Acne, Rosacea and other red faces

1. Acne, Rosacea and other red faces CDLE or Rosacea or………? Steve Goldthorp

3. Quizz: Max 20 What lesions are demonstrated? (1) What is the condition? (1)

4. 1 – what lesions are demonstrated? (1) 2 – name the condition (1)

5. 1 – what lesion is demonstrated? (1) 2 – can it occur alone? (1)

6. 1 - Would you refer this patient? (1) 2 - What treatment would be considered? (1)

7. 1 – What is the diagnosis? (1) 2 – What are the two diagnostic clues? (1)

8. 1 – Give three diagnostic features (1) 2 – and the diagnosis (1)

9. 1 – Give a name to the complication affecting his nose? (1) 2 – Name two ocular manifestations (1)

10. 1 - Diagnosis please? (1) 2 – What microorganism is implicated? (1)

11. 1 – List two classical features of this process (1) 2 – Give the diagnosis (1)

12. 1 – Name the process? (1) 2 – Give two precipitants? (1)

13. Diagnosis?

15. www.gpminorsurgery.com

16. http://www.pathways.scot.nhs.uk/dermatology.htm National Patient Pathways www.pathways.scot.nhs.uk/dermatology.htm

17. We will cover: • Acne • Rosacea • Seborrhoeic dermatitis • Perioral dermatitis • Touch on SLE as part of the above • DLE • Actinic keratoses • Juvenile Spring Eruption • PLE • Melasma

18. Look elsewhere! • Look at nails, hair, mucus membranes, hands, feet • nail pitting for psoriasis • scalp may be clue to seborrhea elsewhere • lichen planus may show a white lacy pattern in the mouth/penis/vulva • Acne of back/chest

19. Acne • Self limiting, inflammatory condition of pilosebaceous unit • Starts puberty because of androgenic stimulation and increased keratinization at follicular orifice • Follicular hyperkeratinization with blockage of PSU (comedone) • Incr. sebum production and PSU distension (whitehead) • Sebum bursts into tissues with triglicaride breakdown by P. acnes all leads to inflammatory reaction • Gives erythematous papules pustules and nodules • Eventual healing with possible scarring

21. Closed comedones ‘whiteheads’

22. Open comedones or blackheads

26. Wide range of disease – few comedones to severe nodulocystic • Areas of greatest density of PSUs, face/back/upper chest, rarely buttocks/upper arms • No racial differences • Benign but physical and psychological scarring • Reluctance to seek help

27. Acne prevalence • Puberty to adulthood, occasionally prepubertal • Women more likely -> 20’s and 30’s • 25 – 85% of 12 – 24 yr olds • 8 – 10% 25 – 34 yr olds • 3 – 8% 35 – 44 yr olds

28. Psychological Problems • Quality of life threatened esp mod/severe acne • Feelings of insecurity & inferiority • Reduced self esteem/confidence/body image • Embarrassment & social withdrawl, depression/anger • Lifestyle limitations • Higher rates of unemployment • Adults>adolescents

29. Rubbing/overcleansing may exacerbate • 50% makeups comedogenic • Occupations – kitchen environments • Sports equipment eg helmets/sweat bands • Drugs – levonorgestrel/progesterone/steroids/some anticonvulsants, lithium • PCOS • Cong adrenal hyperplasia

30. Cardinal sign is the comedone, closed or open • Later papules and pustules • Deeper involvement gives nodules and cysts • Healing -> scarring • Depressed scars –> ice-pick • Hypertrophic scars -> keloids

32. Prognosis Eventually disappears after many years Minority into 20’s, 30’s or later Sequelae Scarring Psychological

33. Treatment • Need to reduce • Microcomedones • Micro-organisms • Inflammation • Androgenic stimulation • External irritants

34. Treatment • Useful to think • Mild • Moderate • Severe

35. Treatment • Comedones – non inflammatory • Peeling agent to remove surface keratin benzoyl peroxide (2.5%, 5%, 10%) retinoic acid gel/cream/lotion isotretinoin gel azaleic acid cream • UV light has similar effect

