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Acne Vulgaris Updates on Approach to Treatment Frank Morocco D.O. December 8, 2012

Acne Vulgaris Updates on Approach to Treatment Frank Morocco D.O. December 8, 2012. Acne Vulgaris. Most common skin disease presenting to primary care physicans. Chronic disease for some patients Don’t underestimate the social and psychological effect of acne on patients

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Acne Vulgaris Updates on Approach to Treatment Frank Morocco D.O. December 8, 2012

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  1. Acne VulgarisUpdates on Approach to TreatmentFrank Morocco D.O. December 8, 2012

  2. Acne Vulgaris • Most common skin disease presenting to primary care physicans. • Chronic disease for some patients • Don’t underestimate the social and psychological effect of acne on patients • Acne is not necessarily a rite of passage

  3. Pathophysiology • Four primary pathogenic factors which interact in complex manner • Sebum production by the sebaceous gland • P. acnes follicular colonization • Alteration in the keratinization process • Release of inflammatory mediators into the skin • Other factors • Androgens, stress, occupational exposure, underlying metabolic abnormalities • Treatment should target these pathogenic factors Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.

  4. Clinical Features • Non-inflammatory Lesions • Open comedones (blackheads) • Closed comedones (whiteheads) • Inflammatory Lesions • Pustules/papules • Nodules • Cysts • Help determine treatment modalities

  5. Primary Lesions

  6. Variants of Acne • Acne cosmetica • Acne excoriee • Senile comedones • Milia • Acne mechanica • Gram-negative acne • Steroid-induced acne • Occupational acne • Favre-Racouchot syndrome • Solid facial edema • Neonatal acne • Drug-induced acne

  7. Treatment • Choice of treatment depends on • Type of acne • Severity • Age • Location • Patient preference • Evaluate patient • Current medications, allergies • Menstrual history • Tanning habits, hobbies • Expectations, myths, fears • Scarring • Pregnancy

  8. Treatment • Approach should be multi-therapy, not monotherapy • Topicals • Antibiotics • Retinoids • Benzoyl peroxide • Combination therapies • Other therapies • Oral therapy • Antibiotics • Isotretinoin • Adjunctive therapy • Hormonal/anti-androgen therapy • Chemical peels • Scar treatment

  9. Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am AcadDermatol2009;60:S1-50.

  10. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne Moderate-Severe Inflammatory Acne Pregnant Azelaic Acid (Cat B) Clindamycin Lotion (Cat B) Topical Therapies Retinoids Antibiotics Salacylic Acid BPO +/- Washes Oral antibiotics Tetracyclines Adjunctive Therapies Severe or Scarring Isotretinoin Adjunctive Therapies OCPs, chemical peels, anti-androgens Failure of oral antibiotics

  11. Treatment Approach • Early, appropriate treatment is best to minimize potential for acne scars • Combination of a topical retinoid and antimicrobial agent remains the preferred approach for almost all patients with acne • Attacks 3 of the 4 major pathogenic factors of acne: abnormal desquamation, P. acnes colonization, and inflammation • Retinoids are anticomedogenic, comedolytic, and have some anti-inflammatory effects • BPO is antimicrobial with some keratolytic effects and antibiotics have anti-inflammatory and antimicrobial effects Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.

  12. Treatment Approach • Topical retinoids should be first-line agents in acne maintenance therapy • Avoid contributing to antibiotic resistance Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.

  13. Benzoyl Peroxide • Mechanism of action1 • Bactericidal for P. acnes • Inhibits triglyceride hydrolysis • Decreases inflammation of acne lesions • Advantages • No resistance demonstrated to date1 • When used in combination with a topical antibiotic can help to prevent resistance2 • Activity is enhanced when combined with other topicals (i.e. clindamycin)1,2 • Formulations • OTC & prescription • Washes, gels, lotion, solution • 1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007. • 2. Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am • AcadDermatol2009;60:S1-50.

