891 likes | 3.91k Views
ACNE VULGARIS. Description & prevalence Types of lesions Pathogenesis Treatment options & tips When to refer (& how …). ACNE. European Consensus 2003 & 2006 Topical retinoids Antibiotic choice Isotretinoin (Roaccutane) prescribing Recent developments Dianette / Yasmin / Spironolactone
E N D
ACNE VULGARIS • Description & prevalence • Types of lesions • Pathogenesis • Treatment options & tips • When to refer (& how…)
ACNE European Consensus 2003 & 2006 Topical retinoids Antibiotic choice Isotretinoin (Roaccutane) prescribing Recent developments Dianette / Yasmin / Spironolactone Pulsed dye laser
ACNE VULGARIS Description Acne is only seen to mankind -sebum composition specific & p. acnes unique Common: -95% males & 83% females aged 16 yrs -Peak age females 17 / males 19 yrs -15% severe enough to warrant Rx Ave list of 2000, @15% aged 15-24 years =300 patients and about 45 on Rx
ACNE VULGARIS Description Typically lasts 8-12 years! Post-adolescent acne becoming more common -reasons unknown 7% acne persists into 3rd & 4th decades
ACNE VULGARIS Sites involved Face 99% Back 90% Chest 80%
ACNE VULGARIS Pilo-sebaceous glands 'oversensitive' to normal androgen levels after puberty Increased sebum production and an oily skin Keratinocytes remain adherent to the follicular canal Ductal hypercornification Open comedones Proliferation of p.acnes Bacteria enzymes breakdown oil in the sebum resulting in the release of cytokines
Pathogenesis of an acne lesion 2 1. Seborrhoea 2. Obstruction 3. P. Acnes 4. Inflammation 1 4 3
ACNE VULGARIS Types of lesions Comedones: -Open 'blackheads' -Closed 'whiteheads’ Papules Inflammatory pustules Nodules Cysts Scars
Treatment General advice & myths -Acne skin is not dirty -Diet -Make-up (50% cosmetics comedogenic) -Site of lesion in skin & effect of trauma
Treatment Standard Rx is slow to effect improvement: 40% improvement at 2 months 50% " 3 ” 60% " 6 ” 80% " 8 "
ACNE VULGARIS TREATMENT Treatment depends on -severity -predominant type -area covered Leeds Acne Grading System Face Grades 1-12 Back & chest Grades 1-8
ACNE VULGARIS Treatment of 'mild' disease Few papules / pustules -non-inflamed (open comedones) -Topical retinoid -inflamed (closed comedones) -Benzoyl peroxide -Topical retinoid -Topical antibiotic -Azelaic acid
Topical retinoids Tretinoin Retin A -twice daily Acticin -once daily / less irritant Isotretinoin Isotrex -twice daily -unlike oral, dose not reduce sebum Adapalene Differin -once daily / less irritant / fast Tazarotene Zorac Epiduo -Adapalene & 2.5% BP
Global Alliance Consensus Statement on topical retinoids 2003 • 'Retinoids target the microcomedo' • -'precursor lesions' • 'Likely to maintain remission • -by inhibiting microcomedos' • 'Topical retinoids should be used as 1st-line • in mild to moderate acne' • 'The goal is to minimize antibiotic use in acne' • Anti-inflammatory benefit under-appreciated • -although slower than antibiotics
ACNE VULGARIS Other topical agents Benzoyl peroxide -Reduces p.acnes resistance -P.acnes is an obligate anaerobe -Improves inflammatory lesions ++ Azelaic acid -Reduces p. acnes resistance -Natural product from m.furfur -Helpful for post-inflammatory hyperpigmentation Salicylic acid Nicotinamide Hydroxyquinoline
ACNE VULGARIS Topical antibiotics July 2011 Clindamycin Dalacin T 10mg/ml 50ml £7.23 Zindaclin 1% OD30g £8.66 Duac 1% OD (+BP 5%) 50g £19.90 Erythromycin Eryacne 4% 30g £4.97 Stiemycin 2% 50ml £7.69 Zineryt 4% 5W shelf life 30ml £7.71 90ml £16.68 Isotrexin 2% (+isotretinoin) 30g £7.47 Aknemycin plus 4% (+tretinoin) 25ml £7.05
ACNE VULGARIS GENERAL CONSIDERATIONS TOPICAL TREATMENTS Topical retinoids contraindicated in pregnancy Azelaic acid ‘not recommended’ in pregnancy Retinoids disrupt blackheads, but are irritant -acne anti-inflammatory effect still useful Benzoyl peroxide bleaches & is irritant -weakly keratolytic Topical Rx prevent new lesions -so treat whole area
ACNE VULGARIS Treatment of 'moderate' disease Superficial inflammatory lesions Few deep seated pustules (20 – 50) Only minor scarring: -only small area affected: -B.P. or ABi am / Retinoid pm -widespread -Oral antibiotic +/- Dianette -Topical retinoid -B.P.
