Transcript acne Pictures - UNC School of Medicine

What’s New (and What’s Not)
in Acne and Rosacea
Adam O. Goldstein, MD
Assistant Professor
Department of Family Medicine
University of North Carolina at Chapel Hill
Email: [email protected]
Objectives
1. Know differential diagnosis acne/rosacea
2. Increased knowledge treatment strategies
3. Increased familiarity new products
4. Learn 2 new patient education tips
GOAL: Improved therapeutic outcomes
Acne
•
•
•
•
Most common dermatologic disease
Onset usually adolescence but anytime
More frequent and severe in males
70% women premenstrual flares
Acne Quiz (T/F)
1. Certain foods make acne worse...
2. Dirty skin makes acne worse...
3. Acne worsens with sexual activity...
4. Acne improves within 24 hours of tx...
5. Sweating may make acne worse...
6. Humidity may exacerbate acne...
7. Acne may worsen during menstruation...
8. Stress may make acne worse...
Art of acne treatment:
• Negotiating long-term treatment
• Increasing compliance by using fewer
•
•
•
•
medications
Contracting with adolescents
Thorough explanation of natural history of
disease
Patience with acne’s emotional toil
Combining drugs @ different mechanisms
Art of acne treatment:
• “Quality of Life” scale
0
1
1. Feeling self-conscious
2. Decrease in socialization
3. Difficulties in relationships
(partner, friends, family)
4. Feeling like an outcast
5. People making fun of you
6. Feeling rejected (romance, friends)
2
3
Common pitfalls in acne
treatment
• Using more than two medications
• Insufficient patient education or unrealistic
•
expectations
Frustration all around
Acne: Etiology
•
•
•
•
•
Combination hormonal (androgen), bacterial
(Proprionibacterium acnes) and follicular
(hyperkeratosis)causing debris and occlusion
Bacteria multiply and inflammatory response
Comedones: “Blackheads” and “Whiteheads”
Blackheads = open comedones
Whiteheads = closed comedones
Acne: Morphology
• Comedones
• Papules
• Pustules
• Nodules
• Cysts
Acne: Differential Diagnosis
• Rosacea:
• Hidradenitis:
• Keratosis Pilaris:
• Perioral Derm.:
• Senile Comed.:
• Topical steroids:
No comedones, erythema striking,
central face
Axilla & inguinal, nodules & cysts,
scarring
Upper arms & trunks, follicularbased papules
Papulovesicles & erythema,
perioral, topical steroid use
Face & neck, comedones and cysts
in damaged skin
Lesions same stage, no comedones
Rosacea
Hidradenitis
Keratosis Pilaris
Keratosis Pilaris
Perioral Dermatitis
Perioral Dermatitis
Senile Comedones
Topical Steroids
Acne Keloidalis
Acne Keloidalis
Acne: Treatment
• Treatment goal is to prevent new lesions/scarring
• Treatment will not improve outcomes for 4-6
weeks
• (Acne exacerbated by iodides, bromides,
hydantoin, chlorinated hydrocarbons, occluding
topical preparations, vigorous washing, and
mechanical occlusion)
Acne and Iodides
Acne and
Dilantin
Acne and Topical Steroids
Acne and Topical Steroids
Mechanical occlusion
Mild acne:
•
•
•
•
Apply one agent thinly to entire face
If two agents selected, use at separate times
Apply after washing with water or mild soap
Choices:
– Benzoyl peroxide Topical antibiotics
– Tretinoin
Birth Control Pills
– Azelaic acid
Salicylic acid
• Use for 6-8 weeks before judging if effective
Mild acne
• Benzoyl peroxide
($)
– Antibacterial, drying and peeling actions
– Rx: 2.5-10% gel/cream/wash
– OTC: 2.5-10% gel/lotion/cream
– Usually start with 2.5-5%, thin layer
QD-BID
Mild acne
• Benzoyl peroxide
– Water based preps are milder and less drying
– Alcohol/acetone preps useful in oily skin
