Guidelines of skin care for Acne PDF

Guidelines of skin care for Acne Saja Hamed, Ph.D Professor of Pharmaceutics & Cosmetic Science Hashemite University Saja Hamed, Ph.D 1  Introduction...

Guidelines of skin care for Acne Saja Hamed, Ph.D Professor of Pharmaceutics & Cosmetic Science Hashemite University Saja Hamed, Ph.D 1  Introduction  Acne is an inflammatory disease of the pilosebaceous follicle  It starts in adolescence and may persist into young adulthood or longer especially in females  Acne is one of the most common chronic skin disorders  Although acne is not physically disabling, its psychological impact can be striking, contributing to low self- esteem, depression, and anxiety Saja Hamed, Ph.D 2 Pathophysiology Saja Hamed, Ph.D 3 Saja Hamed, Ph.D 4 Pathophysiology: A. Sebaceous gland Hyperactivity  Sebaceous glands are largest and most numerous in the face, back, chest, and shoulders  Sebum is a complex mixture of triglycerides, cholesterol, cholesterol esters, fatty acids, wax esters, and squalene  Controlled by hormones  Sebaceous glands become more active during puberty because of the increase in androgens (particularly testosterone)  Imbalance between sebum production and the secretion Saja Hamed, Ph.D 5 Pathophysiology: B. Changes in Follicular Keratinization  In acne patients the exfoliated mature keratinocytes have a tendency to stick together  The clumped keratinocytes block the pore/follicle creating: - A blackhead (open comedone) - Or a whitehead (closed comedone)  The clogged pore is a great nutritional source for bacteria  The immune system recognizes the presence of bacteria and mounts an immune response resulting in redness, pus, inflammation Saja Hamed, Ph.D 6  Acne: The follicle becomes impacted with shed skin cells. The follicle may be blocked leading to comedone formation Saja Hamed, Ph.D 7 Pathophysiology: C. The Influence Of Bacteria  P. acnes is an anaerobic, Gram‐positive bacterium present in acne lesions  The exact role of bacteria is unclear: - It is known that sebum accumulation caused by excess lipid secretion and hyperkeratosis leads to an increase in P.acnes around the hair follicles - The inflammation seen in acne may be caused by free fatty acids that result from the breakdown of triglycerides in the sebum because of bacterial lipases Saja Hamed, Ph.D 8  Acne bacteria produce fluorescent pigments Saja Hamed, Ph.D 9 Open Comedones with histology Saja Hamed, Ph.D A blackhead (open comedone) 10  Closed comedones are likely to progress to inflammatory lesions whitehead (closed comedone) Saja Hamed, Ph.D 11 Acne lesions: papules  Small, raised lesions, up to 0.5 cm in diameter, usually pink/red in colour Saja Hamed, Ph.D 12  Inflamed papules Saja Hamed, Ph.D 13 Acne lesions: Pustules  Pustule: Elevated lesion with exudates (pus) Saja Hamed, Ph.D 14 Acne lesions: Nodules  Are inflammatory swellings that, in comparison to papules, are located deeper under the skin Nodule: Raised solid lesion more than 1 cm in diameter Saja Hamed, Ph.D 15  Acne lesions: Cysts  Even deeper, inflamed, pustular painful lesions that can cause scarring  Closed spaces under the skin’s surface, containing liquid or semisolid material Saja Hamed, Ph.D 16 Follicles may rupture leading to inflammatory lesions and in severe cases they may join into tracts. Saja Hamed, Ph.D 17  Severe acne on the chest Saja Hamed, Ph.D 18  Infant Acne  Sebaceous glands are active in the neonate  Moderate acne may occur for up to 3 months  Clears spontaneously Saja Hamed, Ph.D 19  Infant acne Saja Hamed, Ph.D 20 Cosmetics and acne:  Acne Cosmetica: Acne as a result of cosmetics usage  Some cosmetic preparations may lead to acne which appears after using the cosmetic for several months (Comedogenic preparations)  Some cosmetic preparations may cause acne in the form of pustules within one to two weeks of using the preparation (Acnegenic preparations) Saja Hamed, Ph.D 21  Factors that may exacerbate Acne  Emotional Stress  Premenstrual Stress  Mechanical Trauma  Occlusive Clothing  High humidity  Harsh scrubbing of the skin  Some cosmetic oils  Various medications, especially steroids Saja Hamed, Ph.D 22  Acne may be initiated by heat and humidity Saja Hamed, Ph.D 23 Acne and Diet  