ACNE VULGARIS

Ernie G. Bautista II
May 6, 2014
Learning Objectives:
To know some myths about acne.
To determine the prevalence of acne.
To define acne.
To review both the causes of acne, clinical
features and current acne management
issues in relation to problems and options for
improving outcomes.

What Questions Should I
Ask My Dermatologist?
Washing Your Face Often
Prevents Breakouts.
Acne is caused by poor
hygiene and/or acne is
caused by dirt.
Toothpaste can
cure acne.
Stress causes acne.
Squeezing acne can
eliminate acne/pimples.
Eating certain foods like
chocolate and fried foods
can cause acne.
Only teens get
acne.
Touching your face
moves bacteria around
and causes acne.
STATISTICS
PSU
Chronic Inflammation
acne
PATHOGENESIS
3 4
2 1
Propionibacterium
acnes
Inflammation
Excess sebum
production/
hormonal activity
Follicular epidermal
hyperproliferation



NODULE


CYSTIC
COMEDONES


PAPULOPUSTULE


CLINICAL
PRESENTATION
CLINICAL
PRESENTATION
CLINICAL
PRESENTATION
CAUSES
Cosmetic agents &
Hair pomades
(hair wax)

Medications: steroids,
lithium, some
antiepileptics &iodides






CAH, PCOS, other endocrine
disorders associated with excess
androgens production and even
pregnancy may cause flare up



Mechanical occlusion with
headbands, shoulder pads,
back packs, or under-wire bras
GENETIC
PREDISPOSITION
Aggravating
factors:
CLINICAL


Female patient with
dysmenorrhoea/
hirsutism
= HORMONAL EVALUATION





If with evidence of virilisation
= measure total testosterone level
(free testosterone, DHEA-S, LH, FSH)

skin lesion culture
= to r/o gm (-) folliculitis
WORK-UP
HISTOLOGIC FINDING
TREATMENT & MANAGEMENT
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
TREATMENT & MANAGEMENT
MEDICAL CARE
SURGICAL CARE
DIET
MEDICAL CARE SURGICAL CARE DIET
TOPICAL TREATMENT
Mild tx.
SYSTEMIC TREATMENT
Mod-severe tx.
MEDICAL CARE SURGICAL CARE DIET
I. TOPICAL TREATMENT
A) Topical Retinoid
B) Topical Antibiotic
C) Benzoyl Peroxide
Adapalene (Differin)
MEDICAL CARE SURGICAL CARE DIET
A) Topical Retinoid
*Tazarotene
(Tazorac)
Tretinoin (Retin-A
Micro, Atralin,
Avita, Tretin-X)
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Apply OD;
solution, cream, gel
Early use: irritation w/ peeling &
redness
Assoc. w/ sun sensitivity;
*Pregnancy category X
MEDICAL CARE SURGICAL CARE DIET
B) Topical Antibiotic
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Applied 1-2x daily
Bacterial resistance may develop
Clindamycin topical
(ClincaGel, Cleocin-T)
Erythromycin topical
(Akne-mycin)
There is a gradual decrease in the efficacy of topical erythromycin
in clinical trials of therapeutic intervention for acne, which is
probably related to the development of antibiotic-resistant
propionibacteria. Br J Dermatol. 2005 Aug;153(2):395-403.
MEDICAL CARE SURGICAL CARE DIET
C) Benzoyl peroxide
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Apply OD or BID;
2.5-10% concentration
Bacterial resistance has not been
reported
irritant contact dermatitis
Forms: soaps,
washes, lotions,
creams, gels
MEDICAL CARE SURGICAL CARE DIET
II. SYSTEMIC TREATMENT
A) Oral Antibiotic
B) Oral Contraceptives
C) Spirinolactone
D) Isotretinoin
Tetracycline*
250-500 mg PO bid
MEDICAL CARE SURGICAL CARE DIET
A) Oral Antibiotic
Doxycycline **
(Doryx, Adoxa, Doxy
100, Vibramycin)
Minocycline***
(Solodyn, Minocin)
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
*Sun sensitivity, stains teeth
**GERD, should be taken at least 30
mins prior to sleep
***Rarely: lupus-like syndrome, minocycline-
induced hyperpigmentation, & pseudotumor
cerebri; ****Pseudomembranous colitis
Trimethoprim
/Sulfamethoxazole
80mg/400mg
160 mg/800mg
Clindamycin****
150mg TID
MEDICAL CARE SURGICAL CARE DIET
B) OCP (Estrogens/Progestins)
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Increase sex
hormone-binding
globulin resulting
in decrease in
circulating free
testosterone
Ethinyl estradiol, drospirenon, and levomefolate (Beyaz)
Ethinyl estradiol and norethindrone (Estrostep Fe)
Ethinyl estradiol and drospirenone (Yaz)
Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen)
MEDICAL CARE SURGICAL CARE DIET
C) SPIRINOLACTONE (Aldactone)
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Aldosterone antagonist that competes with testosterone & dihydrotestosterone
binding at the receptor in the sebaceous gland
Also reduces free testosterone levels as more blood is bound by SHB
AE: dizziness,
breast tenderness,
dysmenorrhea
Periodic
evaluation of BP &
potassium levels
Pregnancy must be
avoided because of the
risk of feminization of
the male fetus
MEDICAL CARE SURGICAL CARE DIET
D) ISOTRETINOIN
(Clavaris, Anesteem, Sotret)
Follicular
hyperproliferation
Excess sebum
P. acnes Inflammation
Highly effective in tx of
severe acne (gm-
folliculits, nodulocystic
acne, H. suppurativa)
0.5 mg/kg & increased
to 1mg/kg in 2 divided
doses for 15-20 wks
Co-administration w/
steroids at the onset of
therapy maybe useful in
severe cases to prevent
worsening
May heighten feelings
of depression &
suicidal thoughts
MEDICAL CARE SURGICAL CARE DIET
D) ISOTRETINOIN
(Clavaris, Anesteem, Sotret)
MEDICAL CARE SURGICAL CARE DIET
Acne Products
Mild-moderate acne
w/ antibacterial & comedoyltic properties
In severe cases, used as an adjunct in therapeutic regimens
Erythomycin and benzoyl peroxide (Benzamycin), applied topically bid
1.2 % Clindamycin and 0.025% tretinoin (Ziana, Veltin), apply daily to affected
areas
Clindamycin and benzoyl peroxide (Acanya, Duac CS, BenzaClin), apply 1-2x
daily
Azelaic acid (Azelex, Finacea Finacea Plus), apply bid daily. Improvement may
be seen w/in 4 weeks.

