Acne. Acne. Pediatric Update. Pediatric Update 18/09/2013. Chris Keeling Bio. Keystone Dermatology 23rd Ave & 111St. September 21, 2013

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1 Pediatric Update Acne Chris Keeling MSc MD FRCPC Dermatology Mohs Micrographic Surgery Keystone Dermatology 23rd Ave & 111St September 21, 2013 Chris Keeling Bio BSc Honours University of New Brunswick University of Maine at Orono MSc Aberdeen Scotland PhD work 94-96University of Connecticut Medicine 2000 Dalhousie University Dermatology 2005 University of Alberta Fellowship Mohs Micrographic Surgery 2006 McGill University Pediatric Update Acne 1

2 Stages of Acne Therapy Mild Moderate Severe Mixed and Mixed and Comedonal papular/pustular papular/pustular Nodular Nodular/conglobate Oral antibiotic + 1 st Topical retinoid + topical Oral antibiotic + topical line Topical retinoid topical retinoid + Oral isotretinoin antimicrobial retinoid ± topical BPO topical BPO Alternative topical Oral isotretinoin or Alternative topical retinoid or topical Alternative oral antibiotic High-dose oral alternative oral retinoid or azelaic antimicrobial or + alternative topical antibiotic + topical Alternative(s) antibiotic + topical acid or salicylic alternative topical retinoid retinoid ± alternative retinoid + topical BPO retinoid ± topical acid + topical antimicrobial or topical BPO BPO/azelaic acid azelaic acid Oral antiandrogen Oral antiandrogen + High-dose oral Alternative(s) See 1 for females st line See 1 st + topical topical retinoid ± antiandrogen + line retinoid/azelaic acid ± oral antibiotic ± topical retinoid ± topical antimicrobial topical antimicrobial topical antimicrobial Maintenance Topical retinoid Topical retinoid ± BPO therapy5 Thiboutot D, et al. J Am Acad Dermatol. 2009;60(5):S1-S50. Alt: alternative; BPO: benzoyl peroxide Evidence 2

3 Evidence Evidence Data Pochi P, et al. J Am Acad Dermatol. 1991;24: Tan J, et al. Qual Life Res. 2006;15(7): Magin P, et al. Can Fam Physician Aug;52: Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 suppl):s1 S37. Shalita AR, et al. Cutis Aug;72(2): Tanghetti E, et al. Dermatol Online J. 2007;13:1. Tanghetti E, et al. J Drugs Dermatol. 2006;5: Leyden J, et al. Arch Dermatol. 2006;142(5): Thiboutot D, et al. J Am Acad Dermatol. 2009;60(5):S1 S50. Lookinbill DP, et al: J Am Acad Dermatol 1997; 37(4): Shalita AR, et al: Cutis 2003; 72:

4 Conflicts of Interest Relationships with commercial interests: Speaking Honouraria: Janssen, Amgen, Abbott, Galderma, Roche, Leo Pharma & Astellas, Stiefel. No honourarium for today s presentation 4

5 Objectives 1) What is Acne - Morphology 2) What is the Pathophysiology 3) Differential Diagnosis 4) How to Treat Acne Comedones Blackheads & Whiteheads Papules and Pustules 5

6 Nodulocystic Scaring Acne Pathogenesis of Acne 4 Pathogenic Factors 3) Release of inflammatory mediators into the skin 1) Alteration in the keratinization process 2) P. acnes follicular colonization 4) Sebum production by the sebaceous gland Under hormonal drive Actions of Topical Anti-acne Therapies Topical retinoids Normalize follicular desquamation Reduce inflammatory response Topical and/or Oral antibiotics Reduce inflammatory response Reduce microorganisms Benzoyl peroxide (BPO) Kill microorganisms Estradiol (OCP) +/- cyproterone Settles sebum production 6

7 Acne Mimickers Acne Mimickers Acne Scarring 7

8 Eczema Herpeticum Patient with a Hx of Atopic Dermatitis Blisters all over the face Steroids just not working for eczema The po then iv ABX not working either High fever Swab for viral culture! mg/kg/day Po ABX may be necessary if impetiginized 8

9 Acne Mild/Moderate acne Afraid of isotretinoin Combination Tx Retinoid, BPO ABX po/top OCP Scarring Bad acne Very upset Oral Retinoid Isotretinoin Mild/Moderate acne Afraid of isotretinoin Combination Tx Typical teenage female with optimal combination Tx Rxs: Tactuo gel qhs 30g - 3rpts Minocycline 100mg po qhs 30T - 3rpts +/- Diane 35 qd 30T Follow up every 3 months Drop MCN Drop Topical gel Hold OCP 9

10 Mild/Moderate acne Afraid of isotretinoin Alternative brands Combination Tx Retin A micro 0.1%, 0.04% Stieva / Stievamycin.05%,.025%,.1% cr or gel Differin gel Biacna gel Clindoxyl or Benzaclin gel Doxycyclin 100mg bid or qhs ERYC 333 tid <12yrs old Septra/Bactrim Any OCP Scarring Bad acne Very upset Moderate acne Isotretinoin -Accutane (prednisone) Teen Pill daily for 6-9 months Monthly Blood Work Dry sore Go on the wagon Girls MUST NOT get pregnant Worried Parent Stop po ABX head aches Liver/chol damage monitored and reversible Depression No causal effect of isotretinoin Anecdotal evidence at best Well known evidence that it improves mood - GI (Crohns & Collitis) (OR 4.37) 1-20/100,000/yr Doctor (monthly) - CBC, ALT, GGT, Chol, Tgl, BetaHCG Accutane 10

11 Accutane Dose 0.5-1mg/kg/day (40mg/d) Complete mg/kg/course (6-12mos) All you need to know is: For every 20lbs of pt 1pack of 40mg tablets eg. 120lb female gets 6mos of 40mg qd THAT IS THE MINIMUM DOSE! Mild/Moderate acne Afraid of isotretinoin Combination Tx Retinoid, BPO ABX po OCP Scarring Bad acne Very upset Oral Retinoid Isotretinoin Questions? 11

12 Novel Tx s Intralesional Triamcinolone Surgical excision Laser Acne Treatment Afraid of Drug Tx Pregnant Novel Tx s Blu U Photdynamic therapy (leuvulan) 12

13 PDT - Reaction Acne Scar Assessment Pigmentation: erythema Pulsed dye laser hyperpigmentation Q-switched laser or fractionated CO2/Erbium Sx: Ablative or non ablative fractionated lasers Ablative or non ablative fractionated lasers Acne Scarring with Laser 13

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