ACNE EVALUATION AND MANAGEMENT

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1 ACNE EVALUATION AND MANAGEMENT Katie Fiala, MD Assistant Professor Depar tment of Dermatology Scott and White Nor thside Clinic

2 ACNE 85% of people age % with significant scarring Most common skin condition Pathogenesis: multifactorial Comedone formation Rupture and inflammation Propionibacterium acnes Androgenic hormones Treatment rationale Prevention of scarring Reduction of psychosocial distress

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4 DIAGNOSIS Areas with most sebaceous glands face, upper trunk Acne Fulminans = severe acne with systemic symptoms (Fever, joint aches) Acne Congoblata = severe comedones with scarring, no systemic symptoms Acne Keloidalis Nuchae

5 ACNE VULGARIS Comedonal Mild inflammatory Moderate inflammatory Nodulocystic

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11 OTHER CONTRIBUTING FACTORS Cosmetics, pomades Mechanical occlusion Medications: steroids, lithium, some antiepileptics, iodides Endocrine disorders: congenital adrenal hyperplasia, PCOS

12 RULE OUT Perioral dermatitis Syringomas Tuberous sclerosis Verruca Plana Molluscum

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17 LAB WORK Dysmenorrhea or hirsutisum DHEA-S Free testosterone LH, FSH Wound culture if not responding gram neg folliculitis

18 ACNE TREATMENT Retinoids Mainstay for comedonal acne Also anti-inflammatory Antibiotics: topical vs oral Hormonal treatments Oral contraceptive pills Spironolactone Isotretinoin

19 TOPICAL THERAPY Non-comedogenic/ non-acnegenic Retinoids Antibacterial Azaelic Acid Dapsone

20 TOPICAL RETINOIDS Consider for ALL non-pregnant patients Formulations: Adapalene 0.1% and 0.3% (Differin) cream, lotion, gel Tretinoin (Retin-A and others): must apply at night 0.01%, 0.025%, 0.05%, 0.1% cream, gel 0.04%, 0.1% microgel Tazarotene (Tazorac) 0.05% and 0.1%: Preg category X Side effects Pustular flare Skin irritation Sun sensitivity

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22 Expect a flare initially Pea-sized amount for entire face (do not spot treat ) A facial moisturizer can be used immediately after application Avoid exfoliating scrubs/washes/ waxing/astrigents Every-other-day may be necessary Sun Protection TOPICAL RETINOIDS COUNSELING

23 ACNE TOPICAL ANTIBIOTICS Combination products Benzaclin/Duac/Acanya (BPO + clinda) Benzamycin (BPO + erythro) must be refrigerated Single-agent Benzoyl peroxide (OTC and Rx) Clindamycin (lotion, soln, pledgets ) Erythromycin (rarely indicated resistance common)

24 DAPSONE GEL Aczone Antibacterial and antiinflammatory No significant decrease in Hgb in G6PD def patients May be used in sulfa allergic patients Most helpful in female hormonal acne Risk of yellow discoloration with BPO Piette WW, Taylor S, Pariser D, et al. Hematologic safety of dapsone gel, 5%, for topical treatment of acne vulgaris. Arch Dermatol Dec;144(12):

25 OTHER TOPICALS Azaleic acid Kills bacteria Decreases keratin production Salicylic acid, lactic acid, glycolic acid Keratolytics Chemical peels can be performed Hydroquinone

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27 ORAL THERAPY Minocycline 100mg bid Doxycycine 100mg bid Clindamycin mg bid Bactrim DS bid Azithromycin mg TIW Amoxicillin 500mg bid (pregnancy) Spironolactone mg daily Oral contraceptives (Yasmin) Isotretinoin 1mg/kg bid x 5-6 mo

28 ACNE TETRACYCLINES Regimen: Start twice daily and taper (as tolerated) over 2-6 months Agents Tetracycline (less lipophilic) Doxycycline May take with food Sun sensitivity Minocycline Skin hyperpigmentation Lupus-like syndrome Vestibular effects Side effects: GI distress, hypersensitivity reactions, pseudotumor cerebri, yeast vaginitis

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32 ACNE OTHER ANTIBIOTICS Erythromycin High incidence of P. acnes resistance TMP-SMX (Bactrim) Higher incidence of severe allergic reaction Has been associated with leukopenia Amoxicillin Clindamycin Pseudomembranous colitis Azithromycin TIW dosing QT prolongation

