Transcript Why is Acne? - Back to Medical School

Acne and its Treatment
Mark Goodfield
Basic epidemiology
• 80 -100% of teenagers (physiological acne)
• 1% of 25 year old men
• 15% of 25 year old women (10% at 35, 5%
at 45)
• All races (Chinese)
Acne Vulgaris
• Inflammatory condition of the pilosebaceous unit
– Blockage
– Leakage
– Bacterial overgrowth
Acne Vulgaris
• Over-sensitivity of glandular elements to
normal androgen levels
– High sebum production
– Epithelial proliferation in duct
Endocrine problems
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Acromegaly
Cushings
Androgenisation
Late onset congenital adrenal hyperplasia
PCOS
All rare
Acne Vulgaris
• Enlarged blocked sebaceous glands which
leak
• Bacterial overgrowth
• Lead to inflammatory lesions
• Rupture leads to cystic lesions
Bacteriology
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Propionobacteria Acnes
P.granulosum
Staph epidermidis
Malassezial yeasts
Bacteriology
• Bacterial products
– Lipases
– Proteases
– Phosphatase
Relevant to alterations in sebum that allow
leakage and breakdown of glandular membrane
Acne Vulgaris: Morphology
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Blackheads – open comedones
Whiteheads – closed comedones
Papules
Pustules
Cysts
Pomade acne
SI +++
Differential diagnosis
• Rosacea
• Folliculitis
– Bacterial
– Pityrosporal
– Occlusive
• Pili incarniti
• Keratosis pilaris
• Oddities
– Angio-fibromata
Rosacea
Prominent pores
Trichostasis spinulosa
Factors Modifying Acne
• Menstrual cycle
• UV light
• Diet
• Stress
• Drugs
• Cosmetics; this is discussed under the heading of patient
examination
PCOS
• Consider this possibility, especially if the acne
patient has :
- irregular periods (> 3 months)
- hirsuties
- obesity
- infertility
If appropriate consider relevant investigations but
they are relatively expensive
Some oral and topical drugs/preparations can
induce acne
• Topical corticosteroids
• Some hair
preparations can
produce pomade acne,
especially in Afro Caribbeans
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Oral corticosteroids
anabolic steroids
Lithium
cyclosporin
Iodides taken orally,
which may be part of
some homoeopathic
therapies
Patterns of Acne
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Sandpaper acne
Submarine comedones
Macrocomedones
Localised acne
Acne excoriee
Sinus tract
Acne conglobata
Gram negative folliculitis
Sandpaper acne
Submarine
comedones
Localised muzzle acne
Sinus tract acne
Acne Treatment
• Keep it simple and topical if possible
– Retinoids: modify sebaceous duct activity,
mildly anti-inflammatory
– Benzoyl peroxide: anti-bacterial, modify duct
activity
– Azelaic acid: antibacterial, anti-inflammatory
– Nicotinic acid: anti-inflammatory
– Antibiotics: antibacterial and anti-inflammatory
1.Actions of Anti-Acne Therapies
Topical retinoids:
 Normalizes ductal
desquamation
 Reduces inflammatory
response
Antibiotics:*
• Inhibit P Acnes
• Reduce inflammation
Oral Isotretinoin:
 Reduces sebum
 Normalizes ductal
desquamation
 Inhibit P acnes growth
 Reduces inflammatory
response
Hormones:
 Reduce sebum
production
 Reduce comedones
Benzoyl peroxide:*
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Inhibits P Acnes
• Reduces
inflammation
*also reduce comedones
Acne Vulgaris: Oral Treatment
Options
– Antibiotic for inflamed lesions
– Hormonal treatment in women
– Isotretinoin if severe
Aim Treatment at Morphology
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Blackheads and closed comedones
– Topical retinoid
– Benzoyl peroxide
– Consider cautery
This demonstrates, to the right, an untreated area of
macrocomedones and to the left an area treated 3 weeks
previously
Aim Treatment at Morphology
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Inflamed lesions
– Topical antibiotic
– Azelaic acid
– Nicotinamide
Aim Treatment at Morphology
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Both occlusion and inflammation
– Combinations eg isotrexin, DUAC etc
Oral Antibiotics?
