Dermatology
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Dermatology . Dr Helen Watson Dr Beth Gulliksen. Acne Prevalence. Some degree of acne universal severe acne affects up to 1.4% of young adults. Pilosebaceous glands. sites - face & chest not - hands & feet. Acne has a major impact. vulnerable age group affects visible sites

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Dermatology

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Dermatology

Dr Helen Watson

Dr Beth Gulliksen


Acne Prevalence

  • Some degree of acne universal

  • severe acne affects up to 1.4% of young adults


Pilosebaceous glands

  • sites - face & chest

  • not - hands & feet


Acne has a major impact

  • vulnerable age group

  • affects visible sites

  • affects employment

  • scarring - physical and psychological


Acne pathophysiology

  • endocrine state - usually normal

  • puberty – changing endocrine state

  • severity related to - end organ sensitivity

  • PCOS – associated with acne


Pathology

  • acne - increased sebum excretion

  • acne - duct obstruction


Duct obstruction


Initial acne lesions

  • micro comedone

  • open comedones - blackheads

  • closed comedones - whiteheads


Comodones


Inflamed acne

  • microbial colonisation of obstructed duct

  • P. acnes


Inflamed acne lesions

  • papules - red raised spots

  • pustules - raised spots containing pus

  • nodules - larger, deeper lesions


Inflamed lesion


Inflammatory papule


Larger lesions


Acne – environmental factors

  • anabolic steroids

  • occupations

  • climate

  • topical steroids


How would you explain acne to a 16yr old boy?


Acne scarring

  • Physical

  • psychological


Acne scarring


The neck


Scarring


Ice pick scars


Acne - psychological

  • excoriated

  • dysmorphophobia

  • suicide


Excoriated acne


Differential - rosacea


Peri oral dermatitis


Hidradenitis


Assessment/Examination

  • How would you assess a patient with acne?


Assessment

  • look at face, chest, back and neck

  • severity and extent

  • lesions – comedones, papules, pustules, nodules, cysts & scars

  • subjective - patient & physician assessment (how bad does the patient think it is - ?/10)

  • measurement - grading of the severity & extent – mild-moderate-severe

  • assess - effect on quality of life (how does it make them feel/ stop them doing anything they want to do/ affect relationships)

  • Previous treatments tried – compliance and side effects

  • Important to look for any scarring ( if present, need to up the game regarding treatment)


Acne treatment

  • topical benzoyl peroxide

  • topical retinoid

  • antibiotic – topical or oral

  • hormonal therapies

  • oral retinoid - isotretinoin


Mild acne


Benzoyl peroxide

  • gold standard

  • no resistance

  • irritation can be a problem

  • can bleach clothing

  • use low dosage


Topical retinoids

  • adapaline (Differin®), tretinoin (Retin-A®),

    & isotretinoin (Isotrex®)

  • effective against comedones

  • use in combination - adapaline & benzoyl

    peroxide (Epiduo®)

  • irritation

  • photosensitivity

  • avoid in pregnancy


Other topicals

  • salicylic acid wash (Acnisal®) –

    comedones

  • azelaicacid cream (Skinoren®) – post inflammatory pigmentation

  • nicotinamidegel (Nicam®)- inflammatory lesions


Mild/moderate acne - antibiotics


Topical Antibiotics

  • clindamycin(Dalacin T®)

  • Erythromycin (zineryt lotion – erythromycin & zinc acetate – thought to aid skin healing)

  • Clindamycin is good as can get resistance to erythromycin

    ______________________________________

  • Erythromycin in combination with isotretinoin (isotrexin)

  • use clindamycin in combination with benzoylperoxide (Duac®) to reduce bacterial resistance*


Moderate - severe


Moderate – severe acne

  • use oral antibiotic & topical agent

  • topical agents:

    • benzoylperoxide

    • Topical retinoid (adapalene, tretinoin, isotretinoin)

    • Azelaic acid cream

    • NOT same oral & topical antibiotic


Oral antibiotics

  • oxytetracycline 500mg bd

  • erythromycin 500 mg bd

    • increasing resistance

    • can be used in pregnancy

  • both before food

  • minimum 3 months

  • 3-6 months

  • both can cause GI upset


Oral antibiotics - alternative

  • lymecycline one daily 408 mg

  • less side effects

  • cost implications

  • more efficacious / better compliance


Minocycline pigmentation


Hormones and acne

associated with acne

  • PCOS

  • progesterone - POP, Mirena®

  • improve acne

  • acne friendly pills COCP e.g. Yasmin®

  • hormonal therapy

    tests rarely required

  • testosterone should be below 5


Hormonal Treatment


Co-cyprindiol (Dianette) - indications

  • cyproterone acetate with ethinyloestradiol

  • Females

  • severe acne

  • moderately severe hirsutism


Dianette

  • increased risk of thromboembolism

  • Increased risk compared to COC

  • concerns of liver tumours, from animal studies

  • CSM warning

  • Dermatology in Practice (2001),9(2, 10-13)

  • Current Problems in Pharmacovigilance

    (2002), 28,9-10


Dianette – time scales

  • 2-3 months to work

  • duration of therapy?

  • withdraw 3 months after acne resolves

  • consider acne friendly pill e.g. Yasmin®


Severe acne


Keloid scarring


Oral isotretinoin

  • severe acne

  • resistant acne

  • to prevent scarring

  • dysmorphophobia


Oral retinoids


Oral isotretinoin (Roaccutane)

  • secondary care drug

  • pregnancy prevention for females

  • association with depression?


Oral isotretinoin monitoring

  • FBC

  • LFTs, lipids

  • frequent pregnancy tests


Females – pregnancy plan prevention

  • Teratogenic

  • start 2nd day

  • adequate contraception, x 2 methods

  • frequent pregnancy tests


Oral isotretinoin – possible link with depression

  • RCGP - Rare idiosyncratic reaction? BJGP Feb 2005

    134-136

  • Isotretinoin therapy and mood changes in adolescents

    with moderate to severe acne: a cohort study. Chia CY,

    Lane W, Chibnall J, Allen A, Siegfried E. Arch Dermatol

    2005; 14

  • Association of suicide attempts with acne and treatment

    with isotretinoin: retrospective Swedish cohort study

    Anders Sundström, Lars Alfredsson,Gunilla Sjölin-

    Forsberg, BarbroGerdén, Ulf Bergman, JussiJokinen

    BMJ (Published 11 Nov. 2010)1:557-60.


Acne Fulminans


Acne Conglobata


TREATMENT PERIOD

  • Often good response at 6 weeks.

  • But 4-6 months for max response

    MAINTENANCE TREATMENT

  • To prevent acne flaring up (4-5 yrs)

  • Benzoyl peroxide or Topical retinoid


Further information

  • BAD – www.bad.org.uk

  • Dermnet NZ

  • www.Patient.co.uk

  • CKS.nhs.uk

  • www.BNF.org


What grade of acne is this? How would you treat?


What grade of acne is this? How would you treat?


What type of acne is this? How would you manage it?


What grade of acne is this? How would you treat?


What grade of acne is this? How would you treat?


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