Acne and its Treatment

1. Mark Goodfield Acne and its Treatment

3. Basic epidemiology • 80 -100% of teenagers (physiological acne) • 1% of 25 year old men • 15% of 25 year old women (10% at 35, 5% at 45) • All races (Chinese)

4. Acne Vulgaris • Inflammatory condition of the pilo-sebaceous unit • Blockage • Leakage • Bacterial overgrowth

6. Acne Vulgaris • Over-sensitivity of glandular elements to normal androgen levels • High sebum production • Epithelial proliferation in duct

7. Endocrine problems • Acromegaly • Cushings • Androgenisation • Late onset congenital adrenal hyperplasia • PCOS • All rare

8. Acne Vulgaris • Enlarged blocked sebaceous glands which leak • Bacterial overgrowth • Lead to inflammatory lesions • Rupture leads to cystic lesions

9. Bacteriology • Propionobacteria Acnes • P.granulosum • Staph epidermidis • Malassezial yeasts

10. Bacteriology • Bacterial products • Lipases • Proteases • Phosphatase Relevant to alterations in sebum that allow leakage and breakdown of glandular membrane

12. Acne Vulgaris: Morphology • Blackheads – open comedones • Whiteheads – closed comedones • Papules • Pustules • Cysts

13. Pomade acne

14. SI +++

16. Differential diagnosis • Rosacea • Folliculitis • Bacterial • Pityrosporal • Occlusive • Pili incarniti • Keratosis pilaris • Oddities • Angio-fibromata

17. Rosacea

18. Prominent pores

19. Trichostasis spinulosa

20. Factors Modifying Acne • Menstrual cycle • UV light • Diet • Stress • Drugs • Cosmetics; this is discussed under the heading of patient examination

21. PCOS • Consider this possibility, especially if the acne patient has : - irregular periods (> 3 months)‏ - hirsuties - obesity - infertility Ifappropriate consider relevant investigations but they are relatively expensive

22. Oral corticosteroids anabolic steroids Lithium cyclosporin Iodides taken orally, which may be part of some homoeopathic therapies Some oral and topical drugs/preparations can induce acne • Topical corticosteroids • Some hair preparations can produce pomade acne, especially in Afro - Caribbeans

24. Patterns of Acne • Sandpaper acne • Submarine comedones • Macrocomedones • Localised acne • Acne excoriee • Sinus tract • Acne conglobata • Gram negative folliculitis

25. Sandpaper acne

26. Submarine comedones

27. Localised muzzle acne

28. Sinus tract acne

30. Acne Treatment • Keep it simple and topical if possible • Retinoids: modify sebaceous duct activity, mildly anti-inflammatory • Benzoyl peroxide: anti-bacterial, modify duct activity • Azelaic acid: antibacterial, anti-inflammatory • Nicotinic acid: anti-inflammatory • Antibiotics: antibacterial and anti-inflammatory

31. 1.Actions of Anti-Acne Therapies • Topical retinoids: • Normalizes ductal desquamation • Reduces inflammatory response • Oral Isotretinoin: • Reduces sebum • Normalizes ductal desquamation • Inhibit P acnes growth • Reduces inflammatory response • Antibiotics:* • Inhibit P Acnes • Reduce inflammation • Hormones: • Reduce sebum production • Reduce comedones • Benzoyl peroxide:* • Inhibits P Acnes • Reduces • inflammation *also reduce comedones

32. Acne Vulgaris: Oral Treatment Options • Antibiotic for inflamed lesions • Hormonal treatment in women • Isotretinoin if severe

35. Aim Treatment at Morphology • Blackheads and closed comedones • Topical retinoid • Benzoyl peroxide • Consider cautery

36. This demonstrates, to the right, an untreated area of macrocomedones and to the left an area treated 3 weeks previously

37. Aim Treatment at Morphology • Inflamed lesions • Topical antibiotic • Azelaic acid • Nicotinamide

38. Aim Treatment at Morphology • Both occlusion and inflammation • Combinations eg isotrexin, DUAC etc

39. Oral Antibiotics? • Cochrane Review • Oral no better than topical • Oral no better than BPO • Only indicated for: • Extensive disease • Intolerance of topicals

40. Oral Antibiotic: Tetracyclines • Oxytetracycline 1gram daily (absorption)‏ • Lymecycline: 1(2) tablet daily • Doxycycline 50-100mg daily • Minocycline MR 100mg daily • ANA, LFT pre-treatment: 15% risk of hepatitis or lupus

41. Oral Antibiotics: Others • Erythromycin 1 gram daily • Trimethoprim 200 – 300 mg bd • Gram negative folliculitis

42. How Long Should Treatment Be? • 6 months • 40-50% improvement at 12 weeks • If not, move on • 2-3 courses

43. Treatment failure in primary care • Wrong treatment • Poor treatment usage • Severe disease • Bacterial problems - resistance • Patient expectation

44. Treatment of “Cystic” Acne • Small, acute, 'cyst' (nodule • topical clobetasol • Larger 'cysts' • 'new' - il triamcinalone • 'old' - cryotherapy • Very Large 'cysts' (sinus tracts)‏ • very difficult: probably surgical

45. Isotretinoin: Clinical Guidelines? • Not yet available from the BAD • But – • Severe nodulo-cystic acne • Acne resistant to oral therapies • Severe psycho-social upset

46. Isotretinoin • 13 cis retinoic acid • Adjust duration to suit tolerable dose • 1mg/kg body weight for 16 weeks • 2/3 complete and permanent cure • 20% occasional spot • 10-15% need further treatment

47. Isotretinoin monitoring: Before Treatment • Full discussion of indications for treatment and side effects • Assess patient’s views • Appropriate blood tests • LFT • Lipids • Pregnancy test

48. Isotretinoin Side Effects • Mainly understandable – eg mucocutaneous • Most important for monitoring: • Pregnancy risk management • Mood change

49. Isotretinoin Metabolism • Rapid absorption – enhanced by fatty food • Liver metabolised • Excretion 50% renal, 50% hepato-biliary

50. Isotretinoin Lipid Effects •  triglycerides,  cholesterol,  HDL cholesterol • Can reverse this with fish oil supplementation (70% reduction in TG)‏ • In practice, rare to need to treat • Ensure fasting sample • Discontinue if 2-3 fold increase in lipid levels