36. Treatment – inflammatory lesions • Papules/pustules or nodules need systemic treatment • These are: • Antibiotics • Oxytetracycline 500mgs bd cheap and effective • Empty stomach 30mins before food or 2 hrs after • Chelates with iron/antacids/calcium • Improvement slow and not seen for 2-3/12 with ongoing improvement for 6-12/12 • Maintenance at 250mg bd for a long as it takes

37. Avoid tetracyclines • Under 12 • Pregnant • Lactating • Impaired renal function • Side effects few • Diarrhoea, candidiasis • OCP - contraception x 3/52 then in happy symbiosis

38. If tetracyclines don’t work? • Check compliance – empty stomach and taking it! • Try erythromycin 250mgs bd • Doxycycline 50mgs od • Lymecycline 400mgs od • (minocycline – discoloration of skin/teeth and a rare lupus like syndrome)

39. Topicals • Work well but ?resistance ?contact dermatitis expensive • Apply daily • Negligible systemic absorption • If combine with oral antibiotic use the same agent eg erythromycin with zineryt

40. Tretinoin • Influences desquamation • Alters microclimate • Resolves mature comedones • Prevents new lesions • Enhances penetration of other drugs • Topical or systemic • Topicals – tretinoin: Retin A, adapalene (Differin)

41. Benzoyl peroxide 2.5 – 10% • Antibacterial and reduces keratinization • Improves comedones/papulopustules • Reduces P. acnes, but • Can induce irritation • Bleaches hair, towels etc • Topical antibiotics • Erythromycin & clindamycin • Reduce P. acnes • Decrease neutrophilic activity

42. Azelaic Acid (Skinoren) • Antikeratinizing, antibacterial and antiinflammatory effects • Mild to moderate acne • Use with oral antibiotics • Absence of resistance or systemic side effects

43. Anti-androgens • Anagen bulb in hair follicle and sebaceous gland contain androgen receptors • Influenced by gonadotrophins, insulin, glucocorticoids • Oestrogen, TSH

44. Cyproterone acetate as co-cyprindiol containing 35mcg oestrogen • Useful for women wishing contraception • Avoid over 35 increased risk of cardiovasular and thromboembolic disease • Max effect not seen for 2-3/12 and continue long term, not just 6 months • 83% improvement at 6/12 (placebo 63%)

45. Severe or no response? • Nodules/cysts • Scarring • not controlled by >6/12 oral antibiotics • persisting over 25 yrs • Significant psychological effects • Refer for oral isotretinoin ie roaccutane • Produces long term remission 85% • Single dose daily for 4 months

46. Side effects of roaccutane • Dryness and splitting of lips • Dry eyes • Epistaxes • Myalgia • Menstrual irregularities • Increased lipids • May temporarily worsen acne • May rarely induce depression • Potent teratogen, must not become pregnant on it or for one month afterwards

47. Scarring? • Ice pick scars: • Dermabrasion • Laser resurfacing • Punch grafting for deep scars • Subcision: a surgical technique in which the fibrous band under the scar is divided, allowing the skin to return to its normal position • Larger scars can be excised

48. Soft tissue augmentation techniques such as hyaluronic acid, collagen, gelatin matrix & fat implants • Atrophic scars: • Dermabrasion • Hypertrophic scars: • Potent topical steroids for a few weeks • Intralesional steroid injections • Silicone gel dressings • Cryotherapy • Surgical revision • Unfortunately, hypertrophic or keloid scars are particularly prone to recur even after apparently successful treatment.

49. Education • Patient expectations • Time frame – when to expect improvement! • Discuss compliance • Adverse effects • Duration of treatment • Return visit • Hand outs?

50. www.stopspots.org www.m2w3.com/acne www.bad.org.uk Click here for printable PDF version