ACNE & ROSACEA MANAGEMENT

DR. T. K.

OBJECTIVES

• TO KNOW ACNE & ROSACEA AS A DISEASE • TO UNDERSTAND HOW TO DEAL WITH PATIENT WHO HAS

THEM• TO KNOW THE LATEST RECOMMENDATION REGARDING

THOSE DISEASES• TO UNDERSTAND HOW TO MANAGE & TREAT THEM• TO KNOW WHEN TO REFER

CONTENT

• DEFINITION, EPIDEMIOLOGY & CLINICAL MANIFESTATIONS• MANAGEMENT• PATIENT EDUCATION• NONPHARMACOLOGICAL & PHARMACOLOGICAL• HORMONAL THERAPY• LIGHT-BASED, ADJUNCTIVE, AND OTHER THERAPIES FOR ACNE

VULGARIS • COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM)

ACNE VULGARIS

• A CHRONIC INFLAMMATORY SKIN DISEASE

• THE MOST COMMON CUTANEOUS DISORDER AFFECTING ADOLESCENTS AND YOUNG ADULTS.

EPIDEMIOLOGY

• WORLD WILD PREVALENCE OF ACNE VULGARIS IN ADOLESCENTS FROM 35 TO OVER 90 %

• AGE & GENDER ?

• POST ADOLESCENT AFFECTS WOMEN WHILE ADOLESCENT ACNE, MALE PREDOMINANCE

SURVEY OF OVER 1000 ADULTS, SELF REPORTED ACNE IN MEN & WOMEN :

● 20 TO 29 YEARS: 43 AND 51 %, RESPECTIVELY● 30 TO 39 YEARS: 20 AND 35 %, RESPECTIVELY● 40 TO 49 YEARS: 12 AND 26 %, RESPECTIVELY● AGES 50 AND OLDER: 7 AND 15 %, RESPECTIVELY

EPIDEMIOLOGY

311 RESPONDED TO THE QUESTIONNAIRE. 64.5% SUFFERED FROM ACNE

BOYS > GIRLS85% (--- 12-24 ) YEARS8% (--- 25-34 ) YEARS3% (--- 35 -44 )YEARS

SAUDI MED J 2005; VOL. 26 (10): 1607-1610 PATTERN OF SKIN DISEASES … ALAKLOBY SURVEY

SAMPLE 1076

NON INFLAMMATORY ACNE (COMEDONAL ACNE):

• CLOSED COMEDONES (WHITEHEADS)• OPEN COMEDONES (BLACKHEADS)

INFLAMMATORY ACNE:

PUSTULES AND NODULES.• MILD ACNE• MODERATE ACNE.• NODULOCYSTIC ACNE.• ACNE CONGLOBATA• ACNE FULMINANAS.

PATHOGENESIS

DISEASE OF PILOSEBACEOUS FOLLICLES, FOUR FACTORS ARE INVOLVED:

● FOLLICULAR HYPERKERATINIZATION● INCREASED SEBUM PRODUCTION● PROPIONIBACTERIUM ACNES WITHIN THE FOLLICLE● INFLAMMATION

FOLLICULAR DISTENTION, RUPTURE & INFLAMMATION

RISK FACTORS

• AGE 12 TO 24 YEARS• FAMILY HISTORY • EXTERNAL FACTORS — SOAPS, DETERGENTS, AND

ASTRINGENTS • DIET ? • STRESS • BODY MASS INDEX • MEDICATIONS

CHOCOLATE & ACNEA RANDOMIZED CROSSOVER STUDY, J AM ACAD DERMATOL VOLUME 75, NUMBER 1

• CHOCOLATE CONSUMPTION GROUP HAD A STATISTICALLY SIGNIFICANT (P < .0001) INCREASE IN ACNE LESIONS (+14.8 LESIONS) COMPARED WITH THE JELLYBEAN CONSUMPTION GROUP (-0.7 LESIONS).

STARTED ON PHENYTOIN FOR HIS SEIZURE DISORDER.

DIAGNOSIS

• IDENTIFICATION OF ACNE• SKIN LESIONS (FACE, NECK, CHEST, AND BACK )• NONINFLAMMATORY CLOSED OR OPEN COMEDONE• INFLAMMATORY COULD BE PAPULES, PUSTULES OR NODULES • SYSTEMIC COMPLAINTS (ACNE FULMINANS)

MANAGEMENT

PRETREATMENT ASSESSMENT 

●CLINICAL TYPE AND SEVERITY OF ACNE●SKIN TYPE (EG, DRY, OILY) ●PRESENCE OF ACNE SCARRING●PRESENCE OF POSTINFLAMMATORY HYPERPIGMENTATION●MENSTRUAL CYCLE HISTORY AND HISTORY OF SIGNS OF HYPERANDROGENISM IN WOMEN

●CURRENT SKIN CARE REGIMEN AND ACNE TREATMENT HISTORY●HISTORY OF ACNE-PROMOTING COSMETIC PRODUCTS AND MEDICATIONS●PSYCHOLOGICAL IMPACT OF ACNE ON THE PATIENT

