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ACNE VULGARIS

ACNE VULGARIS. Description & prevalence Types of lesions Pathogenesis Treatment options & tips When to refer (& how …). ACNE. European Consensus 2003 & 2006 Topical retinoids Antibiotic choice Isotretinoin (Roaccutane) prescribing Recent developments Dianette / Yasmin / Spironolactone

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ACNE VULGARIS

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  1. ACNE VULGARIS • Description & prevalence • Types of lesions • Pathogenesis • Treatment options & tips • When to refer (& how…)

  2. ACNE European Consensus 2003 & 2006 Topical retinoids Antibiotic choice Isotretinoin (Roaccutane) prescribing Recent developments Dianette / Yasmin / Spironolactone Pulsed dye laser

  3. ACNE VULGARIS Description Acne is only seen to mankind -sebum composition specific & p. acnes unique Common: -95% males & 83% females aged 16 yrs -Peak age females 17 / males 19 yrs -15% severe enough to warrant Rx Ave list of 2000, @15% aged 15-24 years =300 patients and about 45 on Rx

  4. ACNE VULGARIS Description Typically lasts 8-12 years! Post-adolescent acne becoming more common -reasons unknown 7% acne persists into 3rd & 4th decades

  5. ACNE VULGARIS Sites involved Face 99% Back 90% Chest 80%

  6. ACNE VULGARIS Pilo-sebaceous glands 'oversensitive' to normal androgen levels after puberty  Increased sebum production and an oily skin  Keratinocytes remain adherent to the follicular canal  Ductal hypercornification  Open comedones  Proliferation of p.acnes  Bacteria enzymes breakdown oil in the sebum resulting in the release of cytokines

  7. Pathogenesis of an acne lesion 2 1. Seborrhoea 2. Obstruction 3. P. Acnes 4. Inflammation 1 4 3

  8. ACNE VULGARIS Types of lesions Comedones: -Open 'blackheads' -Closed 'whiteheads’ Papules Inflammatory pustules Nodules Cysts Scars

  9. Treatment General advice & myths -Acne skin is not dirty -Diet -Make-up (50% cosmetics comedogenic) -Site of lesion in skin & effect of trauma

  10. Treatment Standard Rx is slow to effect improvement: 40% improvement at 2 months 50% " 3 ” 60% " 6 ” 80% " 8 "

  11. ACNE VULGARIS TREATMENT Treatment depends on -severity -predominant type -area covered Leeds Acne Grading System Face Grades 1-12 Back & chest Grades 1-8

  12. LEEDS REVISED ACNE GRADING SYSTEM

  13. LEEDS REVISED ACNE GRADING SYSTEM

  14. ACNE VULGARIS Treatment of 'mild' disease Few papules / pustules -non-inflamed (open comedones) -Topical retinoid -inflamed (closed comedones) -Benzoyl peroxide -Topical retinoid -Topical antibiotic -Azelaic acid

  15. Topical retinoids Tretinoin Retin A -twice daily Acticin -once daily / less irritant Isotretinoin Isotrex -twice daily -unlike oral, dose not reduce sebum Adapalene Differin -once daily / less irritant / fast Tazarotene Zorac Epiduo -Adapalene & 2.5% BP

  16. Global Alliance Consensus Statement on topical retinoids 2003 • 'Retinoids target the microcomedo' • -'precursor lesions' • 'Likely to maintain remission • -by inhibiting microcomedos' • 'Topical retinoids should be used as 1st-line • in mild to moderate acne' • 'The goal is to minimize antibiotic use in acne' • Anti-inflammatory benefit under-appreciated • -although slower than antibiotics

  17. ACNE VULGARIS Other topical agents Benzoyl peroxide -Reduces p.acnes resistance -P.acnes is an obligate anaerobe -Improves inflammatory lesions ++ Azelaic acid -Reduces p. acnes resistance -Natural product from m.furfur -Helpful for post-inflammatory hyperpigmentation Salicylic acid Nicotinamide Hydroxyquinoline

  18. ACNE VULGARIS Topical antibiotics July 2011 Clindamycin Dalacin T 10mg/ml 50ml £7.23 Zindaclin 1% OD30g £8.66 Duac 1% OD (+BP 5%) 50g £19.90 Erythromycin Eryacne 4% 30g £4.97 Stiemycin 2% 50ml £7.69 Zineryt 4% 5W shelf life 30ml £7.71 90ml £16.68 Isotrexin 2% (+isotretinoin) 30g £7.47 Aknemycin plus 4% (+tretinoin) 25ml £7.05

  19. ACNE VULGARIS GENERAL CONSIDERATIONS TOPICAL TREATMENTS Topical retinoids contraindicated in pregnancy Azelaic acid ‘not recommended’ in pregnancy Retinoids disrupt blackheads, but are irritant -acne anti-inflammatory effect still useful Benzoyl peroxide bleaches & is irritant -weakly keratolytic Topical Rx prevent new lesions -so treat whole area

  20. ACNE VULGARIS Treatment of 'moderate' disease Superficial inflammatory lesions Few deep seated pustules (20 – 50) Only minor scarring: -only small area affected: -B.P. or ABi am / Retinoid pm -widespread -Oral antibiotic +/- Dianette -Topical retinoid -B.P.

