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What’s New (and What’s Not) in Acne and Rosacea

What’s New (and What’s 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. Objectives. 1. Know differential diagnosis acne/rosacea 2. Increased knowledge treatment strategies

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What’s New (and What’s Not) in Acne and Rosacea

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  1. What’s New (and What’s 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

  2. 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

  3. Acne • Most common dermatologic disease • Onset usually adolescence but anytime • More frequent and severe in males • 70% women premenstrual flares

  4. 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...

  5. 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 acne’s emotional toil • Combining drugs @ different mechanisms

  6. 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)

  7. Common pitfalls in acne treatment • Using more than two medications • Insufficient patient education or unrealistic expectations • Frustration all around

  8. 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

  9. Comedones Papules Pustules Nodules Cysts Acne: Morphology

  10. 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

  11. Rosacea

  12. Hidradenitis

  13. Keratosis Pilaris

  14. Keratosis Pilaris

  15. Perioral Dermatitis

  16. Perioral Dermatitis

  17. Senile Comedones

  18. Topical Steroids

  19. Acne Keloidalis

  20. Acne Keloidalis

  21. 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)

  22. Acne and Iodides

  23. Acne and Dilantin

  24. Acne and Topical Steroids

  25. Acne and Topical Steroids

  26. Mechanical occlusion

  27. 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

  28. 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

  29. 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

  30. Mild acne: Benzoyl peroxide • Side Effects • Occasional hypersensitivity reactions (1-5%) • Oxidating agent: will bleach clothes and hair

  31. 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)

  32. 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

  33. 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

  34. 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

  35. 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

  36. Retinoids-Comparisons • Adapalene 0.1% gel vs. Tretinoin 0.025% gel, meta-analysis of 5 RCT’s (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

  37. Salicylic acid: 2% • OTC ($) • Keratolytic • Many preparations • Useful in combo with tretinoin or topical antibiotics

  38. 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

  39. 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

  40. Moderate acne

  41. 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

  42. Minocycline has fewer GI side effects, but it is more expensive

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