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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

Dermatology

Dr Helen Watson

Dr Beth Gulliksen

acne prevalence
Acne Prevalence
  • Some degree of acne universal
  • severe acne affects up to 1.4% of young adults
pilosebaceous glands
Pilosebaceous glands
  • sites - face & chest
  • not - hands & feet
acne has a major impact
Acne has a major impact
  • vulnerable age group
  • affects visible sites
  • affects employment
  • scarring - physical and psychological
acne pathophysiology
Acne pathophysiology
  • endocrine state - usually normal
  • puberty – changing endocrine state
  • severity related to - end organ sensitivity
  • PCOS – associated with acne
pathology
Pathology
  • acne - increased sebum excretion
  • acne - duct obstruction
initial acne lesions
Initial acne lesions
  • micro comedone
  • open comedones - blackheads
  • closed comedones - whiteheads
inflamed acne
Inflamed acne
  • microbial colonisation of obstructed duct
  • P. acnes
inflamed acne lesions
Inflamed acne lesions
  • papules - red raised spots
  • pustules - raised spots containing pus
  • nodules - larger, deeper lesions
acne environmental factors
Acne – environmental factors
  • anabolic steroids
  • occupations
  • climate
  • topical steroids
acne scarring
Acne scarring
  • Physical
  • psychological
acne psychological
Acne - psychological
  • excoriated
  • dysmorphophobia
  • suicide
assessment examination
Assessment/Examination
  • How would you assess a patient with acne?
assessment
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
Acne treatment
  • topical benzoyl peroxide
  • topical retinoid
  • antibiotic – topical or oral
  • hormonal therapies
  • oral retinoid - isotretinoin
benzoyl peroxide
Benzoyl peroxide
  • gold standard
  • no resistance
  • irritation can be a problem
  • can bleach clothing
  • use low dosage
topical retinoids
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
Other topicals
  • salicylic acid wash (Acnisal®) –

comedones

  • azelaicacid cream (Skinoren®) – post inflammatory pigmentation
  • nicotinamidegel (Nicam®)- inflammatory lesions
topical 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 acne
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
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
Oral antibiotics - alternative
  • lymecycline one daily 408 mg
  • less side effects
  • cost implications
  • more efficacious / better compliance
hormones and acne
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
co cyprindiol dianette indications
Co-cyprindiol (Dianette) - indications
  • cyproterone acetate with ethinyloestradiol
  • Females
  • severe acne
  • moderately severe hirsutism
dianette
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
Dianette – time scales
  • 2-3 months to work
  • duration of therapy?
  • withdraw 3 months after acne resolves
  • consider acne friendly pill e.g. Yasmin®
oral isotretinoin
Oral isotretinoin
  • severe acne
  • resistant acne
  • to prevent scarring
  • dysmorphophobia
oral isotretinoin roaccutane
Oral isotretinoin (Roaccutane)
  • secondary care drug
  • pregnancy prevention for females
  • association with depression?
oral isotretinoin monitoring
Oral isotretinoin monitoring
  • FBC
  • LFTs, lipids
  • frequent pregnancy tests
females pregnancy plan prevention
Females – pregnancy plan prevention
  • Teratogenic
  • start 2nd day
  • adequate contraception, x 2 methods
  • frequent pregnancy tests
oral isotretinoin possible link with depression
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.

treatment period
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
Further information
  • BAD – www.bad.org.uk
  • Dermnet NZ
  • www.Patient.co.uk
  • CKS.nhs.uk
  • www.BNF.org
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