Acne Pathogenesis and Therapy Overview

Acne Pathogenesis

• Acne involves four key mechanisms:
  • Increased sebum production: Driven by androgens, leading to excess sebum from sebaceous glands.
  • Follicular hyperkeratinization: Dead skin cells and sebum clog follicles, forming comedones (whiteheads/blackheads).
  • Bacterial lipolysis: Cutibacterium acnes thrives in sebum, breaking it down and causing irritation.
  • Inflammation: Dead skin cells and bacteria trigger an inflammatory response, creating lesions.

Acne Targets for Therapy

• Reduce sebum production.
• Normalize skin cell shedding.
• Control C. acnes growth.
• Minimize inflammation.

Acne Types: Vulgaris vs. Rosacea

• Acne vulgaris:
  • Linked to androgen activity.
  • Characterized by comedones, papules, pustules, nodules, and cysts.
  • Common in adolescents.
• Acne rosacea:
  • No comedones.
  • Often triggered by alcohol, spicy food, or temperature changes.
  • Common in adults (age 30+), with erythema, telangiectasia, and inflammatory lesions.

Acne-Inducing Medications

• Systemic corticosteroids (e.g., prednisone) can cause pustular acne.
• Antiepileptics (e.g., phenytoin).
• Lithium.
• Halogens (excess dietary iodine).
• Cosmetic ingredients (e.g., isopropyl myristate, cocoa butter, fatty acids).

Acne Palliative Factors

• Non-comedogenic moisturizers.
• Gentle cleansing.
• Balanced, low-glycemic diet.

Non-Pharmacologic Acne Management

• Gentle, fragrance-free cleansing twice daily.
• Avoid harsh scrubbing or friction.
• Use sunscreen (SPF 15+).
• Consider comedone extraction for visible lesions.

Moisturizers in Acne Treatment

• Moisturizers improve tolerance for acne treatments by reducing dryness.
• Choose moisturizers based on skin type:
  • Dry skin: Nutrient-rich.
  • Oily skin: Lightweight, oil-free.
  • Combination skin: Light formulations for problem areas.

Acnegenic Sunscreen Ingredients

• Benzophenones (e.g., dioxybenzone, oxybenzone, sulisobenzone).

Acne Severity

• Mild: Few papules/pustules, no nodules.
• Moderate: Several papules/pustules, few nodules.
• Severe: Extensive papules, pustules, nodules, and/or cysts; scarring common.

Pharmacologic Acne Treatments

• Mild: Topical retinoids (e.g., tretinoin, adapalene), benzoyl peroxide (BPO).
• Moderate: Combination therapy (retinoid + BPO + topical antibiotic).
• Severe: Oral isotretinoin, oral antibiotics (e.g., doxycycline), hormonal therapy (female patients).

Pharmacologic Mechanisms

• Retinoids: Normalize skin cell shedding, prevent comedones.
• BPO: Antibacterial and comedolytic.
• Antibiotics: Reduce C. acnes and inflammation.
• Isotretinoin: Decreases sebum and normalizes skin cell shedding.

Topical Retinoids

• Adapalene (OTC).
• Tazarotene.
• Tretinoin.
• Trifarotene.

Acne Therapy Patient Counseling

• Retinoids: Night application, avoid spot treatment, expect initial worsening.
• BPO: Start at low concentration, avoid contact with clothing.
• Oral antibiotics: Take with water, avoid sun exposure (photosensitivity risk).

Topical vs. Oral Antibiotics

• Topical: Fewer systemic side effects, but risk of resistance.
• Oral: More effective for severe acne, but systemic side effects (photosensitivity).

Overcoming Antibiotic Concerns

• Combine with BPO to prevent resistance.
• Limit therapy duration (4 months).
• Transition to retinoid maintenance therapy.

Hormonal Therapy Patient Population

• Women with acne worsened by hormonal fluctuations (e.g., PCOS).
• Reduces sebum production by suppressing androgen activity.

iPLEDGE Program Goals

• Prevent pregnancy during isotretinoin treatment.
• Prevent pregnant people from using isotretinoin.

Acceptable Contraception for Isotretinoin

• Primary: Hormonal implants, IUDs.
• Secondary: Barrier methods, abstinence.

Isotretinoin Prescription Window Closure

• For women who can become pregnant, prescription must be filled within 7 days of the pregnancy test.

Evidence-Based Acne Treatment Plan

• Tailored to severity.
• Pharmacologic, non-pharmacologic, and monitoring.
• Seek care for worsening symptoms, serious side effects.