Acne and Related Conditions Flashcards
Acne facts
- Most common disease in America
- Affects 85% of Americans at some point in their lives
- 20% will have severe scarring disease
- Affects areas of dense sebaceous units: face, chest, and back
Acne Pathogenesis
***Multi-factorial
- Genetics
- The inclination towards follicular epidermal hyperproliferation is inherited
- Androgen hormones
- PCOS in women or adrenal gland hyperplasia
-Inflammation
- P. acnes infection
- Excessive sebum
Formation of acne
***Occurs in pilosebaceous units
- Microcomedone is formed
- The follicle is distended. Then, the follicular opening becomes dilated, and an open comedone results.
- The follicular wall thins, and ruptures.
- Inflammation and bacteria may be evident, with or without follicular rupture.
- Dense inflammatory infiltrate occurs throughout the dermis.
Acne Pathogenesis
(Image)
Clinical Manifestations of Acne
- pain, tenderness, and pruritis occasionally
- Systemic symptoms are usually absent except with Acne Fulminans
- Psychological symptoms
- Physical: comedones, papules, pustules, and nodules in a sebaceous gland distribution.
- Face may be the only involved skin surface, but the chest, back, and upper arms are often involved
Classification of Acne
(Grades I-IV)
Grade I: multiple open comedones, no inflammatory lesions present
Grade II: multiple closed comedones and few papules and pustules
Grade III: mostly papules and pustules
Grade IV: multiple open and closed comedones, papulopustules, and cysts
Classification of Acne
(mild, moderate, severe)
-Mild acne
-comedones and a few papulopustules
-Moderate acne
-comedones, inflammatory papules, and pustules. Greater numbers of lesions are present.
-Severe acne“nodulocystic acne”
-comedones, inflammatory lesions, and large nodules around 5 mm in diameter. Scarring is often evident.
DDX for Acne
-Rosacea
-Folliculitis
-Perioral Dermatitis
-Keratosis Pilaris
-Steroid-induced acne
If you don’t see comedones, it is not acne!!!
-have to see open comedones (black-heads)
Important things to remember when choosing
Acne Vulgaris Therapy
-Treatment should target all causes of acne
-follicular hyperproliferation, excess sebum, P acnes, and inflammation
-Use the grade or severity to determine course of action
*Remember to always use a benzoyl peroxide wash or topical to prevent bacterial resistance when using topical or oral abx
Topical Treatment for Acne
(agents and MOA)
Topicals:
-Retinoids: comedolytic and anti-inflammatory
adapalene, tazarotene, tretinoin
-Antibiotics: fights P. acnes and maybe anti-inflammatory
erythromycin, clindamycin
-Benzoyl Peroxide: fights P. acnes and reduces bacterial resistance
-Dapsone: Provides anti-inflammatory and anti-sebum benefits
**when patients have dry skin, use a moisturizer as well
Systemic treatments
(agent and MOA)
◦Antibiotics
-doxycycline, minocycline: 1st line therapy lipophilic and anti-inflammatory properties
-trimethoprim, azithromycin: broad spectrum benefits for failed doxy/mino
-avoid unless needed, due to side effects
-tetracycline, erythromycin: less effective than newer abx due to resistance and newer design
◦Hormonal
◦Isotretinoin
Systemic Antibiotics:
Dosing and side effects
-Tetracycline: 400mg BID; age 12y.o.>
◦Use for those unable to swallow pills
-EES: 250-500mg BID-QID; no age restriction
◦S.E.- GI upset, rash
-TMP/SMX: DS BID; >2 mos
◦S.E.- SJS, TEN, photosensitivity, vag. candida
-Azithromycin: 250-500mg TIW; >6 mos
◦S.E.- GI upset, dizziness, rash
-Doxycycline: 50-100mg QD-BID; age 12y.o.>
◦S.E.- GI upset, photosensitivity
-Minocycline: 50-100mg QD-BID; age 12y.o.>
◦good affinity for back acne
◦S.E.- *can be dangerous, neuro side effects, dizziness, headache, blue dyspigment, serum sickness, lupus-like drug eruption, hepatitis, hypersensitivity rxn.
Hormonal Therapy
(Agents and MOA)
-Oral contraceptives: increase sex hormone–binding globulin, resulting in an overall decrease in circulating free testosterone
◦Yasmin, Yaz and Ortho-tricyclen in particular
◦May take 2-3 months for efficacy
-Spironolactone: anti-HTN that binds to the androgen receptors and reduces androgen production
◦May cause dizziness, breast tenderness, and dysmenorrhea (use OCP to help this)
◦Causes feminization of male fetus-must avoid pregnancy
◦Monitor blood pressure
Upcoming Therapies for Acne
Sarecycline- Phase 3 trial
◦improved anti-inflamm activity
◦more narrow spectrum
◦hope to improve efficacy and decrease unwanted side effects/tolerability issues
Topical Minocycline- Phase 2 trial
◦Foam formulation
◦Indication- mod-severe acne
Isotretonoin
(MOA, Dosing, Side effects, Labs)
-Oral retinoid/vitamin A derivative
-MOA:
-normalization of epidermal differentiation
- decreases sebum excretion by 70%
- anti-inflammatory
- reduces the presence of P. acnes
- Used for severe, persistent nodulocystic acne and recalcitrant acne
-Dosing: approx. 1 mg/kg/day x 20-24 weeks
- Can be curative (60%)
- Brand Accutane no longer available
◦Amnesteem, Myorisan, Zenatane, Asorbica, and Claravis are the substitutes
-TERATOGENIC!!!! Causes severe birth defects
◦Must agree to use 2 forms of birth control
◦sign consent forms
-Side effects: Extreme dryness, photosensitivity, headache, nausea/vomiting, joint pain, vision change, paronychia, fatigue, acne flare, mood changes, pseudotumor cerebri (esp. if taken w/ TCN)
-Serologically: Increased TG and LFTs, leukopenia
-Labs: CBC, CMP, TG, total Chol, CK total, HCG quant. (for females)
◦Must have baseline HCG 30 days prior to start of med