  14. Retinoids • Most important class of drugs used to treat acne • Topical form of vitamin A • Mechanism of Action1 • Normalize follicular keratinization • Act on the microcomedone • Proper instruction on application is essential to compliance • Gradual application with small amount of drug • “Training for a marathon” 1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  15. Retinoids • “Least Irritating” (most tolerable) • Adapalene gel (Differin® 0.1%, 0.3%) • May be appropriate starting point for ethnic and/or sensitive skin • “Moderately Irritating” • Tretinoin (cream, gel) • Tretinoin 0.01%, 0.05%, 0.025% • Retin-A Micro® 0.1%, 0.04% • Atralin™ Gel 0.05% • Renova® 0.02%, 0.05% • “Most Irritating” (least tolerable) • Tazarotene (Tazorac®/Avage® 0.05%, 0.01%) Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  16. Topical Antibiotics • Erythromycin • Akne-mycin® 2% gel, Erygel ® 2% gel, • Resistance of some P. acnes strains • Usage fallen out of favor • Clindamycin phosphate 1% • Generic, Cleocin T® (lotion, gel, solution), Evoclin® foam • Antibiotic-associated colitis very unlikely • Work best in combination with BPO • Good choice for pregnant women (Pregnancy Category B) • Azelaic acid • Finacea™ • Bacteristatic/bactericidal against P. acnes • Good choice for pregnant women (Pregnancy Category B) Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  17. Topical Antibiotics • Sodium sulfacetamide/sulfur (10%/5%)1 • Klaron® lotion, Plexion® line, Rosac® line, Clenia® • Keratolytic effects, antibacterial for P. acnes • Used most commonly for rosacea • Metronidazole1 • Benefit for acne debatable • Metronidazole lotion (generic), Metrogel 1%® • Dapsone gel 5% (Aczone®)2 • Approved for moderate to severe acne • BID dosing • May cause a temporary yellow or orange discoloration of skin and facial hair if used along with BPO • Low risk of hemolytic anemia in G6PD deficient patients 1. Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007. 2. Aczone® prescribing information. January 2009.

  18. Combination Therapies • Clindamycin/Benzoyl peroxide • Clindamycin phosphate 1%/benzoyl peroxide 5% (Benzaclin®Gel) • Clindamycin phosphate 1%/benzoyl peroxide 5% (Duac®Gel) • Clindamycin phosphate 1.2% /benzoyl peroxide 2.5% (Acanya™ Gel) • Erythromycin/Benzoyl peroxide • Erythromycin 3%/benzoyl peroxide 5% (Benzamycin®) • Retinoid/Benzoyl peroxide • Adapalene 0.1%/benzoyl peroxide 2.5% (Epiduo™ Gel) • Retinoid/Clindamycin • Tretinoin 0.025%/Clindamycin phosphate 1.2% (Ziana® Gel) Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.

  19. Oral Antibiotics • Therapeutic role in acne • Reduction of P. acnes • Anti-inflammatory activity • Dosing • Start high then taper down after control is achieved • Use PRN during flares • Do not use as monotherapy Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  20. Oral Antibiotics • Antibiotic Choice • Tetracylcine Class (minocycline, doxycycline, tetracycline) • Solodyn® (minocyclineHCl), Minocin ® (minocycline) • Doryx® (doxycyclinehyclate), Adoxa® (doxycycline monohydrate) • Erythromycin (Ery-tab®) • Trimethoprim/sulfamethoxazole • Amoxicillin • Anti-inflammatory antibiotics/no antimicrobial activity • Doxycycline 20 mg (Periostat®) • Doxycycline 40 mg (Oracea®) Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  21. How to Prevent Resistance • Combine a topical retinoid plus an antimicrobial • Limit the use of antibiotics to short periods and discontinue when there is no further improvement or the improvement is only slight • Co-prescribe a BPO-containing product or use as washout • Oral and topical antibiotics should not be used as monotherapy Thiboutot D, et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol 2009;60:S1-50.

  22. Hormonal Therapy • FDA-approved OCPs for acne • Ortho Tri-Cyclen® • Estrostep® • Yaz® • Anti-androgens • Spironolactone • Doses range between 50-200mg • Not FDA-approved for acne • Monitor side effects: menstrual irregularities, hyperkalemia Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  23. Isotretinoin • Approved for the treatment of severe recalcitrant nodular acne in 1982 • Member of the Vitamin A family • Effects on acne • Normalizes the keratinization process • Reduces sebocytes and secretions • Reduces inflammation • Reduction in numbers of P. acnes Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  24. Isotretinoin • Pre-medication counseling • Side Effects • Contraception • Compliance/duration of treatment • Laboratory monitoring • iPledge registration • Dosing 1-2 mg/kg/day • Goal 120-150 mg/kg over course of treatment Wolverton SE. editor Comprehensive Dermatologic Drug Therapy 2nd Ed. Philadelphia: Saunders Elsevier; 2007.