A matter of intense debate  Dairy products mainly milk  Foods with glycemic loads (breads and spaghetti)  The evidence does not demonstrate that diet causes acne, but some diet can aggravate it Saja Hamed, Ph.D uptodate.com 24  Classification  Classification is important as it is used as a basis for selecting the treatment  Mild: - limited to the face - Presence of non-inflammatory closed and open comedones with few inflammatory lesions  Moderate: - Increased number of inflammatory papules and pustules on the face - Often affects other body parts  Sever: - Nodules and cycts are present - SajaWidespread Hamed, Ph.D to other body uptodate.com parts 25  Milder cases are best managed with OTC and prescription topical regimens  Systemic prescription drugs are indicated in sever cases  Adjunctive and/or emerging approaches include chemical peels, optical treatments Saja Hamed, Ph.D uptodate.com 26 Remmeber  Despite the claims, acne treatment does not work overnight  With most treatments, one may see the first signs of improvement in 4-8 weeks  The skin may often get worse before it gets better due to the side effects of commonly used medications  Maintenance therapy is usually necessary for many acne patients Saja Hamed, Ph.D uptodate.com 27 Topical treatment options: benzoyl peroxide  Nonantibiotic antimicrobial agent  Kill bacteria by producing ROS  It is reported to increase cell turn over, cleans pore, desquamate the skin, and has anti-inflammatory properties  Mainstay treatment of mild-to-moderate Acne often combined with antibiotics and/or retinoids  Available in OTC topical products in conc of 2.5-10%  Side effects: peeling, dryness, burning, redness  Irritation resolves with continued use during the first month of treatment  Warn patient the BPO may bleach clothing, bedding, and hair Saja Hamed, Ph.D uptodate.com 29 Topical treatment options: benzoyl peroxide Topical treatment options: benzoyl peroxide  Topical treatment options: Salicylic acid  An option for patient who cannot tolerate a topical retinoid due to skin irritation  As OTC: 0.5-2%  Side effects: skin dryness, scaling, itching dissipate in a few weeks Topical treatment options: Topical Retinoids (Rx only)  Normalize the abnormal desquamation pattern in sebaceous follicles  Decrease the coherence of follicular keratinocytes  Prevent the formation of new microcomedones  Some have anti-inflammatory  Recommended for all cases of acne (except when oral retinoids are used)  Mild noninflammaory comedonal acne may be treated with retinoid monotherapy Topical treatment options: Topical Retinoids (Rx only)  When inflammatory lesions are present: retinoids are combined with antimicrobial therapy or BPO  Topical retinoids can be used for maintenance therapy  Tretinoin, adapalene, tazarotene  Maximum benefits can be expected after 3-4 months of treatment  Liposomally encapsulated tretinoin is much better tolerated than gel  Tazarotene foam’s tolerability is better than that of a gel Saja Hamed, Ph.D uptodate.com 35 Saja Hamed, Ph.D uptodate.com 36 Topical retinoids  Conc??  How to use?  Effect of vehicle Saja Hamed, Ph.D uptodate.com 37 Topical treatment options: Topical antibiotics (Rx only)  They are used for mild-to-moderate acne when inflammatory lesions are present  Commonly used antibiotics: Clindamycin, erythromycin  Antibiotics have bacteriostatic and anti-inflammatory properties  Antibiotic resistance is an important issue, therefore, antibiotic monotherapy and maintenance therapy alone are not recommended, nor the combination of oral and topical antibiotics  Current guidelines recommend combining antibiotics with retinoids and/or BPO  BPO can minimize bacterial resistance, while retinoids can provide synergistic comedolytic and anti- inflammatory properties Saja Hamed, Ph.D uptodate.com 39 Topical treatment options: Azelaic acid  An alternative to retinoids  Has comedolytic, antimicrobial, and anti- inflammatory properties  Not approved by the FDA in the USA Systemic treatment  Recommended for patients with moderate- to-sever acne  Useful also in patients with larger surfaces affected (neck, chest, and back)  Systemic agents include: antibiotics, hormones, oral retinoids Systemic treatment Oral antibiotics (Rx Only)  Management of moderate to sever acne  Most commonly: doxycycline, minocycline, tetracycline, erythromycin  Selection is driven by their side effects and patterns of P.acne resistance  A major problem affecting antibiotic therapy of acne is bacterial resistance  As with topical antibiotics, oral antibiotics should be combined with other agents to minimize the development of bacterial resistance and improve treatment efficacy Systemic treatment Oral antibiotics (Rx Only)  Oral antibiotics should be used with topical retinoids or BPO  Dermatologists usually recommend tapering off these medications (decreasing their doses) as soon as the symptoms begin to improve or as soon as it becomes clear that the drugs do not help  Side effects: upset stomach, dizziness, skin discoloration  Doxycycline can increase sun sensitivity  Tetratcyclines can cause teeth discoloration  Minocycline can lead to skin hyperpigmentation  Prolong antibacterial therapy has resulted in the transfer of resistance to potentially pathogenic bacteria such as strains of staphylococcus or streptococcus species  Combine BPO to minimize development of resistance Saja Hamed, Ph.D uptodate.com 44 Systemic treatment Hormonal Therapy(Rx Only)  Useful adjunct therapy in women with moderate-to-sever acne  Beneficial for those who desire oral contraception or in whom traditional therapy has failed  Hormonal therapy may help reduce or prevent outbreaks, it is not effective for existing lesions therefore it is used as adjunct rather than a stand alone therapy  S.E: Headache, breast tenderness, nausea, depression, risk of heart disease , high blood pressure, blood clots Systemic treatment Isotretinoin (Rx Only)  Sever acne and moderate acne that does not respond to other treatments  Normalizes follicular desquamation, decreases sebum secretion, inhibits the growth of P.acnes, and exerts anti-inflammatory effects  Side effects: dryness of the skin, eye, mouth, lips, and nose, itching, nosebleeds, muscle aches, sun sensitivity, poor night vision  May increase level of TGs and cholesterol  May increase liver enzyme levels  Increased risk of depression and suicide  Teratogenic: recommendation to use two forms of birth control one month before starting treatment, during the treatment, and one month after the treatment Saja Hamed, Ph.D uptodate.com 47 Additional treatments  Chemical peels: AHA and Salicylic acid peelings  Comedone and extraction: Two ways to release the contents of comedones: - Squeezing with fingertips - A comedo exractor There is limited evidence that comedo removal for acne treatment is effective but it can improve patient appearance (enhance compliance with the treatment program) Additional treatments  Optical therapies: - Broad spectrum continuous-wave visible light (blue and red) - Intense pulsed light - Pulsed dye lasers - Potassium titanyl phosphate lasers - Photodynamic therapy (PDT) - Pulsed diode laser Although optical therapy may improve acne initially, a standarized treatment protocol, longer-term outcomes, comparisons with conventional acne therapies, and wide spread clinical experience are lacking Not included among first-line treatments Additional treatments  Herbal and alternative therapies: Aloe vera Fruit derived acids Tea tree oil Very limited data Treatment: Follicular hyperproliferation and abnormal desquamation  Topical retinoids  Oral retinoids  Azelaic acid  Salicylic acid  Hormonal therapies Saja Hamed, Ph.D uptodate.com 51  Treatment: Increased sebum production  Oral isotretinoin  Hormonal therapies Saja Hamed, Ph.D uptodate.com 52  Treatment: Propionibacterium acnes proliferation  Topical and oral antibiotics  Benzoyl peroxide  Azelaic acid Saja Hamed, Ph.D uptodate.com 53  Treatment: Inflammation  Oral isotretinoin  Topical retinoids  Oral tetracyclines  Azelaic acid  Salicylic Acid Saja Hamed, Ph.D uptodate.com 54 Saja Hamed, Ph.D uptodate.com 55 The following concepts guide the selection of therapy  Topical retinoids are beneficial for both comedonal (noninflammatory) and inflammatory acne  Topical retinoids can be used as monotherapy in individuals with exclusively comedonal acne. Saja Hamed, Ph.D uptodate.com 56 Comedonal (noninflammatory) acne  Topical retinoid  alternatives include azelaic acid and salicylic acid Saja Hamed, Ph.D uptodate.com 57 Saja Hamed, Ph.D uptodate.com 58 The following concepts guide the selection of therapy  Patients with an inflammatory component often benefit from antimicrobial therapies (eg, benzoyl peroxide or topical antibiotics).  