Acne Flashcards
What is the proper name for acne, what are some common names?
acne vulgaris, common names are pimples, spots, zits
Where does acne grow?
Acne most often affects the face, but it may spread to
involve the neck, chest and back, and sometimes even more extensively over the body.
What is the incidence (% of people with acne)? Is it chronic?
80% of people between 11-30 years old,
20-30% of 20-40 years old
Earlier onset and more persistent in females, severe in males 15%
50% of cases (especially females) persist into adult years.
It is usually considered self-limiting since it subsides in the mid-late 20s but may evolve into a chronic condition
Describe treatment effectiveness and adherence?
Treat it like other chronic conditions, proper treatment can control disease and morbidity. Treatment is effective but adherence poor (30-65% of patients do not adhere to treatment, and 50% do not achieve full benefit due to poor adherence)
How to improve adherence?
Choose treatment based on symptoms, skin type and skin sensitivity, risk of adverse effects and patient’s preference
Improved treatment satisfaction is likely to adherence
What is the general pathophysiology?
- Increased sebum production (androgens may play a
role) and Increased follicular keratinization - Proliferation of bacteria which results in lipolysis of
sebum triglycerides to free fatty acids (bacteria
feast on the triglycerides) - Inflammation
How is a comedo formed?
- increased androgen production -> increased sebaceous gland size and activity -> increased sebum production
- increased keratinization of the epithelial cells cause obstruction of the follicle forming a dense plug
- Sebum becomes trapped and accumulates forming a comedo
- Comedo contains oily sebum, keratinized cells, bacteria
- Sebum continues to be produced -> comedo continues to grow
How do Cutibacterium acne (C. acnes) grow?
feeds off sebum
- C. acnes hydrolyzes the sebum triglycerides into free fatty acids
- Fatty acids increase keratinization feeding into the cycle of more
microcomedones
-> Increase of C. acnes leading to T cell response and inflammation
polymorphonucleocytes move to follicle and bacteria release chemokines - formation of pus
What are the terms to describe acne and its different presentations?
Papule, pustule, nodule, cyst
Describe papule
Solid, elevated lesion <5mm
Describe pustule
Vesical filled with purulent liquid <5mm
Describe nodule
Deep lesion. Warm, tender, firm >5mm diameter. May result in scarring
Describe cyst
A nodule containing liquid, may result in scarring
What does increase in C. acnes lead to?
T-cell response leads to inflammation. Polymorphonucleocytes move to the follicle, bacteria releasing chemokines -> pus formation
Non-inflammatory comedones, white heads vs black heads?
White head • Closed comedone • First clinically visible lesion of acne • Completely obstructed
Black head • Open comedone • Dark color due to contents of the comedone being oxidized (lipid and melanin)
What are contributing factors of acne (6 main ones and 1 controversial theoretical one).
- Genetic predisposition
- Emotional stress
- Hormones - Pregnancy, oral contraceptive pills
- Occlusion (greasy products on the skin, clothing, sweating) - Coal tar, oily products, Physical occlusion from hats, helmets, headbands
- Picking at lesions
- Bacteriostatic soaps (e.g. hexachlorophene) are acnegenic
? Dietary factors (controversial theory)
Correlation with Western diet
? Milk
High glycemic index foods (e.g. white rice, white bread)
What are some drugs that induce acne? (12)
Anabolic steroids Corticosteroids Testosterone Progesterone Phenytoin Lithium Phenobarbital Azathioprine Cyclosporine Isoniazid Disulfiram Quinidine
How to go about assessment? ie what things to look for? (8)
Symptons, characteristics, history, onset, location, aggravating factors, remitting factors, explanatory model.
What to ask about symptons?
Itch? Pain? Any systemic symptoms? Psychological symptoms?
Excessive hair growth (PCOS)? Weight gain?
What to ask about characteristics?
Number and type of lesions present? Distribution of lesions?
Scarring? Hypo- or hyperpigmentation? Inflammation? Signs and symptoms of infection?
What to ask about history?
How long? Does it come and go? Have you experienced this before? What have you tried?
What to ask about onset?
When did it start? What were you doing? Anything change in your life at that point?
What to ask about location?
Where is it?
What to ask about aggravating factors?
What make it worse? Probe with specific examples. Diet probing, occlusion due to helmets, masks, etc
What to ask about remitting factors?
