4/18/2014 ACNE: THEN & NOW 25 YEARS OF INNOVATION ACNE VULGARIS ETIOLOGY OF ACNE. Jenifer Lloyd, DO, FAAD Professor of Internal Medicine

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1 ACNE: THEN & NOW 25 YEARS OF INNOVATION Jenifer Lloyd, DO, FAAD Professor of Internal Medicine ACNE VULGARIS The most common disease of the pilosebaceous unit. Commonly affects the face, chest & back. 90% of all teenagers will be affected to some degree. Disease spectrum: trivial comedones to severe nodules with scarring ETIOLOGY OF ACNE Hormones Genetics Bacteria (Propionibacterium acnes) Diet Stress Other (drugs, cosmetics pomades, industrial compounds) 1

2 ACNE FORMATION Increased sebum production due to androgenic stimulation Ductal hypercornification (sticky horny cells fail to be secreted at follicle opening) Colonization of the duct with p.acnes Production of inflammation ACNE LESIONS Comedones Papules Pustules Nodules Image courtesy of J. Lloyd, DO CLASSIFYING ACNE GRADE I Non-inflammatory Open comedones (blackheads) Closed comedones (whiteheads) 2

3 CLASSIFYING ACNE GRADE II Inflamed comedones Superficial papules and pustules CLASSIFYING ACNE GRADE III Inflammatory comedones Inflammatory papules and pustules Few nodules CLASSIFYING ACNE GRADE IV Severe nodular cystic acne Nodules are indurated and can become confluent and hemorrhagic Scarring common and often severe 3

4 ACNE TREATMENT Treatment is aimed at the underlying cause of the acne. The severity of the acne and the presence of scarring should determine the aggressiveness of the therapy. Patient compliance is important to consider when choosing a therapy. : TOPICALS Topical antibiotics (Clindamycin, Erythromycin) are still used but not as solo agents due to emerging resistance. Topical benzoyl peroxides (BPO) are now used in conjunction with topical antibiotics. Resistance to BPO has yet to be reported. Combination products are now available: Benzamycin, BenzaClin, Duac, Acanya RETIN-A GEL Remain the mainstay of acne treatment The first generation product became available in 1969 and is the active form of vitamin A Retinoic acid is comedolytic, anti-inflammatory and helps to normalize follicular hyperproliferation and keratinization The first generation gel-based product was not well tolerated 4

5 RETIN-A MICRO GEL Same active ingredient delivered via microsphere sponges that allow for slow timereleased delivery providing better product tolerability Current strengths available: 0.1% and 0.04% Valeant acquired Retin-A and will soon be launching Retin-A Micro 0.08% NEW RETINOIDS Tazarotene gel or cream Third generations retinoid: Tazorac Adapalene gel Differin 0.1% or 0.3% gel (also in cream & lotion) EpiDuo 0.1% gel combined with 2.5% BPO Transretinoic acid in new formulas Hydrogels: Tretin X, Avita and Atralin Clindamycin: Veltin, Ziana, ORAL ANTIBIOTICS Then: Erythromycin Tetracycline Doxycycline Minocycline Now Erythromycin not used Tetracycline no longer available Doxycycline generic is now outrageously expensive Minocycline generic is now cheaper than doxycycline 5

6 ORAL ANTIBIOTICS: NOW Doxycyline and minocycline now have enteric coated slow-released products available that allow for once a day dosing and food compatibility. These factors greatly increase teenage patient compliance and decrease common side effects. STEROIDS Intralesional use to quickly quiet inflammatory cysts and nodules. Oral use occasionally with extensive inflammatory cystic acne. Use with caution - prolong steroid use can cause acne. Do not recommend the use of topical steroids for acne. ORAL CONTRACEPTIVES Several birth control pills are now FDA approved for the treatment of acne. Low dose birth control pills decrease the androgen production thereby decreasing the oil and hence acne formation. Often takes 2-3 months to see an effect. 6

7 ALTERNATIVE CHOICE Contains Nicotinamide, Azelaic acid, Zinc, Pyridoxine, Copper and Folic Acid. Has anti-inflammatory properties and an inhibitory effect on P.acnes. ACCUTANE Then: Accutane was launched by Roche in the 1980s for the treatment of severe nodular cystic acne Now: Roche is no longer making Accutane A US Food & Drug Administration mandated registry is now in place Dosing has changed to decrease side effects and increase tolerance to the medication ( mg/kg) ACCUTANE ipledge recently put in place. You now need to be a member of the ipledge program to prescribe the drug. Accutane can be miraculous for those with severe inflammatory cystic acne. 7

8 INNOVATIVE NEW ACNE TREATMENTS WHAT IS NEW? Clarisonic Microdermabrasion Blu-U light Photodynamic therapy Lasers LED lights/iphone Apps Zeno CLARISONIC Patented sonic frequency of more than 300 movements per second to clean skin. Found to remove 6X more makeup, dirt, etc. than a wash cloth. Studies have demonstrated increased efficacy of topical products. 8

9 MICRODERMABRASION Microdermabrasion is a physical peel using microcrystals and a suction system Came to US in 1997 Help to improve function of the pilosebaceous unit Also helps with postinflammatory hyperpigmentation BLUE LIGHT Works by exciting the porphyrins in p.acnes thereby damaging the bacteria Requires 2 sessions/week for 4 weeks Each session requires 20 minutes in front of the nm of light Maintenance treatments required Usually not covered by insurance PHOTODYNAMIC THERAPY AMINOLEVULINIC ACID & BLUE LIGHT ALA is applied to the skin making it more susceptible to the light ALA is not selective to sebaceous glands ALA-PDT better than blue light alone but did not reach statistical significance in 2007 study ALA is photosensitizing and greatly increase the side effects of blue light 9

10 NEW LASERS Smoothbeam one of the first lasers to be FDA approved for acne. 1450nm penetrates to sebaceous gland. Non-selective destruction. Treatment reported to be very painful. Pulsed-dye lasers have also been used to treat acne. NEW PHOTODYNAMIC THERAPY (PDT) PDT is a two step process: First apply a photo-sensitizer which is selectively absorbed by cells you wish to destroy. Secondly apply a light source to activate the photo-sensitizer which will then destroy the targeted cells - leaving the surrounding tissue intact. 10

11 SELECTIVE PHOTOTHERMOLYSIS NEW : PDT ICG & TI-SAPHIRE LASER ICG is selectively absorbed in the sebaceous glands 800 nm laser targets the ICG filled sebaceous glands Selectively destroying oil glands NEW ISOLAZ PPX 11

12 NEW LED LIGHTS Contains 5 arrays of LEDs emitting at 415 nm LED photons absorbed by phorphyrins creating singlet O2 thereby destroying P.acnes HOME LEDS FTC: SEPTEMBER 8, 2011 Twenty thousand consumers thought that a smartphone could actually get rid of zits, the Federal Trade Commission has ordered two app makers to pay fines. The FTC signed separate settlements with DermApps and Acne Pwner, both of which published apps that promised to help deter the growth of acne by shining colored lights on the affected area via the smartphone. The two apps were named AcnePwner and AcneApp, which sold for 99 cents and $1.99, respectively, on the Apple itunes App Store. "Smartphones make our lives easier in countless ways, but unfortunately when it comes to curing acne, there's no app for that," said FTC chairman Jon Leibowitz, in a statement. 12

13 NEW ZENO Home device used to treat individual acne lesions as they develop. Place device on pimple for 2.5 minutes every hour Retails for $ (replacement tips $35.00) ACNE BE GONE s.com Try to pop as many zits and pimples as possible before the timer runs out. 13

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