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34 ACNE HORMONAL TREATMENT Strongly consider for: Female acne of the lower face and neck Flares with menstrual cycle Any female patient who might be a candidate for isotretinoin (or spironolactone) Agents OCPs Spironolactone

35 OCPS Ortho-Tri-Cyclen, Estrostep, and YAZ are FDA-approved for acne >14 yo Has already started menstruation Increased sex hormone binding globulin, so decreases testosterone

36 SPIRONOLACTONE AR blocker and inhibitor of 5a-reductase SE: hyperkalemia, breast tenderness, irregular periods, fatigue, headache, hypotension Preg Cat D Feminization of male fetus mg per day

37 ISOTRETINOIN Brands: Accutane, Amnesteem, Claravis, Sotret Indicated for the treatment of severe recalcitrant nodular acne ipledge program instituted March 1, 2006 Prescribers, patients and pharmacies must be registered Tracks physician/patient compliance with contraception, pregnancy tests and follow-up Highly restrictive

38 ISOTRETINOIN DOSING mg/kg/day for 20 weeks Total dose mg/kg BID dosing Fatty foods increase absorption

39 ISOTRETINOIN FEMALE PATIENTS OF CHILD BEARING POTENTIAL 2 forms of contraception for one month before until one month after therapy 2 negative pregancy tests before starting isotretinoin Pregancy tests must be repeated every 30 days and reported to ipledge Patients must confirm comprehension of contraceptive counseling online before obtaining each prescription

40 ISOTRETINOIN CONTRACEPTION Primary Highly effective Virtually all hormonal forms, tubal ligation and vasectomy Secondary Barrier methods Abstinence

41 ISOTRETINOIN MALES AND FEMALES OF NON-CHILD BEARING POTENTIAL Females who cannot get pregnant Hysterectomy or bilateral oophorectomy Medically confirmed to be postmenopausal Continuous abstinence from heterosexual contact Males are counseled to use condoms

42 ISOTRETINOIN OTHER ISSUES Transient (sometimes serious) flare Laboratory monitoring: LFTs, lipids Pseudotumor cerebri: more likely when taken along with tetracyclines Xerosis and cheilitis Inflammatory bowel disease Depression

43 INFLAMMATORY BOWEL Crockett SD et al. Isotretinoin use and the risk of inflammatory bowel disease: A case control study. Am J Gastroenterol 2010 Mar 30 8,189 pts with IBD and 21,832 controls 3664 Crohns & 4428 UC Isotretinoin use strongly associated with UC (OR 4.36) but not with Crohns Higher dosage and longer duration increased risk

44 IBD CONTROVERSY Etminan M, et al. JAMA Dermatology. 2013;149(2): Meta-analysis of 4 large studies Did not find indication that isotretinoin confers increased risk of IBD I still makes pts aware of the potential risk, stop if bowel sxs until cleared by GI,? TCN association

45 ISOTRETINOIN DEPRESSION Cohort studies suggest no link between isotretinoin and depression Cohen J, et al. No association found between patients receiving isotretinoin for acne and the development of depression in a Canadian prospective cohort. Can J Clin Pharmacol Summer;14(2):e Epub 2007 Jun 6 Chia CY, et al. Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Arch Dermatol May;141(5):

46 DEPRESSION CONTROVERSY Pts with substantial acne have higher rate of suicidal ideation, regardless of treatment. Halvorsen et al. J Invest Derm. 2011;131(2) I counsel pts on potential association, enlist help from PCP and mental health professional when needed.

47 ISOTRETINOIN TIPS If you believe your patient is a candidate for isotretinoin: Prepare patients for the work involved Be prepared to work with the dermatologist regarding mood issues and contraception If you would like to prescribe isotretinoin: Be very familiar with the side effects and complications Understand appropriate dosing and dosing strategy Become intimately familiar with ipledge

48 ACNE TIPS Have patience I tell my patients to expect 30-40% improvement over 2 months Use topical retinoids Take the time to counsel patients on what to expect and how to avoid irritation Do not use short courses of antibiotics You are treating inflammation, not infection Do not forget about hormones Especially in a patient who may require isotretinoin Be suspicious of physician-dispensed products and light-based therapies More effective and less expensive treatments are available

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