Antimicrobial agents reduce the number of proinflammatory P. acnes colonizing the skin. Saja Hamed, Ph.D uptodate.com 59 The following concepts guide the selection of therapy  Patients with moderate to severe inflammatory acne often warrant more aggressive treatment with oral antibiotics.  Antibiotics in the tetracycline class are most frequently used  Therefore, use of benzoyl peroxide is recommended in patients receiving antibiotic therapy Saja Hamed, Ph.D uptodate.com 60 Mild papulopustular and mixed (comedonal and papulopustular) acne  Topical retinoid AND  Topical antimicrobial (eg, benzoyl peroxide alone or benzoyl peroxide +/- topical antibiotic) Saja Hamed, Ph.D uptodate.com 61 Moderate papulopustular and mixed acne  Topical retinoid AND  Oral antibiotic AND  Topical benzoyl peroxide Saja Hamed, Ph.D uptodate.com 62 Saja Hamed, Ph.D uptodate.com 63 Moderate nodular acne (small nodules 0.5 to 1 cm)  Topical retinoid AND  Oral antibiotic AND  Topical benzoyl peroxide Saja Hamed, Ph.D uptodate.com 64 Severe nodular/conglobate acne  Oral isotertinoin Saja Hamed, Ph.D uptodate.com 65 Saja Hamed, Ph.D uptodate.com 66 A sample regimen for a patient with mild inflammatory facial acne who is using a topical retinoid, topical benzoyl peroxide, and topical clindamycin  Morning: Wash face with a gentle facial cleanser. Apply a thin layer of a fixed-dose combination benzoyl peroxide/clindamycin gel to the entire face?.  Night: Wash face with a gentle facial cleanser. Moisturize?.. Apply a thin layer of the topical retinoid to the entire face. Saja Hamed, Ph.D uptodate.com 67 A sample regimen for a patient with mild inflammatory facial acne who is using a topical retinoid, topical benzoyl peroxide, and topical clindamycin Tretinoin and benzoyl peroxide should not be applied simultaneously to the skin due to the oxidizing effect of benzoyl peroxide on tretinoin.  If both agents are prescribed, benzoyl peroxide should be applied in the morning and tretinoin in the evening  Adaplene, the microsphere formulation of tretinoin, and tazarotene are stable in the presence of benzoyl peroxide. Saja Hamed, Ph.D uptodate.com 68 Saja Hamed, Ph.D uptodate.com 69 Topical Retinoids Considerations  Gels have a drying effect; they may be preferred by patients with oily skin.  Creams and lotions tend to be moisturizing.  Solutions are drying but they cover large areas more easily than other preparations, and foams are easy to apply to hair- bearing areas. Saja Hamed, Ph.D uptodate.com 70 Topical Retinoids Considerations  Patients should be directed to apply a thin layer of a pea-sized amount of medication to cover the face.  The medication should be applied to the entire affected area, not as spot treatment of individual lesions.  Skin should be dry at the time of application Saja Hamed, Ph.D uptodate.com 71 Topical Retinoids Considerations  Topical retinoids cause irritation, dryness, and flaking of the skin, an effect most notable during the first month of therapy.  To minimize irritation, patients should avoid the concomitant use of over-the- counter irritating products, such as harsh soaps, toners, astringents, and alpha hydroxy acid or salicylic acid products. Saja Hamed, Ph.D uptodate.com 72 Topical Retinoids Considerations  A gentle non-soap cleanser should be recommended.  Delaying application of the retinoid for at least 20 minutes after washing and drying the face may also be helpful  If irritation is a problem, a decrease in the frequency of application to every other or every third night can be considered, and the frequency of application can be increased as tolerance improves. Saja Hamed, Ph.D uptodate.com 73 Topical Retinoids Considerations  Tazarotene has been considered the most effective, but also most irritating topical retinoid, when compared with adaplene and tretinoin.  