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Monday, February 6th, 2012

Acne! José L. González, MD. Monday, February 6th, 2012. Risk Factors. first degree relative no data suggesting dietary influences endocrine steroids anabolic cortico- androgen excess PCOS. Classification. inflammatory open comedo (whitehead) closed comedo (blackhead)

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Monday, February 6th, 2012

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  1. Acne! José L. González, MD Monday, February 6th, 2012

  2. Risk Factors • first degree relative • no data suggesting dietary influences • endocrine • steroids • anabolic • cortico- • androgen excess • PCOS

  3. Classification • inflammatory • open comedo (whitehead) • closed comedo (blackhead) • non-inflammatory • papule < 5mm tender, erythematous bump • pustule < 5mm bump containing visible material • nodule / cyst > 5mm

  4. Types of Acne & Acne Impersonators • acne conglobata / acne fulminans • drug-induced acne • rosacea – telengectasias, central face • acne excoriée des jeunes filles • bacterial folliculitis – s. aureus • granulomatous & neoplastic d.o. • sarcoidosis, tuberous sclerosis, multiple trichoepitheliomas

  5. female pts & signs of androgen excess • testosterone (free & total) • dehydroepiandrosterene sulfate • LH, FSH • PCOS? • fasting glucose & insulin levels

  6. pathogenesis • 1. hyperkeratinization • 2. increased sebum production • 3. propionobacterium acnes • 4. inflammation

  7. treatment • non-inflammatory (comedolysis + keratolysis) – topical tx • retinoids • benzoyl peroxide • salicylic acid • azelaic acid • inflammatory – combination tx • topical + oral abx • benzoyl peroxide + tetracycline

  8. common oral abx & SEs • Tetracyclines – phototoxicity, nausea • doxycylcine – tooth staining & vertigo • minocylcine – SLE-like reaction • Macrolides • erythro & azithromycin – GI upset / diarrhea • Bactrim – Stevens Johnson

  9. Other Oral Therapies • Hormonal • OCPs – 50 – 60% improvement • norethindrone acetate-ethinyl estradiol • norgestimate-ethinyl estradiol • SEs: migraines, nausea, VTE • Steroids • high dose → taper; short term • low dose; long term

  10. Isotretinoin aka Retinoic Acid • long term remission • use in severe nodular acne, resistant to abx • SEs • birth defects, iPLEDGE • skin: dry eyes, mm, epistaxis, hair shedding • MSK: hyperostosis, premature epiphyseal closure • neuropsych: it'll make you crazy! (but beautiful) • liver: check triglycerides & LFTs

  11. Other Options • Newer treatments • blue light, phototherapy, laser therapy, radiofrequency non-ablative • high cost • relapse in 3-6 months • Referral to Dermatologist • very severe acne • use of isotretinoin

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