Tiffany Herd, MD

Pediatric Dermatology Fellow

Baylor College of Medicine/Texas Children's Hospital

Review Acne Pathogenesis

Clinical Evaluation

Treatment Guidelines

Psychosocial Impact of Acne Acne is the most common skin condition in the U.S.

50 million people in the U.S. affected

85% of teenagers experience acne1

The impact of acne may be equivalent to asthma or epilepsy2

Acne patients experience functioning and emotional effects similar to patients with psoriasis,vitiligo, atopic dermatitis and urticaria3

1Zaenglein AL et. Al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 20162Thomas, D.R. Journal of Cutaneous Medicine and Surgery. 20043Nguyen CM et al. The psychosocial impact of acne, vitiligo, and psoriasis: a review. Clin Cosmet Investig Dermatol. 2016

Acne negatively impacts self esteem and is associated with poor body image1

Acne is related to decreased willingness to engage socially and poor academicperformance1

Increased rates of suicidal ideation and attempts 2

More likely to be unemployed3

The severity of acne may not correlate with the severity of emotional impact

1Nguyen CM et al. The psychosocial impact of acne, vitiligo, and psoriasis: a review. Clin Cosmet Investig Dermatol. 2016

2Picardi A et al. Clin Dermatol, 2013

3Bhate K, et al. Br J Dermatol, 2013

PATHOGENESIS

4. Ongoinginflammation

leading tonodule/Cyst

formation andpotentialscarring

1. Abnormalfollicular

keratinization(hyperproliferation

and shedding resultsin the microcomedo)

2. Propionibacterium acnesproliferation

3. Increased sebum production fromandrogenic stimuli

PATHOGENESIS

Leakage of sebum into the dermisand proinflammatory mediatorssecreted by P. acnes leads to ongoingINFLAMMATION

Krakowski AC et al. Practical Considerations in Acne Treatment and theClinical Impact of Topical Combination Therapy. Pediatric Dermatology, 2008

James WD. Acne. New Engl J Med. 2005

James WD. Acne. New Engl J Med. 2005

Onset

Severity (good, average or bad day?)

Menstrual History

Treatments (duration)

Menstrual history

Family history (genetic influence on sebum production, etc)

Signs of Hyperandrogenism

Morphology

Location

Scarring?

CASE 1 - MILD COMEDONAL ACNE

ACNE MANAGEMENT

Abnormal desquamation of KCs

• Salicylic acid

• Topical retinoids

• Isotretinoin

Sebum production

• Sal acid; BPO

• Topical retinoids

• Isotretinoin

• Hormonal Rx

Bacterial colonization

• Sal acid; BPO

• Topical antibiotics

• Oral antibiotics

• Isotretinoin

Inflammation

• Sal acid; BPO

• Topical antibiotics

• Topical retinoids

• Oral antibiotics

• Isotretinoin

Thiboutot et al. Practical Management of Acne for Clinicians. J Am Acad Derm. 2017

THE BASICS OF ACNE SKIN CARE

Gentle face cleansing with a mild cleanser, slightevidence to support washing twice a day1

Avoid squeezing/picking acneiform lesions

Non-comedogenic facial moisturizer with sunscreenat least daily (QAM)

Select non-comedogenic (non-acnegenic, oil-free)cosmetic products (QPM)

Treatment takes weeks to months

Don’t “spot treat”

1Choi JM. A Single-Blinded, Randomized, Controlled Clinical Trial Evaluating the Effect of Face Washing on Acne Vulgaris. Pediatr Derm. 2006

Gentle Cleansers Purpose Gentle Cleansing Bar/Wash

Neutrogena Fresh Foaming Cleanser

Cetaphil Antibacterial Soap

Vanicream Gentle Facial Cleanser

Facial moisturizers for daytime Cetaphil UVA/UVB Defense Facial Moisturizer (SPF 50)

Neutrogena Healthy Defense (SPF 30 or 45)

Neutrogenia Oil-Free Moisture (SPF 15)

For nighttime may use similar products/brand without sunscreen

Benzoyl Peroxide Washes Panoxyl Acne Foaming Wash (4% or 10% BPO)

Neutrogena Clear Pore Cleanser Mask

Oxy Rapid Treatment Face Wash

Salicylic acid washes (targets abnormal keratinization) Neutrogena Oil-free Acne Wash

Make-up Oil-free

Non-comedogenic

Neutrogena, Clinique

Bar soaps, washes, gels, lotions, creams, pads2.5% to 10%

Combination: Clindamycin, Erythromycin, oradapalene

• Gels, creams, lotions, solutions,pads, and washes

• Up to 2%

Types: natural vs. synthetic

Benefits

Side effects

Skin peeling, erythema, dryness, burning, and itching

Minimize side effects with a daily non-comedogenic moisturizer (apply aftertopical retinoid)