A short-contact regimen with tazarotene: Patients apply tazarotene for up to five minutes daily, then wash off the medication Saja Hamed, Ph.D uptodate.com 74 Topical Retinoids Considerations  The fine skin flaking that is often seen can be gently exfoliated with a washcloth.  A noncomedogenic facial moisturizer can be applied if needed.  Micronized tretinoin 0.05% gel contains soluble fish proteins. The drug should be used with caution in patients with a known allergy to fish Saja Hamed, Ph.D uptodate.com 75 TOPICAL ANTIMICROBIALS  Benzoyl peroxide: Concentrations of benzoyl peroxide that are higher than 2.5% may not contribute to increased benefit.  Increased concentrations of benzoyl peroxide can lead to increased skin irritation.  Irritation may appear as erythema, scaling, xerosis, or stinging, tightening, or burning sensations Saja Hamed, Ph.D uptodate.com 76 TOPICAL ANTIMICROBIALS  Patients should also be advised that benzoyl peroxide can cause bleaching of the hair and clothing.  Antibiotics may promote the appearance of resistant strains of P. acnes when used alone. Resistance is diminished by combination use with benzoyl peroxide Saja Hamed, Ph.D uptodate.com 77 Saja Hamed, Ph.D uptodate.com 78 Topical antibiotics  Topical erythromycin and clindamycin should not be used as monotherapy for acne  Evidence shows better treatment efficacy when these drugs are combined with retinoids and benzoyl peroxide.  In addition, the use of benzoyl peroxide with antibiotics decreases the occurrence of bacterial resistance Saja Hamed, Ph.D uptodate.com 79 Topical antibiotics  Combination gels containing benzoyl peroxide combined with an antibiotic are available Saja Hamed, Ph.D uptodate.com 80 AZELAIC ACID  Azelaic acid: antimicrobial, comedolytic, and mild anti-inflammatory properties.  Azelaic acid also has an inhibitory effect on tyrosinase and can improve acne- induced postinflammatory hyperpigmentation.  The product is available in a 15% gel and 20% cream. Saja Hamed, Ph.D uptodate.com 81 Saja Hamed, Ph.D uptodate.com 82 ORAL ANTIBIOTICS  Utilization of these drugs is primarily indicated for patients with moderate to severe inflammatory acne.  Oral antibiotics may also be used for patients who have milder truncal acne, for whom the application of topical antibiotics is difficult. Saja Hamed, Ph.D uptodate.com 83 ORAL ANTIBIOTICS  The use of erythromycin is now recommended only for patients in whom tetracycline derivatives are contraindicated.  It has less anti-inflammatory activity than the tetracyclines.  In addition, P. acnes often develops resistance to this drug, resulting in treatment failure.  Many patients experience intolerable gastrointestinal side effects. Saja Hamed, Ph.D uptodate.com 84  ORAL ANTIBIOTICS  studies have found an increased rate of upper respiratory infections in acne patients treated with oral antibiotic therapy  greater risk for upper respiratory infection among acne patients treated with either topical or oral antibiotics Saja Hamed, Ph.D uptodate.com 85 The following practices may reduce the incidence of resistance  Only prescribe antibiotics when necessary  The duration of treatment should be limited; an oral antibiotic should be discontinued when there is no additional clinical improvement or clinical improvement is absent  limit treatment courses to a maximum of 12 to 16 weeks when feasible. Saja Hamed, Ph.D uptodate.com 86 The following practices may reduce the incidence of resistance  In order to avoid changing oral antibiotics prematurely, six to eight weeks of therapy should be allowed prior to evaluating treatment efficacy.  After six to eight weeks, a change in the type of antibiotic can be considered if there is no response.  In cases in which a partial response is seen, therapy should be continued and response reassessed after another six to eight weeks. Saja Hamed, Ph.D uptodate.com 87 The following practices may reduce the incidence of resistance  Do not simultaneously treat with a topical antibiotic and an oral antibiotic  Avoid use of antibiotics (topical or oral) as monotherapy or as maintenance therapy Saja Hamed, Ph.D uptodate.com 88 ORAL ISOTRETINOIN  effective for the treatment of severe, recalcitrant nodular acne.  In clinical practice, it is also used for milder acne that is resistant to other treatments or associated with significant scarring.  