MEDICAL CARE SURGICAL CARE DIET
Manual extraction
of comedones

Intralesional steroid
injections



Superficial peels that
use glycolic or salicylic
acid

OTHER:
phototherapy using
red/blue light,
photodynamic therapy,
fractional laser
Procedural
treatment
MEDICAL CARE SURGICAL CARE DIET
JAMA. 1969 Dec 15;210(11):2071-4.
Effect of chocolate on acne vulgaris.
Fulton JE Jr, Plewig G, Kligman AM.
Performed a study on chocolate,
having teenage patients w/ acne consume
1 bar of chocolate each day. Some of the
patients improved & some worsened, but
the vast majority were unchanged.
Am J Clin Nutr. 2007 Jul;86(1):107-15.
A low-glycemic-load diet improves
symptoms in acne vulgaris patients: a
randomized controlled trial.
Smith RN, Mann NJ, Braue A, Mkelinen
H, Varigos GA.
The improvement in acne and
insulin sensitivity after a low-glycemic-load diet
suggests that nutrition-related lifestyle factors
may play a role in the pathogenesis of acne.

J Acad Nutr Diet. 2014 Mar;114(3):384-92. doi:
10.1016/j.jand.2013.11.010. Epub 2014 Jan 9.
Relationships of self-reported dietary
factors and perceived acne severity in a
cohort of New York young adults.
Burris J, Rietkerk W, Woolf K.
The study suggests that diet,
particularly dietary GI, saturated fat, trans fat,
milk, and fish may influence or
aggravateacne development.
BMC Dermatol. 2012 Aug 16;12:13. doi:
10.1186/1471-5945-12-13.
High glycemic load diet, milk and ice
cream consumption are related to acne
vulgaris in Malaysian young adults: a
case control study.
Ismail NH, Manaf ZA, Azizan NZ.
Glycemic load diet and frequencies
of milk and ice cream intake were positively
associated with acne vulgaris.

FOLLOW-UP
If SPIRINOLACTONE is prescribed
Lab exams: electrolyte evaluation (K), pregnancy test
If MINOCYCLINE >1yr
Baseline assessment of ANA & hepatic transaminase levels

COMPLICATIONS:
Scarring
Hyperpigmentation (darker-skinned)
Pyogenic Granuloma (lobular capillary
hemangioma
Osteoma cutis
Solid facial edema

PROGNOSIS:
Male: acne generally clears by early
adulthood.
5% still have acne at age 25 yrs
Female: frequently have adult acne.
12% still have at age 25 yrs.
5% at age 45 yrs.
Good Prognosis. However, it can result in
long-lasting psychosocial impairment &
physical scarring
Washing Your Face Often Prevents Breakouts.
Acne is caused by poor hygiene and/or acne is
caused by dirt.
Toothpaste can cure acne.
Fact: Washing your face several times a day
will not do anything to keep you from breaking
out. In most cases, it will only serve to irritate
and dehydrate your skin.
Fact: Acne starts deep within the pore dead skin
cells pile up faster than normal and get caught inside
the pore causing a microcomedone (the beginning
of an acne lesion) to form.
Fact: Toothpaste can really burn your skin AND
most brands have sodium lauryl sulfate in the
formulation a know pore clogger.
Stress causes acne.
Squeezing acne can eliminate acne/pimples.
Eating certain foods like chocolate and fried
foods can cause acne.
Fact: stress can cause acne. However,
it is only the excess stress that can
stimulate discharge certain hormones
Fact: Hit or break the pimples can
cause wounds, redness and a scar.
Fact: if you consume those foods in
excess.
Only teens get acne.
Touching your face moves bacteria
around and causes acne.
Fact: Not only teenagers, but everyone can
have acne. Acne is not only connected with
teenagers. Most teenagers have acne because
of hormonal changes in their teenage years.
Fact: Bacteria on the surface of your skin has nothing to do
with acne. It is the bacteria deep within your pores
(Propionibacterium acnes) that are part of the acne formation
process. The reason it is important to leave your skin relatively
untouched is because physically irritating the skin can cause
breakouts and not because you are moving bacteria around.
Thank YOU
for listening.