  25. Case Studies

  26. Case One • 15-year-old male • Non-inflammatory & inflammatory acne • Face only • Open/closed comedones • Papules • Treatment Plan?

  27. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne Moderate-Severe Inflammatory Acne Pregnant Azelaic Acid (Cat B) Clindamycin Lotion (Cat B) Topical Therapies Retinoids Antibiotics Salacylic Acid BPO +/- Washes Oral antibiotics Tetracyclines Adjunctive Therapies Severe or Scarring Isotretinoin Adjunctive Therapies OCPs, chemical peels, anti-androgens Failure of oral antibiotics

  28. Case Two • 17-year-old-female • Inflammatory acne • Regular menstrual cycles (-flares) • Face, chest, back involved • Pustules, papules • Open & closed comedones • Treatment plan?

  29. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne Moderate-Severe Inflammatory Acne Pregnant Azelaic Acid (Cat B) Clindamycin Lotion (Cat B) Topical Therapies Retinoids Antibiotics Salacylic Acid BPO +/- Washes Oral antibiotics Tetracyclines Adjunctive Therapies Severe or Scarring Isotretinoin Adjunctive Therapies OCPs, chemical peels, anti-androgens Failure of oral antibiotics

  30. Case Three • 22-year-old female • Mild-moderate inflammatory acne • Regular menstrual cycles (+ flares) • Face involved • Chest, back spared • Nodular lesions along jawline • Comedones • Treatment plan?

  31. Treatment Approach Non-inflammatory Acne Mild Inflammatory Acne Moderate-Severe Inflammatory Acne Pregnant Azelaic Acid (Cat B) Clindamycin Lotion (Cat B) Topical Therapies Retinoids Antibiotics Salacylic Acid BPO +/- Washes Oral antibiotics Tetracyclines Adjunctive Therapies Severe or Scarring Isotretinoin Adjunctive Therapies OCPs, chemical peels, anti-androgens Failure of oral antibiotics

  32. Atopic Dermatitis and Eczema

  33. Atopic Dermatitis • “The itch that rashes” • Hereditary skin manifestation; family history of eczema, asthma, and hay fever • >50% of children with one atopic parents and 79% of children with both atopic parents develop allergic symptoms before 2yo • Ddx: seb derm, contact derm, scabies, and psoriasis

  34. Atopic Dermatitis • 3 Stages • Infantile (2mos-2yrs): • Risks: African and Asian races, males, greater gestational age at birth, Fam HX • 60% of atopic pts present 2mos-1yo. Disappear by 2yo. • Usually begins as papular or exudative erythema and scaling of the cheeks, may extend to scalp, neck, forehead, wrists, extensor extremities. Plaques become lichenified. • Become secondarily infected. • Worsening after immunization or infection. • Remission in summer (UV and humidity), relapse in winter (wool and dryness). • Role of food allergy is contraversial; may be milk, eggs, peanuts, tree nuts, grains, fish, and soy. Some association with cow’s milk.

  35. Atopic Dermatitis • 3 Stages • Childhood (2-10yrs): • Lichenified, indurated plaques on the antecubital and popliteal fossae, flexor wrists, eyelids, face, and around the neck. • Itching → scratching → secondary changes → itch • If >50% BSA, associated with growth retardation

  36. Atopic Dermatitis Adult: • Pruritus with heat or stress • Localized, erythematous, scaly, papular, exudative, or lichenified plaques. Prurigo-like paps are common. • Hyperpitmentation in dark skin with hypopitmentated healed excoriated lesions • Often antecubital and popliteal fossae, neck, forehead, and eyes. • Older adults: chronic hand dermatitis (women after first child), worse with frequent wet exposure. r/o contact allergy. • Usually improves with time, uncommon after middle life • New-onset in adulthood: HIV can be a trigger

  37. Modified Criteria for Children with Atopic Dermatitis Essential Features • Pruritus • Eczema • Typical Morphology and age-specific pattern • Chronic or relapsing history Important Features • Early age at onset • Atopy • Personal and/or family history • IgE reactivity • Xerosis Associated Features • Atypical vascular responses (e.g. facial pallor, white dermatographism) • Keratosispilaris/ichthyosis/hyperlinear palms • Orbital/periorbital changes • Other regional findings (e.g. perioralchanges;periauricular lesions) • Perifollicular accentuation/lichenification/prurigo lesions