Oral antibiotics Tetracyclines Oxytetracycline Minocycline Doxycycline Lymecycline(European Acne Experts Consensus) Macrolids Erythromycin Trimethoprim
Duration of antibiotic therapy • Prescribe for at least 3 months and / or until no further clinical improvement • For courses longer than 3 months ideally combine with an ‘anti-resistance’ agent (preferably started early): -Benzoyl peroxide -Topical retinoid -Azelaic acid • Adherence is an important issue
GENERAL CONSIDERATIONS Oral treatment Use Benzoyl peroxide as reduces resistance Never use oral & topical ABi Avoid tetracyclines in pregnancy & <12 years ABi inter-reaction with COCP –no longer an issue S/E from Doxycycline / Minocycline Dietary interference with absorption 80% improvement at 8M (earliest sign @ 2-3M)
ACNE VULGARIS For a very rapid response (e.g. wedding) -UVB temporary improvement @2-3W -mechanism of action not clear Generally encourage natural sunlight therapy
ACNE VULGARIS Treatment of 'severe' disease Papules, pustules, nodules & cysts ++ Significant scarring -ice-pick / pigmented / keloidal Poor psychological adjustment REFER -Megadose ABi or -Isotretinoin (Roaccutane) If female should be on Dianette
ACNE VULGARIS ROACCUTANE COUNSELLING Muco-cutaneous side effects: Common: Cheilitis 95% Facial erythema 67% Aggravation of eczema 30% Rare: Paronychia 2% Increased skin fragility 2% Acne flare 2% Hair loss 1% Photosensitivity 1%
ACNE VULGARIS ROACCUTANE COUNSELLING Systemic side effects Serious: Teratogenicity (PPP) 100% Myalgia / arthralgia / h'aches 30% Rarer: @2% Optic atrophy / optic neuritis Benign intracranial hypertension Hepatitis Tinnitus DISH
ACNE VULGARIS ROACCUTANE COUNSELLING General advice Blood tests 4-6 month course (100 –120 mg/ kg) 70-85% 'cure' / Risk of relapse @40% at 3yrs 'milder' Often start low for 1st few weeks (acne fulminans) Alcohol Exercise Contraception: -informed signed consent in women -dual contraception (including Dianette) Avoid concurrent Tetracyclines (esp Minocycline) -B.I.H.
ACNE VULGARIS Nite pulsed dye laser 580nm 1 or 2 sessions of 30 mins -effective for inflammatory lesions -also reduces scars -alters cytokines & pro-inflammatory regulators ?-increased TGF-beta production -activates protoporhyrins release O2 £150 / session 0845 855 0866 www.euphotonics.com
ROSACEA Two peaks of onset: 20-30 years & 40-50 years (?) Characteristically involves the muzzle area of face -rarely extends beyond face / neck (review D.D.) Usually give a clear history of vasomotor instability: -Sun / Temp change / Hot food / Alcohol / Blushing 4 patterns: -Erythro-telangiectactic (no blackheads) -Papulo-pustular -Ocular -Phymatous
ROSACEA General measures Avoid steroids Lymecycline Topicals (newish agent Finacea)
ROSACEA TREATMENT OPTIONS Avoid topical steroids 1st line treatment is topical: Finacea gel Metronidazole / Erythromycin / Dalacin 2nd line treatment oral antibiotic: Lymecycline / Erythromycin / Other tetracyclines 3rd line treatment : Low dose Isotretinoin (5-10mg). (Avoid if any suggestion of active eye disease) Response to treatment usually obvious within 3-4 weeks ?Lyclear
ROSACEA TREATMENT AZELAIC ACID 15% gel (Finacea) Effect on keratinisation Antibacterial action on P Acnes Moderate anti-inflammatory effect Licensed 2006 for mild to moderate AR No 6-month limit (as in acne vulgaris) Therapeutic advantage over Metronidazole 0.75% gel High water content provides cooling effect (keep in fridge) Free of alcohol & fragrances Least expensive -30g only £7.48 (Rosex 40g £15.28)