ACNE AND ROSACEA. Disclosure. Distribution of Acne 6/12/2014. NJAFP 2014 Summer Celebration & Scientific Assembly 1

Transcription

1 ACNE AND ROSACEA Everett Schlam, MD Assistant Director, Mountainside Hospital Family Medicine Residency Program, Verona, NJ Disclosure Dr. Schlam has indicated that he has nothing to disclose relevant to this presentation Distribution of Acne Scientific Assembly 1

2 Pathogenesis of Acne Androgen induced - increased sebum production Abnormal follicular keratinization Proliferation of Propinobacterium Acnes Inflammation The Anatomy of Acne Acne Treatment Determined by the Type and Severity of Lesions Noninflammatory open and closed comedones Inflammatory lesions including papules, pustules, and/or nodules Scientific Assembly 2

3 16 year old with acne on forehead How would you describe her acne? 16 year old with acne on forehead How would you describe her acne? 1) Comedonal Acne 2) Mild Inflammatory Acne 3) Severe Inflammatory Acne 4) Nodulocystic Acne 16 year old with acne on forehead How would you describe her acne? 1) Topical Erythromycin 2) Topical Retinoid 3) Oral Tetracycline 4) Oral Isotretinoin Scientific Assembly 3

4 How would you describe this patient s acne? How would you describe this patient s acne? 1) Comedones with mild inflammation 2) moderate inflammatory acne 3) Nodulocystic Acne 4) Acne Fulminans Which treatment would you choose? 1) Topical Retinoid 2) Topical Retinoid and Topical antibiotic with Benzoyl Peroxide 3) Oral Tetracycline 4) Topical Retinoid and Topical Antibiotic Scientific Assembly 4

5 How would you describe this patient s acne? Which of the following topical medications has been shown to reduce the risk of resistance 1) Topical Retinoids 2) Benzoyl Peroxide 3) Topical Clindamycin 4) Topical Erythromycin How would you describe this patient s acne? Scientific Assembly 5

6 How should he be treated? Isotretinoin Systemic retinoid used for nodulo-cystic acne Most effective treatment with remission in 60% after single course (15-24 weeks) Reduces sebum production Normalized follicular keratinization Decreases inflammation Baseline CBC, LFTs, cholesterol, triglycerides, urinalysis, pregnancy test. Repeat monthly Post pubertal females must be on contraception and have two sequential negative pregnancy tests before starting Isotretinoin Adverse effects Teratogenic (facial dysmorphism, abnormalities of brain, eye, ear, CV system, thymus) and retinoid embryopathy can occur with single exposure during gestation Drying/chapping of skin and mucous membranes Myalgia/arthralgia Photosensitivity GI effect: Transaminitis, lipid abnormalities, pancreatitis Hematological: Leucopenia, elevated platelets and ESR Neurological: Pseudotumor cerebri Renal: Proteinuria, hematuria Mood disorders: depression, suicidal ideations and suicides Scientific Assembly 6

7 32 year old woman with premenstrual flare of acne Androgens in Acne In many post adolescent women, antiandrogen therapy can improve acne These women have hormonal acne: their serum hormone levels are usually normal Hormonal acne lesions are often perioral and along the jawline Many women report a pre-menstrual flare Not all women with hormonal acne are tested for hyperandrogenism However, it should be consider in the female patient whose acne is severe, sudden in onset, or associated with hirsutism or irregular menses American Academy of Dermatology Treatment of Hormonal Acne Commonly used agents to treat hormonal acne include: Spironolactone 50mg 100mg daily Oral contraceptives The following oral contraceptives have been approved by the FDA for the treatment of acne: Yaz, Ortho Tri-cyclen, Estrostep There is good evidence and consensus opinion that other estrogen-containing OCPs are also effective American Academy of Dermatology Scientific Assembly 7

8 Common First-Line Treatments Mild comedonal: topical retinoid, +/- topical benzoyl peroxide Mild papular/pustular: topical retinoid, topical antibiotics (clindamycin, erythromycin), topical benzoyl peroxide Moderate papular/pustular: oral antibiotics with topical retinoid and benzoyl peroxide American Academy of Dermatology Diet, Stress and Acne Controversial link between diet and acne although many patients believe that their acne is influenced by certain foods Western dies may be associated with acne Skim milk is associated with acne in teenage girls Stress: acne among university students was associated with exam stress Scientific Assembly 8

9 Topical Acne Treatment: Side Effects Topical acne treatments are often irritating and can cause dry skin When using retinoids or benzoyl peroxide, consider beginning on alternate days. Use a moisturizer to reduce their irritancy Typical agents take 2-3 months to see effect Patients will often stop their topical treatment too early from red, flakey skin without improvement in their acne Patient education is a crucial component to acne treatment American Academy of Dermatology Scientific Assembly 9

10 Acne Rosacea: The Basics Acne rosacea, also called rosacea, is a chronic inflammatory condition located at the flush areas of the face (nose, cheeks > brow, chin) Papules and pustules superimposed on a background of telangiectasias and general ertherma More common in women Age of onset 30-50s (later than acne vulgaris) Affected persons flush easily Patients often report very sensitive skin American Academy of Dermatology Rosacea Signs and Symptoms Facial Flushing Stinging Sensation Papules and Pustules Telegiectasias Inflammation of the eyes and eyelids Most often affects the central portion of the face Phynatous changes (thickened skin and enlarged pores) often on the nose Rosacea Subtypes 1) Erythromatotelangiectatic 2) Papulopustular 3)Phymatous 4) Ocular Scientific Assembly 10

11 What type of Rosacea does this patient have? Treatments for Rosacea Topical metronidazole (metrogel), azelaic acid (Azelex) or sulfacetamide/sulfer Oral tetracyclines Vascular laser therapy Other options are submicrobial dose doxycycline, topical clindamycin, pimecrolimus (elidel) or tacrolimus (protopic) Facial Redness Treatment in Rosacea Mirvaso Gel (Brimonidine) Topical 0.33% Quick onset of action Apply once daily Duration of action up to 12 hours Mechanism is constriction of dilated facial blood vessels Scientific Assembly 11

12 What type of Rosacea does this patient have? Triggers of Rosacea Sun Exposure Emotional Stress Hot Weather Wind Strenuous exercise Alcohol consumption Spicy Foods Hot Beverages Combination therapy with topical metronidazole, azelic acid, or sulfacetamide/sulfer AND oral tetracycline or submicrobial dose doxycycline Option for Vascular laser therapy Scientific Assembly 12

13 What type of Rosacea does this patient have? Oral tetracyclines Consider referral for oral isoretinoin (Accutane) ablative / pulsed dye laser therapy, electrosurgery Scientific Assembly 13

14 Ocular Rosacea 60% of patients with Rosacea have ocular symptoms Symptoms include foreign body sensation, photophobia, and meibomian gland inflammation Treatment includes eyelid hygiene, warm compresses, and oral doxycycline Take Home Points: Rosacea Rosacea is a chronic inflammatory condition of the face, which may present with east flushing, erythema, telangiectasias, papules and pustules and/or phymatous changes Many patients with rosacea have ocular involvement Unlike acne vulgaris, rosaces does not preend with comedones and is unrelated to hormones Topical and oral treatments often improve the papules and pustules of rosacea, but will not revers the underlying erythema and flushing All patients with rosacea should use sunscreen American Academy of Dermatology Acne and Rosacea Common dermatological conditions encountered in family medicine Description of the type and severity will guide treatment EDUCATION IS ESSENTIAL to optimize treatment outcomes Scientific Assembly 14