  21. Oral antibiotics Tetracyclines Oxytetracycline Minocycline Doxycycline Lymecycline(European Acne Experts Consensus) Macrolids Erythromycin Trimethoprim

  22. Duration of antibiotic therapy • Prescribe for at least 3 months and / or until no further clinical improvement • For courses longer than 3 months ideally combine with an ‘anti-resistance’ agent (preferably started early): -Benzoyl peroxide -Topical retinoid -Azelaic acid • Adherence is an important issue

  23. GENERAL CONSIDERATIONS Oral treatment Use Benzoyl peroxide as reduces resistance Never use oral & topical ABi Avoid tetracyclines in pregnancy & <12 years ABi inter-reaction with COCP –no longer an issue S/E from Doxycycline / Minocycline Dietary interference with absorption 80% improvement at 8M (earliest sign @ 2-3M)

  24. ACNE VULGARIS For a very rapid response (e.g. wedding) -UVB temporary improvement @2-3W -mechanism of action not clear Generally encourage natural sunlight therapy

  25. ACNE VULGARIS Treatment of 'severe' disease Papules, pustules, nodules & cysts ++ Significant scarring -ice-pick / pigmented / keloidal Poor psychological adjustment REFER -Megadose ABi or -Isotretinoin (Roaccutane) If female should be on Dianette

  26. ACNE VULGARIS ROACCUTANE COUNSELLING Muco-cutaneous side effects: Common: Cheilitis 95% Facial erythema 67% Aggravation of eczema 30% Rare: Paronychia 2% Increased skin fragility 2% Acne flare 2% Hair loss 1% Photosensitivity 1%

  27. ACNE VULGARIS ROACCUTANE COUNSELLING Systemic side effects Serious: Teratogenicity (PPP) 100% Myalgia / arthralgia / h'aches 30% Rarer: @2% Optic atrophy / optic neuritis Benign intracranial hypertension Hepatitis Tinnitus DISH

  28. ACNE VULGARIS ROACCUTANE COUNSELLING General advice Blood tests 4-6 month course (100 –120 mg/ kg) 70-85% 'cure' / Risk of relapse @40% at 3yrs 'milder' Often start low for 1st few weeks (acne fulminans) Alcohol Exercise Contraception: -informed signed consent in women -dual contraception (including Dianette) Avoid concurrent Tetracyclines (esp Minocycline) -B.I.H.

  29. ACNE VULGARIS Nite pulsed dye laser 580nm 1 or 2 sessions of 30 mins -effective for inflammatory lesions -also reduces scars -alters cytokines & pro-inflammatory regulators ?-increased TGF-beta production -activates protoporhyrins release O2 £150 / session 0845 855 0866 www.euphotonics.com

  30. ROSACEA Two peaks of onset: 20-30 years & 40-50 years (?) Characteristically involves the muzzle area of face -rarely extends beyond face / neck (review D.D.) Usually give a clear history of vasomotor instability: -Sun / Temp change / Hot food / Alcohol / Blushing 4 patterns: -Erythro-telangiectactic (no blackheads) -Papulo-pustular -Ocular -Phymatous

  31. ROSACEA General measures Avoid steroids Lymecycline Topicals (newish agent Finacea)

  32. ROSACEA TREATMENT OPTIONS Avoid topical steroids 1st line treatment is topical: Finacea gel Metronidazole / Erythromycin / Dalacin 2nd line treatment oral antibiotic: Lymecycline / Erythromycin / Other tetracyclines 3rd line treatment : Low dose Isotretinoin (5-10mg). (Avoid if any suggestion of active eye disease) Response to treatment usually obvious within 3-4 weeks ?Lyclear

  33. ROSACEA TREATMENT AZELAIC ACID 15% gel (Finacea) Effect on keratinisation Antibacterial action on P Acnes Moderate anti-inflammatory effect Licensed 2006 for mild to moderate AR No 6-month limit (as in acne vulgaris) Therapeutic advantage over Metronidazole 0.75% gel High water content provides cooling effect (keep in fridge) Free of alcohol & fragrances Least expensive -30g only £7.48 (Rosex 40g £15.28)

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