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Optimizing The Approach To Acne Therapy

Optimizing The Approach To Acne Therapy. Wilma F Bergfeld MD, FACP Departments of Dermatology & Pathology Cleveland Clinic Foundation Cleveland, Ohio . Acne Prevalence. 25 - 85% of 12-24 year olds 8 -10% of 25 - 34 year olds 3 - 8% of 35 – 44 year olds Stern RS JAAD 1992;26:931-935

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Optimizing The Approach To Acne Therapy

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  1. Optimizing The Approach To Acne Therapy Wilma F Bergfeld MD, FACP Departments of Dermatology & Pathology Cleveland Clinic Foundation Cleveland, Ohio

  2. Acne Prevalence • 25 - 85% of 12-24 year olds • 8 -10% of 25 - 34 year olds • 3 - 8% of 35 – 44 year olds Stern RS JAAD 1992;26:931-935 Cunliffe WJ. Br Med J 1979;166:1109-1100

  3. AcnePsychological & Economic Impact Quality of Life is Threatened - especially – moderate to severe acne • Feelings of Insecurity & Inferiority • Reduced Self Esteem & Self Confidence & Body Image • Embarrassment & Social Withdrawal & Depression & Anger & Frustration & Confusion • Limitations in Lifestyle • Higher rates of Unemployment • Adults suffer > Adolescents

  4. Dermatologist vs Non-Dermatologist Problem of misdiagnosis & inappropriate Rx Non-dermatologist Problem of increased cost by Non-dermatologist Increase patient preference to see Dermatologist Increase employment of Dermatologist by HMO/MC Increased access to Dermatologists

  5. Acne Classification • Type • Comedonal • Papulopustular • Cysts • Severity • Mild • Moderate • Severe

  6. Acne Variants • Neonatal – 1-3 months comedones without scarring • Infantile acne – 3-6 months papulopustules with scarring – M>F • Teenage acne – all types – M>F • Adult acne – papulopustular – cysts – F>M

  7. Acne Epidemiology • American teenagers -17 - 21 million • American adults - 25 million • F > M • United Kingdom adult women • (20-58 years) > males of all ages

  8. Acne Diagnostic Criteria • Patient History • Physical Examination • Lesion Type • Location • Severity Gradation • Therapeutic Options • Adverse Reactions • Therapy • Follow up

  9. Acne ChallengeReduce • Microcomedones • Micro-organisms • Inflammation • Androgen stimulation • External irritants

  10. AcneRx Targets • Genetic predisposition • Inflammatory reaction • Release of neuropeptides >cytokines • IL-1 induces Comedogenesis • TLR-2 & TLR4>TNFa,IL-2,IL-12 (monocyte & macrophage) • Infectious agents • P acnes – proinflammatory lipids • Release TLR-2 &TLR-4 • Keratinizing defects • Sebaceous gland - • Hair follicle – exiting canal keratinized • Microcomedones - inflammation • Hormonal influence • Androgens • Corticotropin-releasing hormone 20 World Congress, Derm Fast Facts, July 1-5,2002

  11. Acne Targets • Comedones • Retinoids • Benzoyl peroxide • Isotretinoin • Sulfur • Salicylic acid – BHA • Azeliac acid • Alpha hydroxy acid - AHA

  12. Acne TargetsInflammatory papules-pustules-nodules • Anti-microbial Antibiotics – Minocycline - Zithromycin • Retinoids Accutane – Vitamin A Retinoids - topical • Anti-inflammatory Corticosteroids Anti-oxidants • Anti-androgens • Estrogens • Spironolactone • Flutamide • Insulin resistance - Metformin • Vitamins & minerals • Zinc • Vitamin C, E

  13. Tretinoin Effects • Influences desquamation of abnormal epithelium • Alters microclimate of microcomedones • Resolves mature comedones • Prevents new lesions • Enhances penetration of other drugs

