad.org/pamphlets/rosacea.html
82. On the Horizon
. New retinoids
Combination products: retinoids and topical antibiotics
Glycolic acid, salicylic acid peels
Hormonal treatments
Antibiotic alternatives
83. Cases 14, Sports PE & whiteheads- incidental
16, with comedones and mild inflammation
16, before the prom
20, with sensitive skin, papular lesions and skin irritation
21, moderate acne on 0.1% Retina cream and 5% Benz. Peroxide, wanting referral to dermatologist
22, with extensive cystic acne for 5 years
84. Conclusion Be confident
Use 1-2 agents if at all possible
Define expectations
Think about acne rosacea in adults