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Cochrane Review
– Oral no better than topical
– Oral no better than BPO
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Only indicated for:
– Extensive disease
– Intolerance of topicals
Oral Antibiotic: Tetracyclines
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Oxytetracycline 1gram daily (absorption)
Lymecycline: 1(2) tablet daily
Doxycycline 50-100mg daily
Minocycline MR 100mg daily
– ANA, LFT pre-treatment: 15% risk of hepatitis
or lupus
Oral Antibiotics: Others
• Erythromycin 1 gram daily
• Trimethoprim 200 – 300 mg bd
– Gram negative folliculitis
How Long Should Treatment Be?
• 6 months
– 40-50% improvement at 12 weeks
– If not, move on
– 2-3 courses
Treatment failure in primary
care
Wrong treatment
 Poor treatment usage
 Severe disease
 Bacterial problems - resistance
 Patient expectation
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Treatment of “Cystic” Acne
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Small, acute, 'cyst' (nodule
– topical clobetasol
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Larger 'cysts'
– 'new'
- il triamcinalone
– 'old' - cryotherapy
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Very Large 'cysts' (sinus tracts)
– very difficult: probably surgical
Isotretinoin: Clinical Guidelines?
• Not yet available from the BAD
• But –
– Severe nodulo-cystic acne
– Acne resistant to oral therapies
– Severe psycho-social upset
Isotretinoin
• 13 cis retinoic acid
• Adjust duration to suit tolerable dose
• 1mg/kg body weight for 16 weeks
– 2/3 complete and permanent cure
– 20% occasional spot
– 10-15% need further treatment
Isotretinoin monitoring: Before
Treatment
• Full discussion of indications for treatment
and side effects
• Assess patient’s views
• Appropriate blood tests
– LFT
– Lipids
– Pregnancy test
Isotretinoin Side Effects
• Mainly understandable – eg mucocutaneous
• Most important for monitoring:
– Pregnancy risk management
– Mood change
Isotretinoin Metabolism
• Rapid absorption – enhanced by fatty food
• Liver metabolised
• Excretion 50% renal, 50% hepato-biliary
Isotretinoin Lipid Effects
•  triglycerides,  cholesterol,  HDL
cholesterol
• Can reverse this with fish oil
supplementation (70% reduction in TG)
• In practice, rare to need to treat
– Ensure fasting sample
– Discontinue if 2-3 fold increase in lipid levels
Isotretinoin LFT Effects
• Unusual to be a problem – personal
experience is of 3 patients in 14 years
• If encounter raised LFTs
– Recheck
– Ask about alcohol
– Ignore if intermittent and  doubled enzymes
– Stop if persistent and higher than double
Isotretinoin Monitoring: Mood
Change
• Depressive symptoms
• Suicidal behaviour
• Aggressive behaviour
Isotretinoin Monitoring: Mood
Change
• No hard evidence that it occurs
• Certainly not predictable: rare in my
experience (50% of patients?)
• May be idiosyncratic if it occurs
• Aggressive behaviour may be more
common than depression
Depression Screening
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How have you been feeling recently?
Have you been low in spirits?
Have you been able to enjoy the things you usually enjoy?
Have you had your usual level of energy, or have you been
feeling tired?
• How has your sleep been?
• Have you been able to concentrate on newspaper articles,
or your favourite TV or radio programme?
• BMJ screening questions
Practical Tip
• Take after large meal – doubles bioavailabilty
Relapse After Isotretinoin
Probably more common than the
published work now that isotretinoin is
widely used
 There are patients who require
multiple courses or long term low dose
treatment – 5%?
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Scarring
• Minor degrees – common
• Pigment change is NOT scarring
• Better to treat early to avoid, rather than
manage later
Ice pick scars
Hypertrophic scar
Post Inflammatory pigmentation is very persistent
and very difficult to treat
This patient suddenly developed many exudative
haemorrhagic lesions
This patient also suddenly developed many exudative
haemorrhagic lesions
Acne Fulminans
Widespread inflammatory acne usually
with cystic lesions
 Systemic upset, arthralgia, erythema
nodosum
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