– Washes and soaps are good for acne on the
chest, back and shoulders (5-10%)
– Benzamycin gel- 23.3 grm- benzoyl peroxide
and erythromycin- must be kept refrigerated
Mild acne: Benzoyl peroxide
• Side Effects
– Occasional hypersensitivity reactions (1-5%)
– Oxidating agent: will bleach clothes and hair
Mild acne
• Topical antibiotics (all Px)
($$)
– Erythromycin 2%- pledgettes, pads, gel
(oily skin), solution, ointment (dry skin)
– Clindamycin 1%- solution, gel, lotion
• (e.g. Cleocin T)
– Meclocycline- cream; useful in patient
with very dry skin
• (e.g. Meclan)
Mild acne: Topical antibiotics
• Sodium sulfacetamide 10%, Sulfur 5%,
Sodium thiosulfate 10%
– Numerous keratolytic/astringent agents
– Useful if lotion preparation preferred and other topical
antibiotics not working or tolerated
– Sulfacet R- tinted (can cover redness)
– Novacet- untinted
• Bacterial resistance may develop after 6-12
months of use
Mild acne: Topical Retinoids
•
•
•
•
•
•
•
Especially good for comedonal or papular acne
Modulates keratinization
Use pea size amount to entire face
Apply 3x week for 2 weeks, then nightly
Increases photosensitivity
Flare reaction frequent
Web Sites:
http://www.healthsquare.com/pdrfg/pd/
monos/retin-a.htm
Topical Retinoids
Retin A (Renova)
($$$)
• Vehicles:0.025%, 0.05%, 0.1% cream; 0.01%, 0.025% gel
• Start with 0.025% strength
• Apply at bedtime 30 minutes after washing
Avita
• Vehicles: 0.025% cream/gel
• Slow release polymer may be less irritating
Retin A Micro
• Vehicle: 0.1% gel; Thick and yellow
• Slow release may be less irritating
Retinoid-Like
• Adapalene (Differin)
($$$)
– Vehicles: 0.1% gel, solution
– May apply right after washing at bedtime
• Tazarotene (Tazorac)
– Vehicles: 0.05, 0.1% gel
– Irritating initially
– May be useful with oily skin
– Short contact therapy
Retinoids-Comparisons
• Adapalene 0.1% gel vs. Tretinoin 0.025% gel, metaanalysis of 5 RCT’s (BMJ, 139S 1998)
– equivalent efficacy reducing total lesions
– Adapalene with significant difference in reduction of
inflammatory and total lesions at week 1
– Adapalene with greater local tolerability
• Adapalene 0.1% gel vs. Tretinoin 0.05% gel, Split-face
clinical and bio-instrumental comparison (Dermatology.
198(2):218-22, 1999)
– Tretinoin with better comedolysis and clinical
improvement than adapalene
– Erythema transiently more pronounced with tretinoin
Salicylic acid: 2%
• OTC
($)
• Keratolytic
• Many preparations
• Useful in combo with tretinoin or
topical antibiotics
20% Azelaic acid (Px)
• Mechanism unknown
($$)
• Useful for patients intolerant to tretinoin or
benzoyl peroxide
• Avoid on broken skin
• Use qd-bid, usually in combination with
other topicals
Acne and Birth Control Pills
• Lowers hormonal factors exacerbating acne
• Use pill with low androgenic potential
• Know side effects and
contraindications
• Acne often improves
during pregnancy
Moderate acne
Moderate acne
• Mild treatment +
• Add oral antibiotics
– Tetracycline- 500 mg bid or doxycycline 50-100
mg/day
– Erythromycin- 500 mg bid
– Minocycline- 50-100 mg/day
– Trimethoprim/Sulfamethoxazole 1 DS qd-bid
• Comedo removal
Minocycline has fewer GI
side effects, but it is more
expensive
Severe acne
• Moderate regimen X 3 months
• Isotretinoin for severe nodulocystic acne
• Steroid injections
– TAC acetonide 10 mg/ml diluted to 3 mg/ml
– Inject 0.1 ml into fresh cyst
• Prednisone rarely
• Consultation
Isotretinoin (Accutane)
•
•
•
•
•
0.5-1 mg/kg/day 16-20 weeks
80% success rate
Indications wider than previous thought