What makes it better? Probe with specific examples.
What to ask about explanatory model?
How does this symptom or condition affect you?
How does acne affect people?
1. Physical symptoms Soreness Itching Painful 2. Psychosocial symptoms (studies show 50% of patients have symptoms of mild to moderate depression and anxiety) Low confidence Low self-esteem Withdrawing from society Depressive symptoms
What global scales are used to access the impact of acne?
DLQI - dermatology life quality index, introduced in PMCO 4
Acne Quality of Life Scales
What are some red flags with acne? (7)
- Acne is drug-induced or due to a known
endocrinopathy (e.g., polycystic ovarian syndrome
as it may be suspected with hirsutism, weight gain) - Systemic symptoms are present (fever, malaise)
- Psychological assessment is required
- Acne at a very young age (may need endocrinology
consult) - Moderate to severe acne requiring prescription
therapy (asses your competency to manage acne) - Acne that is nonresponsive to initial therapy
- Presence of scarring, especially if moderate to
severe
What are 2 differential diagnosis to acne?
- Perioral dermatitis
- excessive steroid use
- erythema, scaling, papulopustular lesions around nasiolabial folds, mouth and chin
- topical steroids on face - refer - Rosacea
Chronic, relapsing condition involving blood vessels
Flushing (redness or erythema), followed by development of inflammatory lesions
Refer to dermatologist
Describe perioral dermatitis
Due to excessive use of steroids on the face Erythema, scaling and papulopustular lesions clustered around the nasolabial folds, mouth and chin. D/c use of topical steroids on face and refer to dermatologist for management
Describe rosacea
Chronic, relapsing condition involving blood vessels Flushing (redness or erythema), followed by development of inflammatory lesions Refer to dermatologist
What are 2 variants of acne?
Neonatal acne
Acne conglobata
Describe neonatal acne
One in 5 infants ≤3 months of age may develop papules, pustules, closed or open comedones on face Due to placental transfer of maternal androgens (neonatal acne) Usually resolves on its own but topical agents under the advice of a paediatrician may be used.
Describe acne conglobata
When acne cysts and nodules fuse together deep in the skin. A form of nodulocystic acne (rare but serious inflammatory skin condition) Face, back, and chest Refer! Requires aggressive management with systemic therapy and cosmetic approaches (lasers).
What are the 4 goals of therapy for acne?
- Clear existing lesions
- Prevent new lesions
- Treat early to minimize scarring, hypo/hyperpigmentation
- Minimize psychological impact
Treatment -> Non-pharm
- Address contributing factors and introduce lifestyle/self-care measures
- Do not pick and touch lesions
- Cleansing
No more than twice daily
Suggest cleansers that are mild and unscented
Do not scrub skin - Cosmetics
Use oil-free make-up, try to avoid multiple layers
Wash off at night!
Hairspray can clog pores, discontinue if possible or wear a headband over exposed skin. - Educate on stress management
- Encourage a well balanced diet
- Cationic (C) bond strips
Activated by water, dirt/oil is anionic, strip adheres to this molecules and removes it when strip peeled off
Temporary improvement in appearance of skin but limited permanent change - Comedone Extraction
Efficacy may be enhanced if pretreated with a peeler (i.e. glycolic acid, salicylic acid)
Treatment - Pharm
- Thousands of non-prescription acne products available
- Different brands, products within the same brand contain varying concentrations of the same medicinal ingredients
Benzoyl peroxide
Salicylic acid
Glycolic acid - Instead of memorizing product names, always look at the active ingredient list on the product label.
Topical Benzoyl Peroxide details
when to use strength MOA Vehicles Administration Response time AE
When to use: First line for mild-moderate acne as monotherapy, combination
Strength:
- 2.5-5% most common
- BPO > 5% no more effective and more irritating
- Unscheduled: strength <5%
- Schedule I: >5%, combination product with a topical antibiotic or retinoid
Mechanism of action: Antibacterial: oxidation of bacterial proteins. Eliminates C. acnes on the surface of the skin and sebaceous follicle. Effective in the prevention of bacterial resistance.