●FOLLICULAR HYPERPROLIFERATION AND ABNORMAL DESQUAMATION

•TOPICAL RETINOIDS•ORAL RETINOIDS

•AZELAIC ACID•SALICYLIC ACID

•HORMONAL THERAPIES●INCREASED SEBUM PRODUCTION

•ORAL ISOTRETINOIN•HORMONAL THERAPIES

●PROPIONIBACTERIUM ACNES PROLIFERATION• BENZOYL PEROXIDE

•TOPICAL AND ORAL ANTIBIOTICS•AZELAIC ACID

●INFLAMMATION•ORAL ISOTRETINOIN

•ORAL TETRACYCLINES•TOPICAL RETINOIDS

•AZELAIC ACID

●FOR COMEDONAL ACNE USE TOPICAL RETINOIDS AS FIRST-LINE THERAPY (GRADE 2A). ADAPALENE 0.1 OR 0.3 % GEL OD.

●FOR MILD TO MODERATE INFLAMMATORY ACNE USE TOPICAL RETINOID, TOPICAL ANTIBIOTIC & BENZOYL PEROXIDE (GRADE 2A).

●FOR MODERATE TO SEVERE INFLAMMATORY ACNE USE TOPICAL RETINOID, TOPICAL BENZOYL PEROXIDE & ORAL ANTIBIOTIC (GRADE 2A). DOXYCYCLINE AND MINOCYCLINE 50-100 MG OD\BD UP TO 3-4 MONTHS.

●WOMEN WITH MODERATE TO SEVERE ACNE UNRESPONSIVE TO TOPICAL THERAPY & ORAL ANTIBIOTICS & WHO DO NOT DESIRE PREGNANCY USE OF COMBINATION ORAL CONTRACEPTIVES (GRADE 2A). 3-6 MONTHS DURATION.●WOMEN WITH MODERATE TO SEVERE ACNE UNRESPONSIVE TO TOPICAL THERAPY, ORAL ANTIBIOTICS & COC USE SPIRONOLACTONE (GRADE 2B). 3-6 MONTHS DURATION.●FOR SEVERE, RECALCITRANT, NODULAR ACNE USE ORAL ISOTRETINOIN < 0.5 MG\KG\DAY FOR 20 WEEKS, OR A CUMULATIVE DOSE OF 120-150 MG PER KG

MAINTENANCE THERAPY 

• ACNE SYMPTOMS TYPICALLY RECUR OVER YEARS• ANTIBIOTIC RESISTANCE LIMIT THE USE OF ANTIBIOTICS AS

LONG-TERM THERAPY.• TOPICAL RETINOIDS IS THE COMPELLING OPTION . (GRADE 2A

). • BENZOYL PEROXIDE CAN BE ADDED TO THE TREATMENT

REGIMEN• 12 WEEKS IN MODERATE TO SEVERE ACNE• 16 WEEKS IN SEVERE ACNE

• LIGHT BASED THERAPIES NOT BE USED AS 1ST LINE TREATMENT FOR ACNE VULGARIS (GRADE 2B).

• PRIMARILY COMEDONAL ACNE, DESIRE AN ACCELERATED RESPONSE USE CHEMICAL PEELS (GRADE 2B).

• NOT USING MICRODERMABRASION FOR THE TREATMENT OF ACNE(GRADE 2C).

• INTRALESIONAL GLUCOCORTICOIDS FOR SELECTED NODULAR INFLAMMATORY ACNE LESIONS IN ORDER TO ACCELERATE THEIR RESOLUTION (GRADE 2C).

POSTINFLAMMATORY HYPERPIGMENTATION

• TOPICAL RETINOID AS A COMPONENT OF ACNE THERAPY (GRADE 2B).

ACNE CONGLOBATA:

• LARGE DRAINING LESIONS, SINUS TRACTS, AND SEVERE SCARRING

• SYSTEMICSYMPTOMS ARE ABSENT.

• LOWER DOSES OF ISOTRETINOIN (0.5MG/KG/DAY OR LESS) PLUS SYSTEMIC GLUCOCORTICOIDS

ACNE FULMINANS:

• ULCERATIONS AND CRUSTS + FEVER & ARTHRALGIAS

• WBC 17,000• TREATED WITH SYSTEMIC

GLUCOCORTICOIDS (0.5 TO 1 MG/KG) PLUS ORALISOTRETINOIN (0.5 MG/KG/DAY OR LESS & GRADUALLY INCREASED) OR ORAL ANTIBIOTICS

ACNE NEONATORUM

• ALSO CALLED NEONATAL CEPHALIC PUSTULOSIS ONSET WITHIN 1ST FEW WEEKS OF LIFE

• USUALLY RESOLVES WITHIN 4 MONTHS WITHOUT SCARRING

• INFANTILE ACNE (WITH TYPICAL ONSET AT AGE 3-6 MONTHS)• IN SEVERE CASES, 2.5% BENZOYL PEROXIDE LOTION CAN BE USED

TO HASTEN RESOLUTION.

