Acne and its Treatment Mark Goodfield Basic epidemiology • 80 -100% of teenagers (physiological acne) • 1% of 25 year old men • 15% of 25 year old women (10% at 35, 5% at 45) • All races (Chinese) Acne Vulgaris • Inflammatory condition of the pilosebaceous unit – Blockage – Leakage – Bacterial overgrowth Acne Vulgaris • Over-sensitivity of glandular elements to normal androgen levels – High sebum production – Epithelial proliferation in duct Endocrine problems • • • • • • Acromegaly Cushings Androgenisation Late onset congenital adrenal hyperplasia PCOS All rare Acne Vulgaris • Enlarged blocked sebaceous glands which leak • Bacterial overgrowth • Lead to inflammatory lesions • Rupture leads to cystic lesions Bacteriology • • • • Propionobacteria Acnes P.granulosum Staph epidermidis Malassezial yeasts Bacteriology • Bacterial products – Lipases – Proteases – Phosphatase Relevant to alterations in sebum that allow leakage and breakdown of glandular membrane Acne Vulgaris: Morphology • • • • • Blackheads – open comedones Whiteheads – closed comedones Papules Pustules Cysts Pomade acne SI +++ Differential diagnosis • Rosacea • Folliculitis – Bacterial – Pityrosporal – Occlusive • Pili incarniti • Keratosis pilaris • Oddities – Angio-fibromata Rosacea Prominent pores Trichostasis spinulosa Factors Modifying Acne • Menstrual cycle • UV light • Diet • Stress • Drugs • Cosmetics; this is discussed under the heading of patient examination PCOS • Consider this possibility, especially if the acne patient has : - irregular periods (> 3 months) - hirsuties - obesity - infertility If appropriate consider relevant investigations but they are relatively expensive Some oral and topical drugs/preparations can induce acne • Topical corticosteroids • Some hair preparations can produce pomade acne, especially in Afro Caribbeans • • • • • Oral corticosteroids anabolic steroids Lithium cyclosporin Iodides taken orally, which may be part of some homoeopathic therapies Patterns of Acne • • • • • • • • Sandpaper acne Submarine comedones Macrocomedones Localised acne Acne excoriee Sinus tract Acne conglobata Gram negative folliculitis Sandpaper acne Submarine comedones Localised muzzle acne Sinus tract acne Acne Treatment • Keep it simple and topical if possible – Retinoids: modify sebaceous duct activity, mildly anti-inflammatory – Benzoyl peroxide: anti-bacterial, modify duct activity – Azelaic acid: antibacterial, anti-inflammatory – Nicotinic acid: anti-inflammatory – Antibiotics: antibacterial and anti-inflammatory 1.Actions of Anti-Acne Therapies Topical retinoids: Normalizes ductal desquamation Reduces inflammatory response Antibiotics:* • Inhibit P Acnes • Reduce inflammation Oral Isotretinoin: Reduces sebum Normalizes ductal desquamation Inhibit P acnes growth Reduces inflammatory response Hormones: Reduce sebum production Reduce comedones Benzoyl peroxide:* • Inhibits P Acnes • Reduces inflammation *also reduce comedones Acne Vulgaris: Oral Treatment Options – Antibiotic for inflamed lesions – Hormonal treatment in women – Isotretinoin if severe Aim Treatment at Morphology Blackheads and closed comedones – Topical retinoid – Benzoyl peroxide – Consider cautery This demonstrates, to the right, an untreated area of macrocomedones and to the left an area treated 3 weeks previously Aim Treatment at Morphology Inflamed lesions – Topical antibiotic – Azelaic acid – Nicotinamide Aim Treatment at Morphology Both occlusion and inflammation – Combinations eg isotrexin, DUAC etc Oral Antibiotics? Cochrane Review – Oral no better than topical – Oral no better than BPO Only indicated for: – Extensive disease – Intolerance of topicals Oral Antibiotic: Tetracyclines • • • • Oxytetracycline 1gram daily (absorption) Lymecycline: 1(2) tablet daily Doxycycline 50-100mg daily Minocycline MR 100mg daily – ANA, LFT pre-treatment: 15% risk of hepatitis or lupus Oral Antibiotics: Others • Erythromycin 1 gram daily • Trimethoprim 200 – 300 mg bd – Gram negative folliculitis How Long Should Treatment Be? • 6 months – 40-50% improvement at 12 weeks – If not, move on – 2-3 courses Treatment failure in primary care Wrong treatment Poor treatment usage Severe disease Bacterial problems - resistance Patient expectation Treatment of “Cystic” Acne Small, acute, 'cyst' (nodule – topical clobetasol Larger 'cysts' – 'new' - il triamcinalone – 'old' - cryotherapy Very Large 'cysts' (sinus tracts) – very difficult: probably surgical Isotretinoin: Clinical Guidelines? • Not yet available from the BAD • But – – Severe nodulo-cystic acne – Acne resistant to oral therapies – Severe psycho-social upset Isotretinoin • 13 cis retinoic acid • Adjust duration to suit tolerable dose • 1mg/kg body weight for 16 weeks – 2/3 complete and permanent cure – 20% occasional spot – 10-15% need further treatment Isotretinoin monitoring: Before Treatment • Full discussion of indications for treatment and side effects • Assess patient’s views • Appropriate blood tests – LFT – Lipids – Pregnancy test Isotretinoin Side Effects • Mainly understandable – eg mucocutaneous • Most important for monitoring: – Pregnancy risk management – Mood change Isotretinoin Metabolism • Rapid absorption – enhanced by fatty food • Liver metabolised • Excretion 50% renal, 50% hepato-biliary Isotretinoin Lipid Effects • triglycerides, cholesterol, HDL cholesterol • Can reverse this with fish oil supplementation (70% reduction in TG) • In practice, rare to need to treat – Ensure fasting sample – Discontinue if 2-3 fold increase in lipid levels Isotretinoin LFT Effects • Unusual to be a problem – personal experience is of 3 patients in 14 years • If encounter raised LFTs – Recheck – Ask about alcohol – Ignore if intermittent and doubled enzymes – Stop if persistent and higher than double Isotretinoin Monitoring: Mood Change • Depressive symptoms • Suicidal behaviour • Aggressive behaviour Isotretinoin Monitoring: Mood Change • No hard evidence that it occurs • Certainly not predictable: rare in my experience (50% of patients?) • May be idiosyncratic if it occurs • Aggressive behaviour may be more common than depression Depression Screening • • • • How have you been feeling recently? Have you been low in spirits? Have you been able to enjoy the things you usually enjoy? Have you had your usual level of energy, or have you been feeling tired? • How has your sleep been? • Have you been able to concentrate on newspaper articles, or your favourite TV or radio programme? • BMJ screening questions Practical Tip • Take after large meal – doubles bioavailabilty Relapse After Isotretinoin Probably more common than the published work now that isotretinoin is widely used There are patients who require multiple courses or long term low dose treatment – 5%? Scarring • Minor degrees – common • Pigment change is NOT scarring • Better to treat early to avoid, rather than manage later Ice pick scars Hypertrophic scar Post Inflammatory pigmentation is very persistent and very difficult to treat This patient suddenly developed many exudative haemorrhagic lesions This patient also suddenly developed many exudative haemorrhagic lesions Acne Fulminans Widespread inflammatory acne usually with cystic lesions Systemic upset, arthralgia, erythema nodosum