ACNE EVALUATION AND MANAGEMENT

(1)

Katie Fiala, MD Assistant Professor Department of Dermatology Scott and White Northside Clinic

ACNE

EVALUATION AND

MANAGEMENT

(2)

 85% of people age 12-24

 20% with significant scarring  Most common skin condition

 Pathogenesis: multifactorial

 Comedone formation

 Rupture and inflammation

 Propionibacterium acnes

 Androgenic hormones

 Treatment rationale

 Prevention of scarring

 Reduction of psychosocial distress

(3)

(4)

Areas with most sebaceous glands –

face, upper trunk

Acne Fulminans = severe acne with

systemic symptoms (Fever, joint aches)

Acne Congoblata = severe comedones

with scarring, no systemic symptoms

Acne Keloidalis Nuchae

(5)



Comedonal



Mild inflammatory



Moderate inflammatory



Nodulocystic

(6)

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

Cosmetics, pomades



Mechanical occlusion



Medications: steroids, lithium, some

antiepileptics, iodides



Endocrine disorders: congenital

adrenal hyperplasia, PCOS

(12)

Perioral dermatitis Syringomas Tuberous sclerosis Verruca Plana Molluscum RULE OUT

(13)

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

Dysmenorrhea or hirsutisum



DHEA-S



Free testosterone



LH, FSH



Wound culture if not responding –

gram neg folliculitis

(18)

Retinoids

Mainstay for comedonal acne

Also anti-inflammatory

Antibiotics: topical vs oral

Hormonal treatments

Oral contraceptive pills Spironolactone

Isotretinoin

(19)



Non-comedogenic/ non-acnegenic



Retinoids



Antibacterial



Azaelic Acid



Dapsone

TOPICAL THERAPY

(20)

Consider for ALL non-pregnant patients Formulations:

 Adapalene 0.1% and 0.3% (Differin) – cream, lotion, gel

 Tretinoin (Retin-A and others): must apply at night

 0.01%, 0.025%, 0.05%, 0.1% cream, gel

 0.04%, 0.1% microgel

 Tazarotene (Tazorac) 0.05% and 0.1%: Preg category X

Side effects

 Pustular flare

 Skin irritation

 Sun sensitivity

(21)

(22)

Expect a flare initially

Pea-sized amount for entire face (do not “spot

treat”)

A facial moisturizer can be used immediately

after application

Avoid exfoliating scrubs/washes/

waxing/astrigents

Every-other-day may be necessary Sun Protection

TOPICAL RETINOIDS

(23)

Combination products

Benzaclin/Duac/Acanya (BPO + clinda)

Benzamycin (BPO + erythro) – must be

refrigerated

Single-agent

Benzoyl peroxide (OTC and Rx)

Clindamycin (lotion, soln, “pledgets”) Erythromycin (rarely indicated –

resistance common)

ACNE

(24)

Aczone®

Antibacterial and antiinflammatory

No significant decrease in Hgb in G6PD def

patients

May be used in sulfa allergic patients Most helpful in female hormonal acne Risk of yellow discoloration with BPO

 Piette WW, Taylor S, Pariser D, et al. Hematologic safety of dapsone gel, 5%, for topical treatment of acne vulgaris. Arch Dermatol. 2008 Dec;144(12):1564–70.

(25)

Azaleic acid

Kills bacteria

Decreases keratin production

Salicylic acid, lactic acid, glycolic acid

Keratolytics

Chemical peels can be performed

Hydroquinone

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Minocycline 100mg bid Doxycycine 100mg bid

Clindamycin 150 -300mg bid Bactrim DS bid

Azithromycin 250-500mg TIW

Amoxicillin 500mg bid (pregnancy) Spironolactone 50 - 150 mg daily Oral contraceptives (Yasmin)

Isotretinoin 1mg/kg bid x 5 -6 mo ORAL THERAPY

(28)

 Regimen: Start twice daily and taper (as tolerated)

over 2-6 months

 Agents

 Tetracycline (less lipophilic)

 Doxycycline

 May take with food

 Sun sensitivity

 Minocycline

 Skin hyperpigmentation

 “Lupus-like” syndrome

 Vestibular effects

 Side effects: GI distress, hypersensitivity reactions,

pseudotumor cerebri, yeast vaginitis

ACNE

(29)

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Erythromycin

 High incidence of P. acnes resistance

TMP-SMX (Bactrim)

 Higher incidence of severe allergic reaction

 Has been associated with leukopenia

Amoxicillin Clindamycin  Pseudomembranous colitis Azithromycin  TIW dosing  QT prolongation