ACNE IN PREGNANCY

• WOMEN WITH SEVERE ACNE, ONLY A FEW TOPICALS ARE CATEGORY B AND SAFE IN PREGNANCY

• INCLUDING CLINDAMYCIN, ERYTHROMYCIN, AND AZELAIC ACID.

PROGNOSIS

• ACNE TYPICALLY IMPROVES AS PATIENTS PROGRESS THROUGH ADOLESCENCE .

• NO LONG-TERM CONSEQUENCES FROM ACNE BUT SEVER LESIONS LEAVE RESIDUAL SCARRING .

INSTRUCTIONS

• ACNE DIET: AVOID MILK, HIGH GLYCEMIC INDEX & CHOCOLATE• COMPLIANCE MINIMUM OF 8 WEEKS & MAINTENANCE• MORNING & EVENING WITH TOPICAL TREATMENT• ISOTRETINOIN IPLEDEGE & REGULAR LAB TESTS • MAY FLARE SLIGHTLY AFTER INITIATING TREATMENT• USE GENTLE CLEANSERS AND SHOULD AVOID IRRITATING SKIN

CARE PRODUCTS. SELECT "NONCOMEDOGENIC" SKIN CARE PRODUCTS AND COSMETICS.

WHEN TO REFER

• SCARS FORMATION • NO RESOLUTION OF THE LESIONS AFTER 8 WEEKS• PSYCHOLOGICAL COMORBIDITY• SIGNIFICANT SCARRING

ROSACEA

EPIDEMIOLOGY

• AFFECT OVER 14 MILLION PEOPLE IN US . • (AROUND 5 %- 10 % OF THE POPULATION )• MOSTLY AFFECTS FAIR-SKINNED WHITE PEOPLE . • FEMALE > MALE

CAUSES

THE UNDERLYING CAUSE IS CURRENTLY UNKNOWN.

RISK FACTORS

STRONG LIGHTER SKIN TYPEHOT BATHS/SHOWERSTEMPERATURE EXTREMESSUNLIGHTEMOTIONAL STRESSHOT DRINKSEXERCISE

WEAK (SPICY FOODS – ALCOHOL - MEDICATIONS )

DIAGNOSIS • PRESENCE OF RISK FACTORS• FLUSHING/ERYTHEMA• PAPULES AND PUSTULES• TELANGIECTASES• OCULAR MANIFESTATIONS• FACIAL DISTRIBUTION• PHYMATOUS CHANGES• BURNING OR STINGING PAIN• ACNE VULGARIS

SUBTYPES

• SUBTYPE 1: ERYTHEMATOTELANGIECTATIC• SUBTYPE 2: PAPULOPUSTULAR• SUBTYPE 3:PHYMATOUS• SUBTYPE 4:OCULAR MANIFESTATIONS

SUBTYPES

SKIN CONDITIONS THAT SHARE SIMILAR FEATURES WITH ROSACEA

Distinguishing features Condition

Comedone formation No ocular symptoms

Acne vulgaris

Associated with itching and often improves over time when causative agent is removed

Contact dermatitis

Rash appears on multiple body parts with sunlight exposure

Photodermatitis

Has distinct distribution pattern involving the scalp, eyebrows, and nasolabial folds

Seborrheic dermatitis

Rarely has pustules Systemic lupus erythematosus

ROSACEA TREATMENT

MANAGEMENT

GENERAL MEASURES: -AVOIDING FLUSHING.

-SKIN CARE. -SUN PROTECTION.

-COSMETIC CAMOUFLAGE.

SPECIFIC TYPE MANAGEMENT: -ERYTHEMATOTELANGECTATIC ROSACEA.

-PAPULOPUSTULAR ROSACEA -PHYMATOUS ROSACEA

-OCULAR ROSACEA.

Treatment

Topical antibiotic(metronidazole) / anti-inflammatory and / or oral antibioticand / or brimonidineoral minocycline, azithromycin, clarithromycin .

T line

1st

Patient group

1st subtype 1(erythematotelangiectatic

2(-papulopustular)

3-mild form subtype 3

Benzoyl preoxide adjunct

Laser treatment ±tacrolimus for telangiectases and erythema

adjunct

(electrosurgery/laser/cryotherapy)

Oral isotretinoin

1st

2nd

4-severe subtype 3

Artificial tears and warm water rinsesTopical metronidazole / topical

ciclosporin

1st

adjunct5-subtype 4(ocular

PROGNOSIS

• THERE IS NO CURE .• MANY PEOPLE ARE UNAWARE.• MILD FORMS CONTROL BY AVOID TRIGGERS . • OTHER PATIENTS NO IMPROVEMENT WITH VARIETY OF

TREATMENT MODALITIES .

INSTRUCTIONS

• AVOIDANCE TRIGGERS • DAILY APPLICATION OF A SUNSCREEN PROTECTION • AVOIDANCE OF MIDDAY SUN• GENTLE SOAP-FREE CLEANSER . • EMOLLIENT.

WHEN TO REFER

•  OCULAR  ROSACEA• REFRACTORY CASES OR PHYMATOUS CHANGES • ORAL ISOTRETINOIN ABLATIVE/PULSED DYE THERAPY –

ELECTROSURGERY

REFERENCES