Acne Vulgaris

(Otherwise known as zits, pimples and blackheads)

Cynthia Salinas, M.D.

PGY-3 Patient Conference
February 2, 2005
Conference Goals
 Review pathogenesis as a way to help us
understand why we use certain meds
 Differentiate common types of acne
 Generate a quick differential diagnosis
 Apply a stepwise approach to treatment
prior to referral to dermatology
Epidemiology
Onset?
 Males 10-17 yrs Females 14-19 yrs
 May persist through 4th decade or older

Prevalence?
 Asians 10%

 African-American 25%

 Caucasians 29%
Causes?
 Majority of patients have a family history
of acne
 Emotional stress
 Androgens
 Dioxins, lithium
 Occlusion and pressure “acne mechanica”
 NOT DUE TO CHOCOLATE OR FATTY
FOODS!
Pathogenesis
 Plugging of the hair follicle
w/ abnormally keratinized
cells

 Androgen-induced sebaceous
gland hyperactivity

 Proliferation of bacteria
- Propionibacterium acnes

 Inflammation
 “Doctor my skin is breaking out!”
 34yo Latina comes to your office stating
that she has had “bad skin forever” and
her face is the worse it’s ever been. Saint
Ivy’s scrub is not helping. She’s trying to
eat healthy but despite her best efforts
keeps gaining weight. She wonders if she
is doing the wrong things and asks for
your help.
HPI
 When was the onset? Adolescence
 Where? Face, neck, trunk &
buttocks
 Does it itch or hurt? Pustules painful
 How have the individual lesions changed?
 Triggers? Worse in fall/winter
 Hirsutism? Oligomenorrhea?
Differential Diagnosis
 Face
 Staph aureus folliculitis
 Rosacea
 Perioral dermatitis
 Trunk
 Pityrosporum folliculitis
 “Hot Tub” folliculitis
 Acne Aestivalis
 Appears after sun exposure
Types of Acne
 Comedonal
 Papulopustular

 Nodulocystic

 Why is this important?

 Directs treatment options
Comedonal Acne
 Closed comedones (whiteheads)
 Sebum accumulation results in a white
papule visible at the skin surface

 Open comedones (blackheads)

 Plug protrudes from canal and turns
dark

 Non-inflammatory
 Usually responds to topical
keratolytic
Papulopustular Acne
 Papules/Pustules
 Follicular wall ruptures
 Releases sebum and
bacteria into dermis

 Topical agents alone

usually insufficient
 Consider topical
retinoids plus
systemic antibiotics
Nodulocystic Acne
 Soft nodules that are
secondary comedones from
repeated ruptures
reencapsulations and
abscess formations
 Painful and disfiguring
 Psychological impact

 Treatment consists of topical

agents, oral antibiotics or
isotretinoin
Management
 Acne often spontaneously clears
 Flares may occur in the winter &

w/menses
 Scarring can be avoided by proper

treatment early in the course of disease

 Assess the psychological impact of

cosmetic disfigurement
Four Major Goals of Treatment
 Correct the abnormal follicular keratinization
 Decrease sebaceous gland activity
 Decrease follicular bacteria
 Inhibit the production of extracellular
inflammation

Take home points:

Retinoids, abx, hormonal treatments target
different areas responsible for acne
Retinoids
Cost
 Tretinoin (Retin-A) $42 (20g)
 Adapalene (Differin) $42 (15g)
 Tazarotene (Tazarotene) $74 (30g)

 Acts as a keratolytic and anti-inflammatory

 Inactivated by UV light
 SE: Dryness, scaling, erythema, burning,
irritation, and photosensitivity
Topical Antibiotics
Cost
 Clindamycin Gel (Cleocin) $32 (30 g)
 Erythromycin Gel (Akne-Mycin) $18 (30 g)

 Kills propionibacterium acnes

 SE: Irritating; stains clothes
Other
Cost
 Benzoyl peroxide gel $24 (90g)
 Reduces antibiotic resistance
 SE: erythema, dryness

 Ortho-Tricyclin $38 (pack)

 Ortho-Cyclen
 Desogen
 Anti-androgenic
 2-4 months before improvement is seen
Comedonal Acne
Tretinoin 0.025% cream or 0.01% gel qhs

0.05% cream or 0.025% gel

0.1% cream

PLUS benzoyl peroxide 5% gel qam

-Gels have a drying effect

-Creams/lotions tend to be moisturizing
Papulopustular Acne
Tretinoin 0.025% cream or 0.01% gel qhs

0.05% cream or 0.025% gel

0.1% cream

 PLUS clindamycin 1% gel or

erythromycin 2% gel

 PLUS benzoyl peroxide 5% gel

Oral antibiotics
Cost
 Tetracycline $8 (30caps)
 Least efficacious but cheap

 Decreases efficacy of OCP’s; need backup

 Must take 1hr before meals; wait 2hrs after taking

 Doxycycline $75 (30caps)

 SE: Dyspepsia, nausea, emesis

diarrhea, photosensitivity, esophagitis

 Minocycline $117 (30caps)

 Most effective but also most expensive

 Can take with food unlike other tetracylines

 Infrequently causes photosenstivity

 SE: vertigo, mouth & shin hyperpigmentation

Papulopustular Acne
 Tetracycline 500mg po tid-qid x 3 months

 Doxycycline 100mg po bid x 3 months

 Minocycline 100mg daily then  to 100mg bid

x 3 months
Consider
 Hormone Therapy
 Ortho-Tricyclen, Desogen, Ortho-Cyclen
 Spironolactone 100mg daily
Nodulocystic Acne
 Only indication to use Acutane
 Acts against the four pathogenic factors that
contribute to acne
 It is the only med w/ the potential to suppress
acne over the long term
 To prescribe this med the physician must be a
registered member of System to Manage
Accutane-Related Teratogenicity (SMART)
program to educate patients about the possible
severe adverse effects and teratogenicity of
isotretinoin
Education
 Improvement occurs over 2-5 months
 Face, upper arms and legs tend to respond more
quickly than those on the trunk
 Retinoids should be applied at bedtime
 Clinda/Erythro/BP are applied in the morning
 Combination therapy is BEST!
 Avoid using topical antibiotic alone
 Should combine with antibacterial agent such as
benzoyl peroxide or oral antibiotic
 No improvement? Change topical or add oral
antibiotic
 Soaps, detergents, and astringents
remove sebum from the skin surface but
do not alter sebum production
 Avoid repetitive mechanical trauma
 Avoid occlusive clothing and refrain from
rubbing their faces or picking their skin
 Water-based cosmetics and hair products
are less comedogenic than oil-based
products
 Completing Therapy
 Once acne cleared you can attempt to
wean meds. Typically wean down from bid
to daily dosing for 2-3 months then off
completely. Some will have complete
remission while others made need repeat
treatment.
Follow-up on Patient
 Sent labs for PCOS – all negative
 Concern for early metabolic syndrome
 Started on topical tretinoin cream and
benzoyl peroxide and spironolactone
 Advised to apply tretinoin on acanthosis
nigracans
 Referred for PMD
Conclusions
 Keratinization  androgens  bacteria
 inflammation
 Comedonal, Papulopustular, Nodulocystic
 1st Line: Topical Retinoids!
 Minimum use of 3 months prior to labeling
treatment as a failure
 Intervene early to prevent scarring
 Sources
 AAFP
 Uptodate
 Fitzpatrick, et al Color Atlas & Synopsis of
Clinical Dermatology
 Brian Swan’s Foom Handout