Improvement continues after treatment stops
Very teratogenic: (2 forms birth control for one
month beforehand)
• Laboratory monitoring: (HCG before & monthly, CBC, LFT,
TG, LDH, TG’s, Cholesterol, Q 2 weeks, then monthly)
• Use moisturizers, lip balms and artificial tears
• Monthly costs $200-400
Acne: Myths
• NO relation to junk foods
• NO relation to “hygiene”
• NO relation to masturbation or other sexual
•
activity
NO way to make acne go away overnight
Acne: Truths
•
•
•
•
YES acne may worsen premenstrual
YES sweating may worsen acne
YES humid environments may worsen acne
YES stress can exacerbate acne
Acne: Patient Education
• 6-8 week response
• Avoid scrubbing
• Keep regimen simple
• Compliance is key to FTIP; Have
patient bring medications to office
Acne: Patient Education
• Use water-based makeup
• “Oil-free” moisturizers
• Web Sites:
http://www.pslgroup.com/ACNE.htm
Useful general information for clinicians
http://www.derm-infonet.com/acnenet/toc.html
Comprehensive site
http://www.m2w3.com/acne/
Patient support group
Acne Rosacea
• “Rosy” dilatation of the central face:
– eyes, nose, chin, cheek, forehead
• Diverse spectrum of disease•
(papules, pustules, nodules, cysts)
Rhinophyma -hyperplasia of the
nose in middle aged men
Acne Rosacea
• Look for periodic facial flushing after
temperature increase, spicy food ingestion
or alcohol
• Absence of comedones
• Disease is chronic: Treatment goal is
control
Acne Rosacea:
Differential Diagnosis
• Acne Vulgaris:
• Seb. dermatitis:
• Lupus:
• Carcinoid:
comedones, younger
patient, lack of flushing,
less erythema
no acneiform lesions
no papules and pustules
flushing is transient
Acne Rosacea: Treatment
• Topical
•
•
•
•
– Antibiotics, Benzoyl peroxide, Tretinoin
Oral antibiotics
Isotretinoin for severe, recalcitrant cases
Referral for surgery, dermabrasion, laser
Potent topical steroids often worsen disease
Acne Rosacea: Topical Therapy
• Preferred topical antibiotic:
– Metronidazole
• 0.1% cream (Noritate): qday
• 0.75% cream or gel: bid
– Alternatives:
• Sodium sulfacetamide 10%/sulfur 5% lotion
• Clindamycin 1% lotion, gel or solution
• Erythromycin 2% solution
Acne Rosacea: Topical Therapy
• Benzoyl peroxide at 2.5% & up to 10% if
tolerated
• Tretinoin 0.025%, 0.05% 0.1% cream
– Start with lowest dose
– May be used in combination with other
products
Acne Rosacea: Oral antibiotics
• Useful for nodular lesions
• Doxycycline 50-100 mg/day or tetracycline
500-1000 mg/day
• Minocycline 50-100 mg at bedtime
• Treat until improvement occurs, then taper
for control
Acne Rosacea: Patient
Education
• Control vs cure
• Avoid excessive sunlight, alcohol, temperature
•
•
extremes and precipitating foods
Flares may require higher “pulse” treatment
Good web sites:
– National Rosacea Society
http://www.rosacea.org/home.html
– Patient education brochure
– http://www.aad.org/pamphlets/rosacea.html
On the Horizon….
• New retinoids
• Combination products: retinoids and topical
antibiotics
• Glycolic acid, salicylic acid peels
• Hormonal treatments
• Antibiotic alternatives
Cases
•
•
•
•
•
•
14, Sports PE & whiteheads- incidental
16, with comedones and mild inflammation
16, before the prom
20, with sensitive skin, papular lesions and skin
irritation
21, moderate acne on 0.1% Retina cream and 5%
Benz. Peroxide, wanting referral to dermatologist
22, with extensive cystic acne for 5 years
Conclusion
•
•
•
•
Be confident
Use 1-2 agents if at all possible
Define expectations
Think about acne rosacea in adults