Acne Vulgaris Treatment and Evaluation PDF

Acne Vulgaris A common pilosebaceous disorder that affects 85% of people between the ages of 12-24 and 15-35% of adults Clinical presentation can range from mild comedonal acne to severe nodulocystic acne Psychosocial repercussions, including depression, anxiety, and social with...

Acne Vulgaris A common pilosebaceous disorder that affects 85% of people between the ages of 12-24 and 15-35% of adults Clinical presentation can range from mild comedonal acne to severe nodulocystic acne Psychosocial repercussions, including depression, anxiety, and social withdrawal should be considered Pathogenesis Acne Vulgaris: Pathogenesis Dermatology Essentials, 2nd Edition  Acne Vulgaris Why is this happening? 4 Main Contributing Factors  Acne Vulgaris: 4 Main Factors 1. Abnormal Keratinization Keratinocytes are proliferating too fast Keratinocytes are more cohesive than normal “Top layer of skin cells are thicker and stickier than normal” Acne.org  Acne Vulgaris: 4 Main Factors 2. Increased sebum production Increased levels of androgens cause increase in sebum production “ A change in hormones cause more oil production” Acne.org  Acne Vulgaris: 4 Main Factors 3. Propionibacterium acnes overgrowth P. acnes love an oily environment! “The bacteria that causes acne loves the excess oil” Sciencephotogallery.com  Acne Vulgaris: 4 Main Factors 4. Inflammation P. acnes induce inflammation by activating toll-like receptor 2, located on the surface of keratinocytes and macrophages. This causes a release of inflammatory mediators such as IL-1, IL-8, IL-12, and TNF-alpha. “The increase in bacteria cause inflammation”  Acne Vulgaris Additional Triggers Stress Personal care products ○ Foundations, hair spray, pomades ○ Recommend mineral based, non comedogenic products Mechanical ○ Sports gear, masks, musical instruments Medications ○ Anabolic steroids, prednisone, bromides (found in sedatives and cold medicine), lithium, progesterone only contraceptives Diet ○ Mild association between skim milk intake and increase in acne ○ Recommend eating healthy, whole foods and decrease sugar intake  Acne Vulgaris Moderate Mild Severe  Acne Vulgaris: Evaluation and Treatment Start with counseling, very important! Ask them about their skin care regimen or routine Do they know how to wash their face? What products are they using? ○ Too many can worsen acne ○ Keep it simple Do they pick at their pimples? Is today a good day or a bad day? Do they want their acne to improve? Emphasize that the amount of improvement they will see reflects the amount of effort they put in. Consistency is key!!!  Acne Vulgaris: Evaluation and Treatment History Sex, consider transgender identity if appropriate Age ○ If between 2-7 yo consider hyperandrogenism (precocious puberty) Lifestyle, hobbies, occupation Current and previous treatments, including OTC products Use of personal care products Menstrual hx, birth control Medications PMH Family hx of acne  Acne Vulgaris: Evaluation Physical Exam Distribution of acne- look in all locations! ○ Face (T-zone, cheeks, jawline, forehead) ○ Neck, chest, back, upper arms Degree of involvement ○ Mild, moderate, or severe Lesion morphology ○ Comedones ○ Inflammatory papules and pustules ○ Nodules and cysts ○ Scarring  Acne Vulgaris: Treatment Recommended regimen for most acne patients Wash face with warm water twice daily ○ CeraVe, Cetaphil, Vanicream gentle cleansers ○ Depending on type of acne may recommend a benzoyl peroxide wash, sulfur wash, or salicylic wash Apply a moisturizer with SPF 30+ every morning ○ Prevents PIH Apply a non-comedogenic moisturizer in the evening after washing and after after applying any topical treatments ○ CeraVe, Cetaphil, Vanicream  Acne Vulgaris: Treatment Types of treatment: Topical Retinoids ▪ HOW: Comedolytic, decreases hyperproliferation, and has anti-inflammatory effects, so…it’s the most important tx for acne! ▪ WHO: Works well for comedonal acne all the way