Western University of Health Sciences Silver Falls Dermatology

Transcription

1 Western University of Health Sciences Silver Falls Dermatology Lauren Boudreaux, PGY2 Bryce Desmond, PGY3 Stephanie Howerter, PGY2 Ben Perry, PGY3 Karla Snider, PGY4 Scott Thomas, PGY4

2 40-50 million individuals in the US affected each year Infants to adults Peaks in adolescence and affects 85% of people between age years old 35% of women and 12% of men $2.5 billion in annual cost

3 1. Microcomedo formation Alteration in the keratinization process/epidermal hyperproliferation Secondary to androgens, decreased linoleic acid, increased IL-1 alpha 2. Sebum production Androgens 3. P. acnes follicular colonization Breaks down TGs, stimulates ab production, inflammatory response, binds TLR2 release of IL-1a, IL-8, IL-12, TNFa Coproporphyrin III 4. Release of inflammatory mediators Before or after microcomedo formation

4 Controversial High glycemic diets and dairy (especially milk) have been found to be associated with increased prevalance and severity High glycemic index foods and dairy consumption increase androgen levels and insulin-like growth factor-1 (IGF-1) IGF-1 controls signaling of the Fox01 nuclear transcription factor Fox01 in combination with nutrient-sensitive kinase mtor complex 1 signaling currently hypothesized to be primary mediators of food-induced acne promotion

5 Non-flammatory Comedones (follicular) Open (blackhead) Closed (whitehead) Inflammatory Papules Pustules Cysts Nodules Sinus tracts Scarring can occur from all forms, including comedones PIH and persistent erythema can be permanent

6 Neonatal: 2-3 weeks to 3 months, no comedones, Malassezia Infantile: 3-6 months, comedones presents, transient elevation of DHEA

7 Severe nodulocystic acne WITHOUT systemic symptoms Follicular occlusion tetrad Acne conglobata, dissecting cellulitis of the scalp, hidradenitis suppurativa, pilonidal cyst Treatment: Isotretinoin

8 Most severe form of acne Abrupt onset in young men Systemic symptoms Fever, arthralgias, myalgia, hepatosplenomegaly Osteolytic bone lesions in the clavicle and sternum Painful, oozing, friable plaques with hemorrhagic crusts Labs: elevated ESR, leukocytosis, anemia, proteinuria Treatment: Isotretinoin + oral corticosteroids May be associated with SAPHO syndrome Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis Treatment: NSAIDS, sulfasalazine, infliximab

9 Pyogenic Arthritis, Pyoderma gangrenosum, Acne PSTPIP1 gene encoding CD2 antigen-binding protein 1 (CD2BP1) Tx: Infliximab, Anakinra

10 Acne mechanica Acne excoriee des jeunes Acne with endocrine abnormality PCOS/Stein-Leventhal syndrome Congenital adrenal hyperplasia

11 Monomorphorous inflammatory papules Hormones Anabolic steroids (danazol, testosterone) Corticosteroids, Corticotropin Phenytoin Lithium Isoniazid Iodides, bromides EGFR inhibitors

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13 Exposure to chlorinated aromatic hydrocarbons Chloracnegens fat-soluble, persist in body fat Insecticides, insulators, fungicides, herbicides, wood preservatives Malar, retroauricular, mandibular, axillae, scrotum Scarring, recurrent outbreaks for many years TREATMENT Topical/oral retinoids and antibiotics

14 Topicals Systemics Light/Laser Surgery

15 Benzoyl peroxide (BPO), salicylic acid, glycolic acid, azelaic acid, lipohydroxy acid, sulfur, tea tree oil Antibiotics: Clindamycin, Dapsone Retinoids: 1 st gen Tretinoin, isotretinoin 2 nd gen Etretinate, alitretin 3 rd gen Tazarotene, adapalene, bexarotene Cornerstone of combination therapy Bind nuclear retinoic acid receptors RAR, RXR Reverse abnormal keratinization; down regulating K6, K16 Comedolytic effect Anti-inflammatory effect via inhibition of TLR-2