Apply at night and not in the morning

Use 3 times weekly if necessary

BPO inactivates topical tretinoin

ACNE MANAGEMENT

Abnormal desquamation of KCs

• Salicylic acid

• Topical retinoids

• Isotretinoin

Sebum production

• Sal acid; BPO

• Topical retinoids

• Isotretinoin

• Hormonal Rx

Bacterial colonization

• Sal acid; BPO

• Topical antibiotics

• Oral antibiotics

• Isotretinoin

Inflammation

• Sal acid; BPO

• Topical antibiotics

• Topical retinoids

• Oral antibiotics

• Isotretinoin

Doxycycline

Minocycline

Erythromycin (47% resistance)

Azithromycin

Trimethoprim-sulfamethoxazole

Limit therapy to 3 to 6 months

James WD. Acne. New Engl J Med. 2005

HORMONAL ACNE: EVALUATION Endocrine work-up is rarely indicated Strength of Recommendation A/Level I Evidence

Reserved for Females w/ recalcitrant acne

Females w/ demonstration of hyperandrogenism

Acanthosis and Hirsutism are the most reliable markers of PCOS1

Mid-childhood acne

Bone age

Total/free testosterone

DHEA-S

Sex hormone-binding globulin

17-hydroxyprogesterone

LH/FSH

Total and free Testosterone

1Schmidt TH et al. Cutaneous Findings and Systemic Associations in Women with Polycystic Ovarian Syndrome. JAMADermatol. 2016

Combined Oral Contraceptives

Oral Spironolactone 5 alpha reductase and sex hormone globulin

25 mg daily (up to 100-200 daily)

Can be combined with OCP (augmented benefit?)

? Increased risk of breast cancer

No need to check K in healthy patients1

1Layton AM et al. Oral Spironolactone for Acne Vulgaris in Adult FemalePatients. Am J Clin Dermatol. 2017

ACNE MANAGEMENT

Abnormal desquamation of KCs

• Salicylic acid

• Topical retinoids

• Isotretinoin

Sebum production

• Sal acid; BPO

• Topical retinoids

• Hormonal Rx

• Isotretinoin

Bacterial colonization

• Sal acid; BPO

• Topical/oral antibiotics

• Isotretinoin

Inflammation

• Sal acid; BPO

• Topical/oral antibiotics

• Topical retinoids

• Isotretinoin

Oral isotretinoin should be first-line therapy for very severe acne

Weight-based dosing starting at 0.1 mg/kg/day

Goal dose of 120mg-150mg/kg = average 6 months therapy Some studies suggest higher cumulative doses to 225 mg/kg (should proceed until full

clearance of acne)

Ipledge

Side effects

Lab monitoring

Ages 1-7*

Concern for underlying hyperandrogenism

Full history and physical examination including assessment of height growthvelocity Precocious puberty

Cushing syndrome

Late-onset congenital adrenal hyperplasia

Adrenal or gonadal secreting tumor

Consider bone age, DHEA-S, FSH, LH, prolactin, 17-OHP, cortisol, endocrineinvolvement

Bree AF et al. Acne Vulgaris in Preadolescent Children: Recommendations for Evaluation. Pediatr Dermatol. 2014

A. Fried foods

B. Polycystic ovarian syndrome

C. Chocolate

D. Stress

E. Hypothyroidism

A. Fried foods

B. Polycystic ovarian syndrome

C. Chocolate

D. Stress

E. Hypothyroidism

A high-glycemic-index/-load diet was positively

associated with acne vulgaris1

A positive association exists between intake of skim

milk and acne2

1Cerman AA et al. Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris. J Am Acad Dermatol 2016

2LaRosa CL et al. Consumption of dairy in teenagers with and without acne. J Am Acad Dermatol 2016

Some evidence that topical tea polyphenols may decrease sebum production (anti-inflammatory and anti-microbialproperties)1

Topical antioxidants and niacinamide may have sebostatic effects 2

Salicylic acid and alpha-hydroxyl acids, linoleic acids target abnormal keratinization 2

Zinc salts may have anti-inflammatory effects and may have a role in acne therapy (limited data) 2

1Saric S et al. Green Tea and Other Tea Polyphenols: Effects on Sebum Production and Acne Vulgaris. Antioxidants 2016.

2Araviiskaia E et al. The role of topical dermocosmetics in acne vulgaris. JEADV 2016.

Acne Guidelines

Early and effective treatment is important to minimize potential risk for acnescarring

Abnormal follicular keratinization has an early role in acne pathogenesis Retinoids essential role in acne therapy

For the majority of patients a topical retinoid plus BPO is first line therapy

Avoid topical or systemic antibiotics as a monotherapy

Benzoyl peroxide concentrates within the sebaceous follicle and works throughfree-radical mediated degradation of bacterial proteins thus decreasingantibiotic resistance and increasing efficacy when used with topical/systemicantibiotics

Most patients with acne should receive maintenance therapy with a topicalretinoid with or without BPO

Consistent use of medications for 8-12 weeks is necessary before efficacy can bedetermined