ACNE

1. ACNE

2. Introduction • One of the commonest skin conditions seen • Easily diagnosed • May affect mental and social well being • Multiple therapeutic options require skill to treat • Successful management requires tailormade treatment • Affects more than 80% people at some point in their life

3. Acne vulgaris Definition: Acne is a chronic inflammatory disease of the pilosebaceous units, characterized by seborrhoea, formation of comedones, erythematous papules, pustules & less frequently by nodules, cysts and scarring.

4. Epidemiology • Typically occurs around adolescence • Can present in neonate, can persist beyond adolescence in susceptible individuals • Physiological acne considered a normal variant of maturation • Clinical acne persists and progresses beyond the period of adolescence • 30% of teenagers have acne of sufficient severity to require some form of treatment

5. Pathogenesis of acne • Increased sebum production • Hypercornification of the pilosebaceous duct • Colonisation of the duct with Propionibacterium acnes • Inflammation

6. Seborrhoea • Increased androgenic sex hormones of gonadal / adrenal origin(especially in women with polycystic ovarian disease) • Abnormal end-organ response to normal level of hormones • Abnormal composition of sebum • Lower levels of linoleic acid → ductalhypercornification

7. Comedogenesis • Abnormalities in proliferation and differentiation of ductalkeratinocytes • Retention of hyperproliferatingductalkeratinocytes • Increased cohesiveness of ductalkeratinocytes These lead to formation of the microcomedone which is the precursor of all acne lesions

8. Propionibacterium acnes • Resident anaerobe which colonises the pilosebaceous duct in the presence of seborrhoea • Hydrolyses the triglycerides in sebum to produce free fatty acids • Produces mediators of inflammation • The cell wall of P.acnes is a potent chemoattractant

9. Inflammation • Cytokines produced by sebum and ductalkeratinocytes • P.acnes & free fatty acids also contibute to the inflammation • Cytokines attract neutrophils and mononuclear cells • In moderate and severe cases there is rupture of the duct and a macrophage giant cell foreign body reaction

10. Grades of Acne (Pillsburry’s classification) • Grade I: comedones (open or closed), occ. papules • Grade II: papules, comedones, few pustules • Grade III: predominant pustules, nodules, abscesses • Grade IV: mainly cysts, abscesses, scars

11. Scarring • Consequence of abnormal resolution or wound healing following the inflammation • Ice-pick scars are seen in most patients with grades I and II acne while depressed or hypertrophic scars are seen in nodulocystic acne

12. Hyperpigmentation • In patients paticularly with type III/IV skin, hyperpigmentedmacules may persist following the resolution of inflammatory acne lesions

13. Uncommon Variants of Acne • Drug induced acne/ acneiform eruption • Acne excoriee • Acne conglobata • Acne fulminans • Acne mechanica • Occupational acne/chloracne • Pyodermafaciale • Late onset acne/endocrine acne • Cosmetic/pomade acne • Tropical acne • Gram negative folliculitis

14. Drug induced acne • Papules and pustules , comedones usually absent • Drugs implicated: • Halogens • Androgens • Steroids • INH,Rifampcin • Lithium • Phenytoin • PUVA

15. Co-factors • Relieving • UV radiation? Aggravating • Premenstrual • UV radiation? • Stress • Sweating • Smoking

16. Psychosocial aspects • Stress induces acne • Increased anger and anxiety • Social embarrassment • Lack of self confidence • Depression • Dysmorphophobia

17. Differential diagnosis • Rosacea • Pityrosporumfolliculitis • Pseudo folliculitis • Milia • Plane warts • Tuberous sclerosis • Acne scarring may be mistaken for acne keloidalis, varioliform, atrophy and porphyriacutaneatarda.

18. Guidelines of treatment • Acne assessment (of severity) • Patient education • Discussion of goals of treatment and patient expectations • Choice of therapy

19. Guidelines of treatment • Topical antibiotics - erythomycin, clindamycin, tetracycline, clarithromycin, doxycycline • Benzoyl peroxide • Azelaic acid • Topical retinoids - retinoic acid, adapalene, tazarotene

20. Oral therapy • Antibiotics : Erythromycin Azithromycin (pulse dosing) Tetracycline Doxycycline Minocycline Trimethoprim Dapsone

21. Side effects of oral antibiotics • Doxycycline - onycholysis, oesophagitis with ulceration, fixed drug eruptions, photosensitivity etc. • Minocycline - benign intracranial hypertension, pappiloedema, blue-black pigmentation and rarely hypersensitivity reactions • Macrolide group - gastritis, diarrhoea • Co-trimoxazole - severe drug reactions • Dapsone - hemolytic anemia, dapsone syndrome etc.

22. Hormonal therapy • Antiandrogens – cyproterone acetate(50-100 mg/day) • Oral contraceptives - 35 mcgsethinylestradiol plus 2 mgs cyproterone acetate • Levonorgestrel+ethinylestradio (100+20 mcgs) • Other regimens - prednisolone plus oestrogen, spironolactone and antiandrogens • Drosperinone – novel progestin derived from spironolactone • Oral contraceptives containing androgenic progesterones such as norethisterone must be avoided.

23. Side effects of Hormonal therapy • Weight gain • Menstrual irregularity • Occasional fluid retention • Melasma • Hypertension • Thrombophlebitis • Pulmonary embolism

24. Isotretinoin 13-cis- retinoic acid (Vitamin A derivative ) • Mechanism of action: • Decreases the size of sebaceous glands • 80% reduction in sebum • Alters the composition of sebum • Reduces comedogenesis • Lowers P.acnes concentration and has anti- inflammatory activity

25. Isotretinoin • Indicated for : • Nodulocystic/ severe Acne • Pyodermafaciale • Acne recalcitrant to routine treatment • Excessive seborrhoea • Depression / Dysmorphophobia • Acne conglobata / other unusual variants • Scarring

26. Isotretinoin • Dose: 0.5 – 1 mg/ kg per day is given after meals. Cumulative dose: 120-150 mgs/kg • Side effects • Teratogenicity • Mucocutaneous side effects, dryness • Elevation of serum lipids • Neurological : pseudotumorcerebri, optic • Neuritis, depression, mood swing • Arthritis, myalgia • Acne flares

27. Physical modalities • Comedo expression • Superficial electrocautery • Aspiration of cystic lesions • Intralesionalsteriods • Cryotherapy • Alpha-hydroxy acids

28. Newer options • Photodynamic therapy using blue red light • Low fluence pulsed dye laser light • Dermabrasion / CO2laserbrasion (ice-pick scars) • Erbium-YAG laser for atrophic /hypertrophic scars • Punch grafting / punch floats (for depressed scars) • New anti inflammtory agents such as 5-lipooxygenase inhibitors *

29. Acne treatment plan • Topical therapy for grade I & grade II acne • Oral antibiotics in moderate to severe acne • Combination with topical retinoids improves efficacy and with benzoyl peroxide decreases resistance • Duration 4-6 months • Any treatment started must be continued for atleast 6 weeks before changing • Advise on potential side effects • Systemic isotretinion is indicated in severe nodulocystic acne, acne conglobata and acne recalcitrant to routine therapy Contd..

30. Acne treatment plan • Hormonal therapy is used for patients with moderate acne who also need contraception, or those who need hormonal therapy to regulate hormonal irregularities • Encourage compliance

31. Poor response to therapy • Poor compliance • Inadequate instructions • Side effects • Resistance of P. acnes • Inadequate dosage • Folliculitis due to staphylococci, gram negative enterobacteria or malassezia

32. Thank you