  38. Features Associated with Atopy • Dennie-Morgan fold: linear transverse fold just below the lower eyelid • Prominent nasal crease • “Normal” skin is subclinically inflamed, dry, scaly • Pityriasis alba: hypopigmentation with sclight scale on cheeks, upper arms, trunk in young children. Responsive to emollients and topical steroids • Keratosis pilaris: horny follicular lesions of outer aspects of upper arms, legs, cheeks, and buttocks; refractory to treatment • Dirty neck appearance due to hyperkeratosis and hyperpigmentation

  39. Features Associated with Atopy • Perioral, perinasal, and periorbital pallor • White dermatographism • Increased susceptibility of cataracts • Increased susceptibility of infection; • Patients heavily colonized with Staph. Treatment of lesional skin reduces colonization even w/o ABX • Chronic suppressive ABX therapy may stabilize disease: Cephs, Bactrim, clinda, doxy • Eczema herpeticum: generalized herpes simplex, sudden vesicular, pustular, crusted or eroded lesions. Become secondarily infected. • Eczema vaccinatum: widespread vaccinia infxn • Extensive flat wart or molluscum; poor tolerance to Tx

  40. Atopy: Pathogenesis • Immunologic defects are the main component • Th2 activation with IL-4, 5, 10, and 13. Elevated IgE and eosinophilia; impaired antiviral activity. • Defects in barrier function with increased transepidermal water loss, correlating with disease severity. Increased TEWL in winter and in stress. • Environmental factors: increased with increased hygeine and higher socioeconomic status. May have allergens to dust mites, grass pollens

  41. Management of Atopy • Infants and children: • Avoid hot baths, alkaline soaps, vigorous rubbing and scrubbing. • Short, once-a-day, tepid baths followed by a barrier cream using soak and smear; ointment bases are preferred. • Immediate change of wet or soiled diapers. • Nighttime sedating antihistamines for itch • Dietary restriction for a specific known antigen

  42. Management of Atopy • Adults • Avoid temperature extremes • Hydrate dry skin especially in winter • Avoid overbathing and hot water • Avoid wool • Biofeedback techniques for emotional stress

  43. Topicals for Atopy • Topical corticosteroids are the mainstay • 1-2.5% hydrocortisone in infants. Monitor growth in infants and young children. • Mid-potency (TAC) in older children and adults except on the face • 1-2x a day is enough to saturate receptors; more provides only emollient effect • Occlusion increases penetration and receptor saturation • Must be strong enough to control pruritus and remove inflammation • Regular emollients: petrolatum, hydrophilic creams with ceremides • Anti-Staph therapy for acute flares • Topical calcineurin inhibitors

  44. Systemics for Atopy • Antihistamines for sedation: hydroxyzine, diphenhydramine, or clopheniramine. • The nonsedating antihistamines do not relieve pruritus • Short courses of anti-Staph ABX, topical mupirocin for nasal carriage • Systemic steroids only for acute exacerbations, in short courses of 3 weeks or less • Cyclosporin is usefule but expensive; symptoms recur on stopping meds • Immunosuppressives and antiproliferatives (Immuran, Cellcept, MTX) can be effective for unresponsive dz • Phototherapy: PUVA, UVA, narrow-band UVB, or Goeckerman with tar may be helpful

  45. Atopy: Treating the Acute Flare • Treat triggers and the precipitant of the flare • Short course of systemic steroids • 3-4 days of home hospitalization: • Bedrest and isolation of stressors with large doses of antihistamine at bedtime • Daily tub soaks followed by topical steroid ointment under wet pajamas and a sauna suit

  46. Eczema • Broad range of conditions beginning as spongiotic progressing to lichenified • Acute: red edematous plaque with small grouped vesicles • Subacute: erythematous plaques with scale or crusting • Chronic: dry scale and lichenification

  47. Regional Eczemas • Ear: external canal most frequently affected. Earlobe = nickel allergy. • Gentle lavage to remove scale and cerumen. Topical steroids if not infected. • Eyelid: may be related to volitle chemicals, or transfer of allergen from hands. • Allergic contact affects upper lids, atopic affects both • Breast/Nipple: Painful fissuring can occur, esp in nursing mothers. If >3 mos BX to r/o Paget’s

  48. Hand Eczema • Most commonly in atopic patients • Complete H&P and patch testing to distinguish from atopic/allergic/irritant/psoriasis • Allergens: glyceryl monothioglycolate, ammonium persulfate, isothiazolinones, formaldehyde, paraben, Compositae plants, nickel, dyes (p-phenylenediamine)

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