HELP! MY FACE IS RED
Christine Rivet
MD,CM,CCFP(EM),MClScFM,FCFP,DipPDerm
Montebello presentation to colleagues
September 21, 2014
Agenda
• Introduction
• Objectives
• Warm-up quiz
• Discussion of photos in pairs
• Group discussion
Objectives for today’s session
• At the end of the session you will be able to :
• 1-discuss treatment of acne with oral retinoids.
• 2-describe the differences between acne and conditions
with a similar appearance.
• 3-discuss treatment of rosacea, perioral dermatitis and
seborrheic dermatitis.
• 4-give advice to patients about the natural history of these
chronic skin conditions and the limitations of treatments.
WARM-UP QUIZ
Question 1: in a patient with perioral
dermatitis
• A)The lip vermilion and adjacent skin are
inflamed and scaly.
• B)Treatment should include mild topical
corticosteroids to reduce the inflammation.
• C)Oral tetracyclines given over a 4-6 week period
are likely to be the most successful agents.
• D)Topical retinoids are likely to be of benefit.
• E)As the condition is inherited, other family
members will be affected
Question 2:
A man of 30 has developed a reddened face and nose.
On examination he has scars, comedones and a greasy skin. Which of the
following are true?
• A) The diagnosis is likely to be rosacea.
• B) A diagnosis of acne would be supported by the finding
of papules and papulopustules on the back.
• C) Prominent closed comedones are a feature of rosacea.
• E) Seborrhoea(greasy skin) is not a feature of rosacea.
Question 3:Regarding emollients the following are true
in atopic dermatitis (eczema):
• A)Once the eczema is treated emollient use
should be discontinued to avoid folliculitis.
• B)Pump dispensers are a way of storing emollient
to lessen the risk of contamination.
• C)Patients can be advised to bathe daily.
• D)Emollient should be applied more than 30
minutes after bathing.
Question 4:Which of the following statements regarding
isotretinoin are true?
• A)Relapse rates are < 30% on stopping treatment
• B)Pre-treatment kidney function tests are recommended
• C)Night blindness has been reported
• D)Patients should be advised to avoid pregnancy for 6
months following treatment
• E)Dermatitis is a common side effect
Question 5: The following are recognised side effects of acne
therapies:
• A)Bleaching of clothes with topical adapalene
• B)Benign intracranial hypertension with tetracycline
• C)Light-sensitive eruption with doxycycline
• D)Dermatitis with benzoyl peroxide
• E)GI side effects with tetracyclines
A 13 y o boy who complains of a rash on
his face
• It started at age 11 but
has been worse in
recent months.
• How do you describe
his face?
• What is the likely
diagnosis?
Differential?
• What do you tell the
patient?
The 13 y o boy’s arm
How does KP differ from acne?
How does keratosis pilaris differ from acne?
• Keratosis pilaris has
• Acne papules and
small uniform papules
• KP is associated with
dry skin and chapping
pustules vary in size.
• Acne is associated
with oily skin
Keratosis pilaris
• Very common and peaks in adolescence then
tends to improve.
• Small rough follicular papules or pustules can
occur at any age.
• Frequently upper arms and anterior thighs but
any area except palms and soles may be
involved.
• Usually asymptomatic.
Treatment for keratosis pilaris
• Urea (10-40%) or salicylic acid lotion 6% or ammonium
lactate ( LaC-Hydrin) reduce roughness. Avoid abrasive
washing.
• Consider tazarotene (topical retinoid) in slowly increasing
timed applications: start with 5 min then wash off etc.
• Before an important event: a short course of medium
strength steroid reduces the redness: eg betamethasone
valerate (betaderm) .1% BID for 3-4 weeks.
• Patients often need the reminder that these treatments do
not cure but only control keratosis pilaris.
15 y o girl who is discouraged about her acne
• She’s tried prescription
creams and tetracycline by
mouth but it is not
improving.
• She avoids social outings
because she is
embarrassed.
• What treatments do you
discuss with her?
• What can she expect from
the treatments?
Severe inflammatory acne
• For women only:
• Diane 35 ( 35 mcg EE and cyproterone 2mg); ALL OCs
may be beneficial.
• Spironolactone 100 mg/d
• Isotretinoin 1 mg/kg x 16-20 wks; goal is to reach
120-150 mg/kg/course to avoid relapse
• Monitor: LFTs, cholesterol and tg: 0, 1 and q3 mos
• Pregnancy test before, monthly and 1 mo after stopped
The logistics of starting oral retinoids
• Weigh the patient eg wt of 60 Kgs
• Accutane and Clarus exist in 10 and 40 mg capsules
• Do not prescribe the 10 mg capsules since the overall
course will cost twice as much as using 40 mg capsules.
• Start with .5 mg/kg first month: in 60 Kg woman, this
would be 30 mg but use 40 mg cap/day first month, then
increase to usual dose of 1 mg/kg: this would be 60 mg/d:
use 40 mg caps and give 40 mg and 80 mg on alternate
days.
• Follow-up visits: at one month and do BW: CBC, LFTs,
lipids and pregnancy test.