  14. Retinoids • Topical • Tretinoin • Retin A • Retin A Micro • Renova • Adapalene • Differin • Tazarotene • Tarzorac

  15. Azelaic Acid • Natural occurring dicarboxylic acid • Antikeratizing & Antibacterial & Anti-inflammatory • Mild to moderate acne • Used with combined Rx • Oral antibiotics • Topical retinoids • AHA • Absence of systemic AE or resistance to P acnes

  16. AcneAntimicrobial Rx • Benzoyl peroxide is a potent bactericidal agent -2.5-10% • Improves comedones & papulopustules • Reduces P acnes • Can induce irritation • Topical antibiotics – Erythromycin & Clindamycin • Reduces P acnes • Decrease neutrophilic & monocyte activity • Oral Antibiotics • Tetracyclines • Broad spectrum antibiotics

  17. AcneBacterial Resistance • Microcomedone – lipid environment • P acnes • P granulosum • Organisms produce proinflammatory substances • Sensitive to wide range of Antibiotic butIncreasing Resistance • Need for New Combined Rx

  18. Androgen Activity • Hair follicle • Anagen bulb – androgen receptors • Sebaceous gland • Androgen receptors • 5 AR type 1 • Influenced by: Gonadotrophins, Insulin-like growth factors, insulin, glucocorticoids, estrogen. Thyroid hormone Deplewski D Endocrinol Rev 2000;21(4)364-92:

  19. Plasma AndrogensFemale Acne Patients • Acne patients #-75n, 23 +/- 6,5 y • Most common elevated androgen- • Free Testosterone - 25% • Free 17 beta-hydroxysteroids - 23% • DHEAS – 19% • Total Testosterone – 12% • Lucky Aw J Investig Dermatol 1983;81(1):70-4

  20. Acne StudyOrthoTri-Cyclen • 250 females/acne patients (15-49 y ) • Moderate acne • 6 mo Rx with OrthoTri-Cyclen or placebo • Results: • 51 % vs 35% reduction –lesions • 46 % vs 34 % total reduction-lesions • 83 % vs 63% improved • Reduced testosterone & increased SHBG • Obst & Gyn1997;89:615-22

  21. Acne DHEAS 47% Testosterone Total 28% Free 23% Androstenedione 7% Hirsutism DHEAS 50% Testosterone Total 27% Free 5% Androstenedione 20% CCF Androgen Excess Study1000 Females- Registry (1989)

  22. Hormonal Rx • Usually in Females with severe acne resistant to common Rx. • Hormones • Low dose BCP • Estrogens • Corticosteroids • Antiandrogens • Retinoids-oral • Anti-inflammatory

  23. Comedogenesis Retinoids Benzoyl peroxide Isotretinoin Sulfur Azelaic acid Sebum production Retinoids Antiandrogens Low-dose BCP P. acnes Antibiotics Retinoids Benzoyl peroxide Inflammation Oral antibiotics Retinoids AcneTherapeutic Targets

  24. AcneNewer Combined Therapies • Combined Rx • Combination Antibiotic-BPO • Erythromycin • Clindamycin • Combination Antibiotic-BP-Zinc • Combined Oral & Topical Rx • Combined Retinoids –oral – topical with above O

  25. Acne Patient Education • Education • Discuss patient Expectations • Time Frame - Expected Improvement • Establish Therapy • Discuss Therapy Expectations & Adverse Events • Re-Evaluation of Therapy • Patient Compliance Needed

  26. Patient ComplianceImportant • Active agreement – Proposed Rx • Patient responsibilities • Discuss cost • Prescription choices • Mesh Rx Choice with patients Skin Type & Life Style • Allot time for patient’s questions • Remember patient ability to listen to only 3 messages • Provide Educational pamphlets/handouts • Provide patient with Written Instructions

  27. Quick visit Over Rx Non-compatible Rx / Lifestyles Irritation Overwashing Medical facials Too many meds Lack of education Fear of therapies Acne Rx Pitfalls

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