Oral isotretinoin is used as monotherapy; a typical treatment course is 120 to 150 mg/kg, which usually translates to a 20-week course for most patients. Saja Hamed, Ph.D uptodate.com 89 Saja Hamed, Ph.D uptodate.com 90 Saja Hamed, Ph.D uptodate.com 91  https://www.drugs.com/dosage/isotretinoin.html Saja Hamed, Ph.D uptodate.com 92 https://www.drugs.com/dosage/isotretinoin.html Saja Hamed, Ph.D uptodate.com 93 https://www.drugs.com/dosage/isotretinoin.html Saja Hamed, Ph.D uptodate.com 94 https://www.medscape.com/answers/1069804-90352/what-is-the-dosing- schedule-for-isotretinoin-in-the-treatment-of-acne-vulgaris Saja Hamed, Ph.D uptodate.com 95  Isotretinoin | DermNet NZ  Isotretinoin Saja Hamed, Ph.D uptodate.com 96 HOME SKIN CARE RECOMMENDATIONS  Patients should apply a gentle synthetic detergent cleanser (i.e, syndet) with their fingers, and rinse with warm (not hot) water twice daily.  Synthetic detergent bar uses exhibited less skin peeling, dryness, and irritation than soap. Saja Hamed, Ph.D uptodate.com 97 Moisturization and acne  Swinyer et al. identified skin dryness as an important factor in exacerbating the pathogenic cycle of acne, thus hampering its treatment  Jackson (1999) found that an emollient facial wash to outperform pure soap and a benzoyl peroxide wash in decreasing open comedones and papules  Hydrate while cleanse  Use an emollient facial cleanser Saja Hamed, Ph.D uptodate.com 98 HOME SKIN CARE RECOMMENDATIONS  Water-based lotions, cosmetics, and hair products are less comedogenic than oil- based products.  Patients should be encouraged to seek out noncomedogenic skin care and cosmetic products. Saja Hamed, Ph.D uptodate.com 99 HOME SKIN CARE RECOMMENDATIONS  Patients should be advised not to pick their acne lesions, as this may exacerbate scarring Saja Hamed, Ph.D uptodate.com 100 HOME SKIN CARE RECOMMENDATIONS  Patients should be given realistic expectations regarding timelines for improvement.  At least two to three months of consistent adherence to a therapeutic regimen is often necessary prior to concluding that treatment is ineffective. Saja Hamed, Ph.D uptodate.com 101 PREGNANCY AND ACNE THERAPY  If acne therapy is desired, reasonable options include oral or topical erythromycin, topical clindamycin, and topical azelaic acid, which are pregnancy class B drugs  Benzoyl peroxide is categorized as pregnancy class C Saja Hamed, Ph.D uptodate.com 102 Saja Hamed, Ph.D uptodate.com 103 Tips for Skin care:  Facial Cleansing should be done gently  Vigorous rubbing and scrubbing may worsen the acne  Use an emollient facial cleanser or a mild soap  If the skin becomes red, irritated or scaly while using a certain soap another more gentle type should be tried Tips for Skin care:  The skin should not be touched very often  People who squeeze or pinch their blemishes may develop scar  Men who have acne should find out whether an electric razor or blade razor is more comfortable  If you are using a wet-shaving technique, be sure to adequately soften the beard with warm water and shaving cream for at least a minute or two before you start to shave and allow enough time to shave lightly and carefully Shaving and Acne  No one method of shaving is best for patients with acne  Some men find blade shaving more comfortable, while others prefer electric shavers  Sometimes it’s more comfortable to rotate between the two  A few individuals most stop shaving at least temporarily  Try to avoid daily shaving  Post-inflammatory hyperpigmentation after acne is a particular problem for Asian patients Tips for Skin care:  Choose cosmetics carefully. All cosmetics, such as foundation, blush, eye shadow, and moisturizer should be oil-free or non- comedogenic  Lip products that contain moisturizers may cause small open and closed comedones https://www.aad.org/member/clinical-quality/guidelines/acne Saja Hamed, Ph.D uptodate.com 109 https://www.aad.org/member/clinical-quality/guidelines/acne Saja Hamed, Ph.D uptodate.com 110  The rational use of systemic isotretinoin in acne: A call for moderation  http://www.samj.org.za/index.php/samj/a rticle/view/5310/4048 Saja Hamed, Ph.D uptodate.com 111  THANK YOU Saja Hamed, Ph.D uptodate.com 112