• Avoid other topical acne treatments: too drying.
Commonly asked questions about oral retinoids
• What is the ideal duration of oral retinoids? 120-150
mg/kg/course; eg in 60 Kg woman: 9000 mg which is 5
months.
• Can this treatment be repeated? Yes, the same dose and
course can be repeated; wait at least 8 wks and more
usually 4-5 months before retreatment.
• What is the likelihood that this treatment will work?
remission rate 70-90% with long-term remission 55-80%
after one course.
• When can a patient safely become pregnant after
stopping oral retinoids? 6 weeks.
Side effects of oral retinoids
• Dry skin and mucous membranes: lips, mouth, eyes.
• Headache.
• Sun sensitivity.
• Minor aches.
• Serious: abrupt decrease in night vision, depression and
suicide (controversial).
WHO ARE CANDIDATES FOR
ORAL RETINOIDS?
Candidates for oral retinoids:
• Cystic acne.
• No response to oral antibiotics for 2
courses of 3 mos each.
• Scarring.
• Mild to moderate acne that is causing
psychological distress.
28 y o woman
• She has had acne for
years and would like
treatment.
• How would you
describe her acne?
• What do you suggest?
Pitted acne scars
• Difficult problem.
• Techniques available:
dermabrasion, laser
resurfacing.
• Will not respond to
usual topical or oral
treatments for acne:
there are no active
lesions.
A 35 y old woman who says she is too old for acne!
• What is this rash and
what do you suggest
for treatment?
• What do you tell the
patient about what she
can expect from the
treatment?
What are the differences between rosacea and acne?
How do rosacea and acne differ?
Rosacea
• affects face only and on
•
•
•
•
•
convexities
Age older onset: 3rd-4th
decades
Red papules not tender and
similar size; no comedones
Can have pustules
Telangiectasia; NO cysts
Inflammation around eyes
common
Acne
• affects face, shoulders, chest,
•
•
•
•
back
Age teens to mid 20s but can
last to 40s
Comedones; greasy; papules
tender and different sizes
Several pustules
Cysts but NO telangiectasia
Treatment of rosacea
• Patients often need reminder that rosacea
can be controlled but not cured.
• Avoid sun exposure and use sunscreens.
• Avoid hot drinks (flushing).
• If mild: topical metronidazole .75% bid or
1% daily (Metrogel). Will help papules but
will not affect flushing or telangiectasia.
Treatment of rosacea continued
• Tetracyclines: some can stop when pustules clear
and some require long-term suppression (use
min. effective dose).
• New tetracycline: Apprilon 40 mg doxycycline:
antiinflammatory but not antibacterial. Cost.
• If refractory: isotretinoin .5 mg/kg/day for 20 wks.
• For flushing and telangiectasia: laser but
expensive.
• New treatment for flushing: brimonidine
vasoconstrictor lasts 6-9 hours. Very expensive.
• (same medication as Alphagan for eyes)
A 22 y o woman with pimples around her nose
• She noticed them about 3-
4 months ago and they are
increasing.
• She has tried acne creams
for 2 weeks then
moisturizers but nothing
seems to help.
• What is the diagnosis and
treatment?
What is the diagnosis?
Perioral dermatitis ( periorificial dermatitis)
• Typical: papules and pustules confined to chin
and nasolabial folds sparing a clear zone around
the vermillion border.
• Initially pustules adjacent to nostrils. Can also be
adjacent to eyes and nose.
• Cause unknown but associated with abundant
use of moisturizers and makeup.
• Aggravated by topical steroids, tretinoin and
antibiotic lotions
• What is the treatment?
Treatment of perioral dermatitis
• 6-8 weeks of oral tetracyclines (or erythromycin)
• Unlike typical acne which takes longer, perioral
dermatitis will improve after initial 2-4 weeks of
treatment.
• Topical antibiotics are not effective.
• Metronidazole cream reduces papules but is not
as effective as oral antibiotics.
52 y o woman who is embarrassed to go to work
because of her red face
• She has had eczema
since she was a child.
• She has been applying
1% hydrocortisone
cream bid for 2 weeks
but is no better.
• What do you see?
• What do you suggest?
What do you see?
• Diffuse erythema face
• Lichenification: increased
skin lines around the eyes.
WHAT CAN YOU DO FOR THE FACE
WHEN TOPICAL STEROIDS ARE
NOT ENOUGH?
What can you do for the face when topical steroids are
not enough: Immune modulators=calcineurin inhibitors
• Tacrolimus ointment (Protopic).
• Suppress cytokine release from T-lymphocytes.
• .1% BID for adults and .03% BID for age 2-15.
• Indicated if failure of topical steroids or when
steroids not advisable (face) since no risk of
atrophy.
• Efficacy similar to mid-potency steroid.
• Advise patient: burning at site of application.(can
be lessened by keeping in refrigerator.)
• Do not use on infected skin.
• Expensive: $89/30g
Tips about treating eczema
• Remember tachyphylaxis (tolerance) and use
topical steroids in ‘bursts’ of 2-4 wks and stop for
at least 1 week before retreating to reduce
tolerance.