- Mildly comedolytic
Vehicles: Gel, cream, solution, lotion, wash, soap
• Avoid recommending washes, soaps -> little contact time with the face = least effective
Administration: Apply topically to entire affected area
To minimize irritation, start with applying for 15 mins 1st night, 30 mins 2nd night, increase to over night eventually
Response time: • Rapid bactericidal effects may start seeing a decrease in inflamed lesions ~5 days. See optimal improvement 8-12 weeks
Adverse effects • Dryness, peeling, erythema, burning, bleaches clothing, smell that lingers (body odor)
Other counseling • Decrease irritation at initiation by decreasing frequency (eg. apply every 2-3 days, various regimens)
• Sunscreen during the day, BP at night
• Can bleach hair/ clothing
• PRACTICAL TIP: use at night to avoid staining of clothes
Examples: Non-prescription
• Neutrogena On-the-Spot (2.5% benzoyl peroxide)
Prescription
• BenzaClin gel (benzoyl peroxide 5% clindamycin 1%) - Rx
Salicylic acid details when to use strength MOA Vehicles Administration Response time AE
Schedule U: in topical preparations in concentrations <40%
Mechanism of action: Mildly comedolytic Keratolytic, mildly antibacterial, mildly antiinflammatory
Available strengths: 0.5-3.5% daily-BID
Vehicles: Gels, toners, cleansers, washes, pads
Adverse effects: Drying, burning, stinging, erythema, pruritus, peeling
Other • Well tolerated • Less potent than equal strength benzoyl peroxide • 8-12 weeks time to effect
Glycolic acid details
schedule strength MOA Vehicles Administration Response time AE
Schedule: U
Mechanism of action: Mildly comedolytic, causes desquamation
Available strength: 2-15% (40% used as a peel)
Vehicles:
• solution, gel, lotion, cream;
• apply once to BID
Adverse effect:
Burning, stinging, erythema, dryness, pruritus
Other:
• At higher concentrations used for chemical peels
• 6-7 weeks time to effect
zinc acetate or zinc gluconate details
schedule strength MOA Vehicles Administration Response time AE
Schedule: U Mechanism of action: Absorb excess sebum Available strengths: n/a Vehicles: cleansers Adverse effects: burning, stinging Other: • Well tolerated • Time to effect? Assess for improvement @ 4-8 weeks
Resorcinol details
Schedule: U
Mechanism of action: Keratolyltic (mild) and
bactericidal and fungicidal
Available strengths: 1-2% (+ sulfur, salicylic acid)
Vehicles: Variety of formulations
Adverse effects:
• Burning, stinging (Do not apply to large areas of skin or broken skin)
• Can pigment skin in darker individuals
Other: • Needs protective packaging because reactive to light and O2.
• Time to effect? Assess @ 4-8 weeks
ProActiv
Very expensive “acne system”
Contains mostly benzoyl peroxide 2.5% and sulphur
Mask-ne
Due to occlusion of the skin around the perioral region and jawline:
- Hormonally dependent area (more so in
females)
Development of blackheads and white heads along the mask line
Management: - Non Pharm: Wash mask frequently Choose a cotton mask Follow general care measures as discussed
- Pharm: OTC Benzoyl Peroxide OTC Salicylic Acid Prescription: Topical Retinoid, Topical Dapsone, BP + Topical Antibiotics
Patient education (6) things to tell them to be aware of
- Therapy needs to be used for an extended period of time with a switch to maintenance therapy once control established (recall the cascade of acne development).
- Frame patient’s expectations. Empathy from and encouragement from clinician enhances adherence.
- Those with darker skin tones are more susceptible to
hyperpigmentation.
- Need early and aggressive treatment
- Therapy duration is longer in these individuals - Encourage sunscreen use
- Avoid sunscreens with acnegenic benzophenones - Assess adherence and implement strategies to enhance adherence
- Maintain a balanced, low-glycemic-load diet
Monitoring for patient
Encourage patient to record their treatment response in a diary
- Timeframe 4-8 weeks for monitoring
- Lesion count and type (blackheads, white heads, pustules)
- Inflammatory lesions (weeks?)
- Anxiety/depressive symptoms
- The amount and time frame of acne free periods
- Scarring or pigmentation
Follow up for patient
may take several months (2-4 months or longer) to see
results. However, it may be beneficial to check in with the patient within a few days of initiating therapy to see how the patient is tolerating therapy. Future follow-up periods can be extended as applicable and based on parameters that patient monitors.
