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Dermatology

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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  1. Dermatology Dr Helen Watson Dr Beth Gulliksen

  2. Acne Prevalence • Some degree of acne universal • severe acne affects up to 1.4% of young adults

  3. Pilosebaceous glands • sites - face & chest • not - hands & feet

  4. Acne has a major impact • vulnerable age group • affects visible sites • affects employment • scarring - physical and psychological

  5. Acne pathophysiology • endocrine state - usually normal • puberty – changing endocrine state • severity related to - end organ sensitivity • PCOS – associated with acne

  6. Pathology • acne - increased sebum excretion • acne - duct obstruction

  7. Duct obstruction

  8. Initial acne lesions • micro comedone • open comedones - blackheads • closed comedones - whiteheads

  9. Comodones

  10. Inflamed acne • microbial colonisation of obstructed duct • P. acnes

  11. Inflamed acne lesions • papules - red raised spots • pustules - raised spots containing pus • nodules - larger, deeper lesions

  12. Inflamed lesion

  13. Inflammatory papule

  14. Larger lesions

  15. Acne – environmental factors • anabolic steroids • occupations • climate • topical steroids

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

  17. Acne scarring • Physical • psychological

  18. Acne scarring

  19. The neck

  20. Scarring

  21. Ice pick scars

  22. Acne - psychological • excoriated • dysmorphophobia • suicide

  23. Excoriated acne

  24. Differential - rosacea

  25. Peri oral dermatitis

  26. Hidradenitis

  27. Assessment/Examination • How would you assess a patient with acne?

  28. 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)

  29. Acne treatment • topical benzoyl peroxide • topical retinoid • antibiotic – topical or oral • hormonal therapies • oral retinoid - isotretinoin

  30. Mild acne

  31. Benzoyl peroxide • gold standard • no resistance • irritation can be a problem • can bleach clothing • use low dosage

  32. Topical retinoids • adapaline (Differin®), tretinoin (Retin-A®), & isotretinoin (Isotrex®) • effective against comedones • use in combination - adapaline & benzoyl peroxide (Epiduo®) • irritation • photosensitivity • avoid in pregnancy

  33. Other topicals • salicylic acid wash (Acnisal®) – comedones • azelaicacid cream (Skinoren®) – post inflammatory pigmentation • nicotinamidegel (Nicam®)- inflammatory lesions

  34. Mild/moderate acne - antibiotics

  35. 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*

  36. Moderate - severe

  37. Moderate – severe acne • use oral antibiotic & topical agent • topical agents: • benzoylperoxide • Topical retinoid (adapalene, tretinoin, isotretinoin) • Azelaic acid cream • NOT same oral & topical antibiotic

  38. 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

  39. Oral antibiotics - alternative • lymecycline one daily 408 mg • less side effects • cost implications • more efficacious / better compliance

  40. Minocycline pigmentation

  41. 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

  42. Hormonal Treatment

  43. Co-cyprindiol (Dianette) - indications • cyproterone acetate with ethinyloestradiol • Females • severe acne • moderately severe hirsutism

  44. 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

  45. Dianette – time scales • 2-3 months to work • duration of therapy? • withdraw 3 months after acne resolves • consider acne friendly pill e.g. Yasmin®

  46. Severe acne

  47. Keloid scarring

  48. Oral isotretinoin • severe acne • resistant acne • to prevent scarring • dysmorphophobia

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