• Recommend moisturizers every day to protect
the skin barrier: petrolatum is cheap and
effective.
• Use ointment base with topical steroids for
moisturizing effect; also creams are complex
substances and can be sensitizing.
More tips for atopic dermatitis (AD)
• If 1% HC ointment is not sufficient for the face, do
not use 2.5% HC ointment: same potency
category.
• Instead use desonide .05%: low potency but
slightly more potent than HC; safe for the face of
children.
• For the body of adults use moderate (eg
betamethasone valerate .1%) to high
potency(betamethasone dipropionate .05%)
topical steroid. Safe to use for 2-4 wks.
If topical steroids are not working
• Consider:
• Non-adherence to treatment
• Superinfection
• Sensitivity/allergy to the vehicle in the topical steroid
• The topical steroid is not sufficiently potent.
BACK TO THE QUIZ
Question 1: in a patient with perioral
dermatitis
• A)The lip vermilion and adjacent skin are
inflamed and scaly.
• B)Treatment should include mild topical
corticosteroids to reduce the inflammation.
• C)Oral tetracyclines given over a 4-6 week period
are likely to be the most successful agents.
• D)Topical retinoids are likely to be of benefit.
• E)As the condition is inherited, other family
members will be affected
Question 1: in a patient with perioral
dermatitis
• A)The lip vermilion and adjacent skin are
inflamed and scaly.
• B)Treatment should include mild topical
corticosteroids to reduce the inflammation.
• C)Oral tetracyclines given over a 4-6 week
period are likely to be the most successful
agents.
• D)Topical retinoids are likely to be of benefit.
• E)As the condition is inherited, other family
members will be affected
Question 2:
A man of 30 has developed a reddened face and nose. On examination he has
scars, comedones and a greasy skin. Which of the following are true?
• A) The diagnosis is likely to be rosacea.
• B) A diagnosis of acne would be supported by the finding
of papules and papulopustules on the back.
• C) Prominent closed comedones are a feature of rosacea.
• E) Seborrhoea(greasy skin) is not a feature of rosacea.
Question 2:
A man of 30 has developed a reddened face and nose. On examination he has
scars, comedones and a greasy skin. Which of the following are true?
• A) The diagnosis is likely to be rosacea.
• B) A diagnosis of acne would be supported by the
finding of papules and papulopustules on the back.
• C) Prominent closed comedones are a feature of rosacea.
• E) Seborrhoea(greasy skin) is not a feature of
rosacea.
Question 3:Regarding emollients the following are true
in atopic dermatitis (eczema):
• A)Once the eczema is treated emollient use
should be discontinued to avoid folliculitis.
• B)Pump dispensers are a way of storing emollient
to lessen the risk of contamination.
• C)Patients can be advised to bathe daily.
• D)Emollient should be applied more than 30
minutes after bathing.
Question 3:Regarding emollients the following are true
in atopic dermatitis (eczema):
• A)Once the eczema is treated emollient use
should be discontinued to avoid folliculitis.
• B)Pump dispensers are a way of storing
emollient to lessen the risk of contamination.
• C)Patients can be advised to bathe daily.
• D)Emollient should be applied more than 30
minutes after bathing.
Question 4:Which of the following statements regarding
isotretinoin are true?
• A)Relapse rates are < 30% on stopping treatment
• B)Pre-treatment kidney function tests are recommended
• C)Night blindness has been reported
• D)Patients should be advised to avoid pregnancy for 6
months following treatment
• E)Dermatitis is a common side effect
Question 4:Which of the following statements regarding
isotretinoin are true?
• A)Relapse rates are < 30% on stopping treatment
• B)Pre-treatment kidney function tests are recommended
• C)Night blindness has been reported
• D)Patients should be advised to avoid pregnancy for 6
months following treatment
• E)Dermatitis is a common side effect
Question 5: The following are recognised side effects of acne
therapies:
• A)Bleaching of clothes with topical adapalene
• B)Benign intracranial hypertension with tetracycline
• C)Light-sensitive eruption with doxycycline
• D)Dermatitis with benzoyl peroxide
• E)GI side effects with tetracyclines
Question 5: The following are recognised side effects of acne
therapies:
• A)Bleaching of clothes with topical adapalene
• B)Benign intracranial hypertension with tetracycline
• C)Light-sensitive eruption with doxycycline
• D)Dermatitis with benzoyl peroxide
• E)GI side effects with tetracyclines
references
-Naldi L,Rebora A. Seborrheic Dermatitis NEJM 2009;360:387-96
-Bieber T. Atopic Dermatitis. NEJM 2008;358:1483-94
-Lewis-Jones S,Mugglestone MA. Management of atopic eczema in
children aged up to 12 years: summary of NICE guidance.BMJ
2007;335:1263-4
-Laubscher T,Regier L,Jin M. Taking the stress out of acne
management. CFP 2009,55:266-69.
-Goldgar C,Keahey DJ,Houchins J.Treatment Options for Acne
Rosacea. Am Fam Physician. 2009;80(5):461-468,505.
-Habif T. Clinical Dermatology: A Color guide to diagnosis and Therapy.
5th edition 2010.