up to moderate-severe inflammatory acne ▪ WHEN: Start every other night working up to nightly ▪ Contraindicated in pregnancy ▪ SE: Redness, dryness, photosensitivity, retinoid dermatitis ▪ Ex: Retin-A, Tretinoin, Adapalene  Acne Vulgaris: Treatment Types of treatment: Topical Antimicrobials ○ HOW: decreases P. acnes ○ WHO: Appropriate for mild-moderate inflammatory acne ○ WHEN: Once to twice daily, depending on type and severity ○ SE: Dryness, redness, irritation ○ EX: Benzoyl Peroxide (BPO) comes in wash or topical cream/gel. Can be irritating so recommend starting will low percentage, 4%. Can find OTC or can be prescribed. Antibiotic: Clindamycin 1% lotion is my favorite. Must be prescribed ○ They work really well when used together. Wash with a BPO wash, dry the area, then apply topical antibiotic. This also helps decrease antibiotic resistance!  Acne Vulgaris: Treatment Types of treatment: Oral Antibiotics ○ HOW: Anti-inflammatory at lower dose, anti-microbial at higher dose ○ WHO: Used in patients over 8 yo with moderate-severe acne, especially if back, chest, and arms are involved ○ WHEN: once to twice daily, typically used for 3-6 months ○ EX: Tetracyclines (Doxycycline or Minocycline) ○ SE Doxycycline: GI (nausea, vomiting, diarrhea, so recommend taking with glass of water and meal), photosensitivity. ○ SE Minocycline: GI, hyperpigmentation of scars, on shins, or sun exposed areas, discoloration of teeth, vertigo. ○ Contraindicated in pregnancy and under the age of 8 ○ If patient has an allergy consider azithromycin, erythromycin, or bactrim  Acne Vulgaris: Treatment Types of Treatment: Hormonal HOW: inhibit ovarian androgen production which decreases sebum production WHO: females presenting with acne on the jawline, typically flares with menses WHEN: once daily EX: OCPs: FDA-approved for acne: Ortho Tri-Cyclen, Yaz, Estrostep CI: Risks outweigh the benefits if: ○ >35 and smoker ○ History of HTN, diabetes, venous thromboembolism, ischemic heart disease, stroke, current breast cancer or other malignancy  Acne Vulgaris: Treatment Types of Treatment: Antiandrogen (Oral) HOW: androgen antagonist, so decrease sebum production WHO: for hormonal acne, think jawline, typically female only WHEN: 50-200 mg/day EX: Spironolactone Contraindications Spironolactone: renal insufficiency, hyperkalemia, pregnancy, and hx or family hx of breast cancer SE: urinary frequency, orthostatic hypotension, hyperkalemia, irregular menses, breast tenderness, gynecomastia Works well when combined with Yaz Potassium monitoring no longer required if under 45 yo and no history of elevated potassium. Otherwise, potassium checked every 3-6 months.  Acne Vulgaris: Treatment Types of Treatment: Oral Retinoid HOW: Works on all 4 components of acne and decreases the size of sebaceous glands, exact MOA is unknown WHO: Typically used for moderate-severe acne, or recalcitrant acne WHEN: Taken daily for ~6 months, dosed at 0.5-1 mg/kg/day; cumulative dose is 120-150 mg/kg EX: Isotretinoin, “Accutane” SE: Commen: cheilitis, mucosal dryness (nose and eyes), xerosis, headaches, slow healing CI: pregnancy or intending to become pregnant, hypertriglyeridemia, hx severe depression, personal or family hx of IBD  Acne Vulgaris: Treatment Types of Treatment: Oral Isotretinoin Teratogen (craniofacial and cardiac defects), female patients are required to be two forms of birth control and must have monthly pregnancy tests Fasting lipid panel and LFTs monitored for all patients Recommend avoidance of alcohol and following a healthy diet All patients must register with iPledge  Acne Vulgaris: Treatment MILD MODERATE SEVERE Mostly inflammatory: BPO Oral abx, + topical retinoid, Isotretinoin wash/Clindamycin lotion, +/- BPO/Clindamycin lotion topical retinoid Comedonal: topical retinoid Hormonal: anti androgen Topical BPO + oral abx + +/- OCP + topical retinoid topical retinoid (female) Isotretinoin if resistant to previously tried tx plan, scarring, or fhx of scarring