ACNE

OTHER ANTIBIOTICS

(33)

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Strongly consider for:

Female acne of the lower face and neck Flares with menstrual cycle

Any female patient who might be a candidate for isotretinoin (or

spironolactone) Agents OCPs Spironolactone ACNE HORMONAL TREATMENT

(35)

Ortho-Tri-Cyclen, Estrostep, and YAZ are

FDA-approved for acne

>14 yo

Has already started menstruation

Increased sex hormone binding globulin,

so decreases testosterone

(36)

AR blocker and inhibitor of 5a-reductase SE: hyperkalemia, breast tenderness,

irregular periods, fatigue, headache, hypotension

Preg Cat D

Feminization of male fetus 25-200mg per day

(37)

Brands: Accutane, Amnesteem, Claravis,

Sotret

Indicated for the treatment of severe

recalcitrant nodular acne

iPLEDGE program instituted March 1, 2006

 Prescribers, patients and pharmacies must be registered

 Tracks physician/patient compliance with

contraception, pregnancy tests and follow-up

 Highly restrictive

(38)



0.5 – 1.0 mg/kg/day for 20 weeks



Total dose 120-150mg/kg



BID dosing



Fatty foods increase absorption

(39)

2 forms of contraception for one month before

until one month after therapy

2 negative pregancy tests before starting

isotretinoin

Pregancy tests must be repeated every 30

days and reported to iPledge

Patients must confirm comprehension of

contraceptive counseling online before obtaining each prescription

ISOTRETINOIN

(40)

Primary

“Highly effective”

Virtually all hormonal forms, tubal ligation and vasectomy

Secondary

Barrier methods Abstinence

ISOTRETINOIN

(41)

Females “who cannot get pregnant”

Hysterectomy or bilateral oophorectomy “Medically confirmed” to be

post-menopausal

“Continuous abstinence from

heterosexual contact”

Males are counseled to use condoms

ISOTRETINOIN

MALES AND FEMALES OF NON-CHILD BEARING

(42)

Transient (sometimes serious) flare Laboratory monitoring: LFTs, lipids

Pseudotumor cerebri: more likely when

taken along with tetracyclines

Xerosis and cheilitis

Inflammatory bowel disease

Depression

ISOTRETINOIN

(43)

 Crockett SD et al. Isotretinoin use and the risk of inflammatory bowel disease: A case–control study. Am J Gastroenterol 2010 Mar 30

8,189 pts with IBD and 21,832 controls 3664 Crohns & 4428 UC

Isotretinoin use strongly associated with UC

(OR 4.36) but not with Crohns

Higher dosage and longer duration increased

risk

(44)

 Etminan M, et al. JAMA Dermatology.

2013;149(2):216-220.

Meta-analysis of 4 large studies

Did not find indication that isotretinoin

confers increased risk of IBD

I still makes pts aware of the potential risk,

stop if bowel sxs until cleared by GI, ? TCN association

(45)

 Cohort studies suggest no link between isotretinoin

and depression

 Cohen J, et al. No association found between patients receiving isotretinoin for acne and the development of depression in a Canadian prospective cohort. Can J Clin Pharmacol. 2007 Summer;14(2):e227-33. Epub 2007 Jun 6

 Chia CY, et al. Isotretinoin therapy and mood changes in

adolescents with moderate to severe acne: a cohort study. Arch Dermatol. 2005 May;141(5):557-60.

ISOTRETINOIN

(46)

Pts with substantial acne have higher

rate of suicidal ideation, regardless of treatment.

Halvorsen et al. J Invest Derm. 2011;131(2)363-70

I counsel pts on potential association, enlist help from PCP and mental health professional when needed.

(47)

If you believe your patient is a candidate for

isotretinoin:

 Prepare patients for the work involved

 Be prepared to work with the dermatologist regarding mood issues and contraception

If you would like to prescribe isotretinoin:

 Be very familiar with the side effects and complications

 Understand appropriate dosing and dosing strategy

 Become intimately familiar with iPLEDGE

ISOTRETINOIN

(48)

 Have patience

 I tell my patients to expect 30-40% improvement over 2

months

 Use topical retinoids

 Take the time to counsel patients on what to expect and how to avoid irritation

 Do not use short courses of antibiotics

 You are treating inflammation, not infection  Do not forget about hormones

 Especially in a patient who may require isotretinoin

 Be suspicious of physician-dispensed products and light-based therapies

 More effective and less expensive treatments are available