Acne. Sofia Chaudhry M.D. Histology of an inflamed comedo. Bolognia, 2008.

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1 Acne Sofia Chaudhry M.D. Histology of an inflamed comedo. Bolognia, 2008.

2 Acne Vulgaris (Common Acne) Multifactorial disorder of pilosebaceous unit Affects million individuals annually in U.S. alone Peak incidence during adolescence 12% females, 3% men have acne till 40s

3 Pilosebaceous Unit

4 Pathogenesis Formation of microcomedo (clogged pore) corneocytes (outer skin cells) abnormally retained within the follicular lumen, causing hyperkeratosis Increased cohesiveness and proliferation Increased sebum (skin oil composed of fats & waxes) production by sebaceous glands Accumulation of keratinocytes and sebum rupture of comedo inflammatory response Of note, inflammation also seen in early lesions prior to rupture (affects type of acne and scarring) Propionibacterium acnes (P. acnes): gram positive rods: production of enzymes and pro-inflammatory mediators Skin s response to P. acnes: TLR-2 pathway of innate immune response

5 Pathogenesis Bolognia, 2008.

6 Pathogenesis Hormonal effects on sebum production: DHT (dihydrotestosterone) stimulates androgen receptors in sebaceous glands Increased androgen production with onset of puberty Acne develops where we have the most sebaceous glands. These glands make sebum and are found in the greatest number on our face, neck, chest, back, shoulders, and upper arms. (AAD.org)

7 Clinical Features Non-inflammatory acne: open & closed comedones Bolognia, 2008.

8 Bolognia, Clinical Features Inflammatory acne: originate with comedo formation, but expand to form papules, pustules, nodules and cysts

9 Clinical Features Severe cystic acne Bolognia, 2008.

10 Other Variants Acne fulminans Ance conglobata Solid facial edema Acne excoriee Drug induced acne Occupational acne Neonatal acne Infantile acne Endocrinologic abnormalities Bolognia, 2008.

11 Long term sequelae Scarring Bolognia, 2008.

12 Treatments Topical Tretinoin: (all-trans-retinoic acid) Cornerstone of all acne treatment Comedolytic Normalizes follicular keratinization Anti-inflammatory properties Most common side effect: local irritation improves with use Less irritating formulations, ex. Retin-A microgel, Atralin

13 Treatments Topical Other retinoids: Adapalene (Differin): Less comedolytic properties, but less irritating Tazarotene (Tazorac): Strongest topical retinoid, pregnancy category X

14 Treatments Topical Benzoyl Peroxide: bacteriocidal agent, reduces P. acnes within follicle Most effective in combination with other agents Risk of contact dermatitis Topical Antibiotics: Clindamycin and Erythromycin (do not use alone, increased resistance)

15 Treatments Topical Salicylic acid: comedolytic and mild anti-inflammatory Azelaic acid (Finacea): antiinflammatory, reduction of P. acnes, comedolytic activity Can lighten post-inflammatory hyperpigmentation Sodium sulfacetamide: anti P. acnes

16 Treatments Oral Oral Antibiotics: moderate to severe inflammatory acne Most commonly used: Doxycycline & Minocycline Intrinsic anti-inflammatory properties Anti P. acnes properties Doxycycline common side effects: sun sensitivity, GI upset Minocycline: rare risk of permanent blue-gray pigmentation (usually gums and shins), rare risk of drug induced lupus

17 Treatments Oral Hormonal Therapy: for female patients Can be very effective despite androgen levels still being within normal limits Most effective for Adult Females Acne tends to flare with menstrual cycle Acne concentrated on lower face OCPs: three are FDA approved for acne Estrostep, Ortho Tri-Cyclen, Yaz Spironolactone: androgen receptor blocker and 5α-reductase inhibitor (not use during pregnancy)

18 Treatments Oral Isotretinoin (Accutane): 13-cis-retinoic acid Can be very effective for severe inflammatory or nodulocystic acne unresponsive to other therapies Typical course 5-6 months Up to 1/3 of patients (usually younger females) may need to repeat course later in life Most common side effects: dryness, myalgias, increased triglycerides/cholesterol Other possible side effects: HA, pseudotumor cerebri, changes in blood counts, hepatotoxicity, joint pains Causes serious birth defects: I-Pledge Program Associations reported with depression and inflammatory bowel disease*

19 Acne Medications Considered Safe in Pregnancy Topical erythromycin or clindamycin (category B) Topical Azelaic Acid - Finacea (category B) If oral Abx needed: Ampicillin (category B) Microdermabrasions

20 Few Tips All acne medicines typically take 2-3 months before you see the improvement, so need to be patient Don t pick or squeeze acne lesions! Makes pigment change and scarring worse Don t spot treat with topical medications, apply evenly to entire face Chose mild skin care products, look for non-comedogenic and oil free products

21 References Bolognia, Jean L., Lorizzo, Joseph L., Rapini, Ronald P. Dermatology, 2 nd Edition. Elsevier:

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