16 Antibiotics: doxycycline, cephalosporins, minocycline Isotretinoin: Teratogenic ipledge Adverse effects: xerostomia/cheilitis, pseudotumor cerebri, hypertriglyceridemia OCPs Hypertriglyceridemia: lifestyle changes >500 first line = treatment 1 st line treatments: niacin, omega 3 fatty acids 2 nd line: fibrates, statins Spironolactone Zinc Probiotics

17 P. acnes makes coproporphyrin III light (blue) reactive oxygen species Red light penetrates deeper PDT

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19 CO2 Picosecond PDL Picosecond Alexandrite Histology suggest improvement in scarring from laser goes beyond remodeling of collagen

20 Bolognia J, Jorizzo JL, Rapini RP (eds). Dermatology. 2 nd ed. Vol. 2. St. Louis: Mosby/Elsevier; Chapter 68 Alopecias; p Bowe, Whitney P. et al. Diet and Acne, Journal of the American Academy of Dermatology, Volume 63, Issue 1, Bowe W, Logan A. Acne vulgaris, probiotics and the gut-brain-skin-access back to the future? Gut Pathogens. 2011;3(1):1-11 Bowe, WP. Probiotics in acne and rosacea. Cutis. 2013;92:6-7. Brauer, Jeremy A., Viktoryia Kazlouskaya, Hamad Alabdulrazzaq, Yoon Soo Bae, Leonard J. Bernstein, Robert Anolik, Patricia A. Heller, and Roy G. Geronemus. "Use of a Picosecond Pulse Duration Laser With Specialized Optic for Treatment of Facial Acne Scarring." JAMA dermatology 151, no. 3 (2015): Eichenfield LF, Fowler JF Jr, et al. Perspectives on therapeutic options for acne: an update. Skin All News. 2010;41(8)S12-16 Enshaieh S, Jooya A, et al. The efficacy of 5% tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo control trial. Indian J Dermatol Venerol Lerol. 2007;73(1): Kwon H, Yoon J, et al. Clinical and Histological Effect of a Low Glycaemic Load Diet in Treatment of Acne Vulgaris in Korean Patients: A Randomized, Controlled Trial. Acta Derm Venereol. 2012;92(3) Leyden JJ, Del Rosso JOral antibiotic therapy for acne vulgaris: pharmacokinetic and pharmacodynamic perspectives. J Clin Aesthet Dermatol Feb;4(2):40-7. PubMed PMID: ; PubMed Central PMCID: PMC Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009;18(10): Melnik BC. Diet in acne: further evidence for the role of nutrient signaling in acne. Acta Derm Venererol. 2012;92(3) Rai R, Natarajan K. Laser and light based treatments of acne. Indian J Dermatol Venereol Leprol May-Jun;79(3): Seidler EM, Kimball AB. Meta-analysis of randomized controlled trials using 5% benzoyl peroxide and clindamycin versus 2.5% benzoyl peroxide and clindamycin topical treatments in ace. J Am Acad Dermatol. 2011;65(4):e117-e119. Smith R, Mann N, et al. The effect of a high-protein, low glycemic load diet versus a conventional, high glycemic load diet on biochemical parameters associated with acne vulgaris: A randomized, investigator-masked, controlled tria. J Am Acad Dermatol. 2007;57(2): Tanghetti E, Dhawan S, et al. Clinical evidence for the role of topical antiinflammatory agent in comedonal acne: findings from a randomized study of dapsone gel 5% in combination with tazoarotene cream 0.1% in patients with acne vulgaris. J Drugs Dermatol. 2011;10(7) Taylor MN, Gonzalez ML. The practicalities of photodynamic therapy in acne vulgaris. Br J Dermatol. 2009;160(60): Tennaud I, Khammari A, et al. In vitro modulation of TLR-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol Jun;16(6):500-6 Tennaud I, Khammari A, et al. In vitro modulation of TLR-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol Jun;16(6): Thielitz A, Gollnick H. Recent therapeutic developments for acne. Exp Rev Dermatol. 2013;8(1): Williams H, Dellavalle R,et al. Acne Vulgaris. Lancet 2012;379: