ACNE VULGARIS

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2. Causes. Increased sebumAbnormal follicular differentiationColonization of pilosebaceous duct with Propionibacterium acnesRelease of inflammatory mediators Genetic factors ie FHxEndocrine factors - PCOS, excessive corticosteroidsPsychological stress and depressionEnvironmental factors - cos

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ACNE VULGARIS

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1. 1 ACNE VULGARIS Caroline Jewels ST3 14-1-9

2. 2 Causes Increased sebum Abnormal follicular differentiation Colonization of pilosebaceous duct with Propionibacterium acnes Release of inflammatory mediators Genetic factors ie FHx Endocrine factors - PCOS, excessive corticosteroids Psychological stress and depression Environmental factors - cosmetics, petroleum oils, physical occlusion Medication - hormonal, antiepileptics, anti-TB, antidepressants, ciclosporin, B vitamins

3. 3 ACNE - Aims Decrease scarring Decrease unsightly appearance Decrease psychological stress Explain long length of treatment may be several months and initial response may be poor but must persevere (poor compliance has been demonstrated in studies at 3/12)

4. 4 ACNE Classification Blackheads (open comedones) Whiteheads (closed comedones) Inflammatory papules Cystic areas Nodules and scars from old lesions +/- keloid formation

5. 5 Acne vulgaris comedones dominant

6. 6 Acne vulgaris- pus dominant

7. 7 Management Don’t dismiss as trivial Dispel myths Gentle soap and water BD Apply medications to all skin area Look for underlying depression Assess every 6-8 weeks Examine all acne prone areas

8. 8 Management cont…. Benzoyl peroxide bd +/- topical Abx (Duac) or Azelaic acid (Skinoren) Topical retinoids (Differin, Retin A, Isotrex) Nicam gel (inflammatory acne) Topical Abx - Zineryt, Dalacin (be aware of resistance to Propionibacterium acnes) Oral tetracycline/oxytetracycline 500mg bd or Trimethoprim 300mg BD - 4-6/12 Anti-androgen (Dianette also Cilest/Marvelon) Oral retinoid (Roaccutane) - specialist only

9. 9 Benzoyl peroxide Cheap+cheerful Start at low strength 2.5% at night Mild erythema - transient Bleaches clothes Build up to 10% gradually Stop if irritation occurs In combination with Abx (Duac once daily) Expect improvement within 2/12

10. 10 Topical retinoids (Isotretinoin/adapalene) Start low strength (0.025%)every other night - may cause redness/irritation Increase strength until response Avoid sunlight/uv light + pregnancy

11. 11 Topical Antibiotics ? Better than benzoyl peroxide Reduces propionobacterium acnes Less irritation Glows in UV light (warn patient not to go clubbing)

12. 12 Azelaic acid Antimicrobial and anticomedonal properties Alters composition of fat/decrease bacteria Short term use only (1/12) May cause irritation/ photosensitivity (although less likely than benzoyl peroxide)

13. 13 Oral Antibiotics Oxytetracycline 500mg bd (tetracycline/trimethoprim) Warn patient can take 6/52 for response-must be compliant. Treat for 6 months Avoid milk,and have 30mins before meals If effective reduce dose to 500mg od and then 250mg od at 3/12 intervals Do not give in combination with topical Abx due to risk of resistance

14. 14 Hormonal In women on COCP consider less androgenic progestogen (marvelon/cilest) but increased risk of DVT Consider cyproterone acetate with oestrogen(Dianette)

15. 15 When to refer? (NICE) Acne fulminans Nodulocystic acne Dysmorphophobia Scarring Failure to respond to 6/12 topical and systemic treatment Suspected underlying endocrine cause

16. 16 Rosacea Flushing/erythema, telangectasia, papules, pustules, absence of comedones Metronidazole gel (Rosex) Oral Abx (OTC 500mg BD, Tetralysal 1mg OD, Erythromycin 500mg BD) Combination treatment Long courses May need referral for isotretinoin May need surgery/laser for rhynophyma Laser may help erythema but not permanent and not NHS

17. 17 Perioral/periorbital dermatitis Nearly always female Monomorphic itchy pustules around mouth Topical steroids exacerbate - Oral tetracyline/erythromycin 3/12

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