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ACNE
Jason M Cheyney, MPAS, PA-CDermatologic Surgery Specialists
Macon, Ga 31211
Pathogenesis of Acne
Causative Factors
Therapy
On the horizon
Approximately 45 million Americans have acne
It is often the first assault on teenagers ego
It can become an overly emotional situation
Acne is much worse than a bad hair day
Acne can affect ~ 40% of people over 25 y/o
Over $100 million spent annually to treat acne
Hair follicle plugged by abnormally keratinized cells
Increased oil retention by pilosebaceous unit
Proprionibacterium overgrowth and digestion of oil and production of free fatty acids
Free fatty acids induce inflammation
Androgen induced sebaceous gland hyperactivity
Diet plays a role with increased carbohydrate intake triggers insulin release which causes excess hormone production
Comedonal (Non-inflammatory)Open = blackheads
Closed = whiteheads
Papules: Solid inflamed elevations above the skin
Pustules: pus-filled inflammatory bumps
Nodules: Deeper lesions, often painful and can lead to discoloration and scarring.
Inflammatory or Not?- Determines Need for Antibiotics (topical or oral)
Depth of the Lesions?- Determines Role of Oral Medication
PIH or Scarring Present?- Determines How Aggressive you NEED to Be- Is Patient a Candidate for Isotretinoin?
Psychological Impact?- Will Determine How Aggressive to Get
TopicalRetinoids
BPO
Antibiotics
AHA/BHA
Azaleic Acid
Dapsone
Ivermectin
Brimonidine
SystemicAntibiotics
Doxycycline and Minocycline
Spironolactone
IsotretinoinDon’t let the rumors scare you
Has been a life-saver for many patients
A Cornerstone of Treatment for All Stages
Maintenance Therapy
MOA: Normalizes Desquamation of Skin Cells
Reduces obstruction in the follicle which reduces P. acnes growth, facilitates the removal of existing comedones, and hinders formation of new lesions and reduces inflammation
Adverse effects: skin irritation, “worse before better”
“Pea-sized” amount to a clean and DRY face
Avoid eyelids – no breakouts there anyway
Wash hands after application
Often a period before skin is “retinized”
May get worse before it gets better
May get dry with use; use moisturizer
If too irritating, use every other day until ready for daily use
Mechanism of Action:- Decreases P. acnes (bactericidal)- Comedolysis
Preparations:- OTC/RX 2.5% - 10%- Wash, creams, gel, foam, combination products
Safety:- Bleaches clothes - Irritation and dryness
Retinoid + Benzoyl Peroxide
1 + 1 = 3
Available by prescription only: Lotion, Gel, Cream
Erythromycin, clindamycin, sulfacetamide, metronidazole
MOA: Reduces the bacterial population, also possess anti-inflammatory properties.
Should not be used as monotherapy
Increased incidence of bacterial resistance
Erythromycin is virtually ineffective at this point
Adverse effects: generally mild dermatitis, allergy
Available over the counter and prescription in concentrations ranging from 0.5% to 10% for the treatment of Acne vulgaris (higher concentrations are for the removal of warts).
Most often found in facial cleansers
MOA: Possesses a keratolytic effect and is a mild antiseptic.
Adverse effects: erythema, pruritus, burning/stinging sensation
Apply up to twice daily
Helpful in skin of color due to skin lightening affect
Stinging most common side effect
Apply twice daily
?G6PD
Stinging burning can occur
Apply once daily
Effective against demodex
Improvement with continued usage
Apply in AM
Rebound erythema after 10-12 hours
Significant improvement with continued usage
Generally reserved for moderately severe to severe acne
Inflammatory acne only (not effective for comedonal acne)
Cystic or inflammatory acne resistant to topical treatment
Systemic treatment options:Oral antibioticsIsotretinoinHormonal therapy
Isotretinoin
Indicated for the treatment of severe, nodulocystic acneAffects RNA synthesis at a cellular level which in turn modifies the cell turnover rate, decreases follicle and sebaceous gland size, and decreases sebum production.Also possesses anti-inflammatory properties.Dose: 0.5 – 2.0 mg/kg/day x 20 weeksRemission can be permanent after one course of treatment.Use is governed by the iPledge program
- Used Rx Exactly as Prescribed
- No OTC meds unless told to do so
- Never pop, squeeze or pick lesions
- Avoid using abrasive products
- Use hands or gentle washcloth to wash your face
- Wait 5 – 30 min after showering or washing to apply topical medications
- It is possible for your acne to get worse before it gets better- Add moisturizer early on in treatment
Tips for Better Outcomes
Use only oil-free skincare and hair care products
This is your condition; It is your responsibility to use meds as directed
Apply medications before make-up or facial moisturizers
Use only non-comedogenic products
Continue to use medications even after skin clears
Gently cleanse skin after sweating
Give your medications adequate time to work
Tips for Better Outcomes
Too Many Steps to the Regimen (especially boys)
Inadequate Patient Education
Unrealistic Expectations
Patient Frustration
Your Patient Won’t Succeed If:
“YOU, Make the Call”
Best Method to Treat Scarring?
Don’t Let the Redness Fool You!
Acne Rosacea
Primarily seen in Northern European decent
Called the “curse of the Celts” in Europe
3x more common in women
Predominantly seen in caucasions
Typically arises between the ages of 30-50
Acne Rosacea
Cause unknown
Sunlight is most common trigger
Heat can induce
FoodCaffeine
Alcohol
Spicy foods
DemodexFeces?
Bacteria in Feces?
Acne Rosacea
Erythematotelangectatic
Papulopustular
Phymatous
Ocular
SubtypesPerioral dermatitis
Treatment
Directed at type
ErythematotelangectaticMetrocream
Mirvaso
Cleocin/hydrocortisone
Laser
TopicalsMetrocream
Azaleic acid
Ivermectin
BPO/clindamycin combo
SystemicAntibiotics- low dose
Isotretinoin?
Spironolactone
Isotretinoin
Surgery
TopicalBPO/Clinda combo
Metrocream
SystemicAntibiotics
Blue light
Biofilm agents
Retinoic acid blockers
Cytokine blockers - Th1