ACNE. Nisakorn Saewan, Ph.D.

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1 ACNE, Ph.D.

2 Contents Definition Cause of acne Type of acne Acne grades Acne treatments

3 Objectives To explain the definition of acne To elucidate cause of acne To identify type and grade of acne To explain the treatment of acne

4 Definition Acne is a disorder resulting from the action of hormones and other substances on the skin's oil glands (sebaceous glands) and hair follicles. These factors lead to plugged pores and outbreaks of lesions commonly called pimples. Acne is usually not a serious health threat, it can be a source of significant emotional distress. Severe acne can lead to permanent scarring.

5 What is acne? A normal follicle

6 What is acne? Follicles sometimes get blocked and bacteria begins to grow Both whiteheads and blackheads start out as a microcomedone

7 Types of acne Non-inflammatory acne Whitehead Blackhead Inflammatory acne Papule Pustule Nodule Cyst

8 Whitehead Occurs when the trapped sebum and bacteria stay below the skin surface May show up as tiny white spots, or may be so small that they are invisible to the naked eye

9 Blackhead Occurs when the trapped sebum and bacteria partially open to the surface and turn black due to melanin Can last for a long time because the contents very slowly drain to the surface

10 Papule Occurs when there is a break in the follicular wall White blood cells rush in The pore become inflamed

11 Pustule Forms several days later when white blood cells make their way to the surface of the skin Usually refer to as a zit or pimple

12 Nodule Solid spots Much bigger than papules and extend deeper into skin When a follicle breaks along the bottom, total collapse can occur Causing a large, inflamed bump

13 Cyst Cysts are bags of liquid that is a mixture of pus and bacteria. Cysts usually occur only with nodules, often when two or three are close together. They are even more destructive than nodules to the structure of the skin but, luckily, are quite rare. Sometimes a severe inflammatory reaction can result in very large pus filled lesions

14 Acne grading Mild mainly comedones with perhaps a few papules and pustues Moderate mainly papules and pustules Severe deeper lesions, nodules and some cysts Very severe many nodules and cysts with scarring

15 Cause of acne 1. Hyperactive sebaceous gland (overactive lipid secretion) 2. Hyperkeratosis (accelerated keratinization) at hair infundibulum 3. Effect of bacteria 4. Others; genetic factors, food, stress

16 1. Hyperactive sebaceous gland Sebaceous gland locate Located all over body: most numerous in face, back, chest and shoulders

17 1. Hyperactive sebaceous gland Sebaceous gland functions Produce sebum Secrete sebum to the skin surface via the hair follicle pore Controlled by androgen hormone (androgen increase sebaceous gland more active)

18 1. Hyperactive sebaceous gland Imbalance between sebum production and secretion sebum blockage in hair follicle then get inflammation

19 2. Hyperkeratosis Stages of acne Normal process of keratinocytes occur (like on skin s surface) Keratinocytes slough into the hair follicle

20 2. Hyperkeratosis Stages I: Comedogenesis The sloughed cell stick together inside the hair follicle Resulting in a clogged pore or comedone

21 2. Hyperkeratosis Stages II The clogged pore is a great nutritional source for bacteria Bacterium acnes gravitate to the blocked pore

22 2. Hyperkeratosis Stages III Inflammation continues with increased redness and pus

23 2. Hyperkeratosis Stages IV Continued inflammation lead to so much inflammation Hair follicle rupture Bacteria and debris are released into the dermis

24 3. Effect of bacteria Propionibacterium acnes (P. acnes) Present on the skin and in the duct Prefer dark places with no air to breed (ex. Blocked pore) Lipase from P. acnes hydrolyzes sebum triglycerides into free fatty acid

25 Acne treatment 1. Reduce abnormal keratinization 2. Inhibit sebum production 3. Limit the production and activity of P. acnes

26 Acne treatment Topical treatment for mild to moderate acne Cream sensitive or dry skin Lotion any skin type Gel oily skin Solution oily skin Active ingredients Anti comedonal agents: azelaic acid, retinoid, salicylic acid Anti inflammatory agents: benzoyl peroxide Antibiotics: clindamycin, erythromycin

27 Acne treatment Systemic treatment for severe and recalcitrant acne will require systemic medication Oral antibiotics Hormonal therapy

28 Topical treatment: Azelaic acid A dicarboxylic acid derived from Pitysporum ovale Usual Dose 20 % Comes in cream and gel Antimicrobial activity against P. acnes and S. epidermidis Reduction in the thickness of the stratum corneum

29 Topical treatment: Azelaic acid Reduction in number and size of keratohyalin granules Reduction in the amount and distribution of filaggrin Decrease microcomedo Anti inflammatory No effect to sebum

30 Topical treatment: Azelaic acid Side effect Itching Burning Stinging Tingling About 1-5% of people have side effects

31 Topical treatment: Retinoids A chemical compounds that related to vitamin A Come in cream, gel Usal dose %

32 Topical treatment: Retinoids Reduce abnormal growth and development of keratinocytes Inhibits microcomedone formation Reduces the number of comedones Reduces the inflamed lesions

33 Topical treatment: Retinoids Adverse effects Retinoids increase the sensitivity of skin to UV light Applied at night and washed off in the morning Rarely eye irritation, edema and blistering of the skin occur Hypopigmentation may result from retinoin use

34 Topical treatment: Retinoids Comment not used during pregnancy or by women of childbearing age who are not taking adequate contraceptive precautions

35 Topical treatment: Tretinoin The acid form of vitamin A Knownasall-trans retinoic acid or ATRA Comedolytics Antibacterials

36 Topical treatment: Tretinoin Antikeratinizing activity The most effective topical agent: noninflammatory acne comprised of open and closed comedones Its efficacy in the reduction of lesions

37 Topical treatment: Isotretinoin The acid form of vitamin A Knownasall-trans retinoic acid or ATRA Developed as a safer alternative to the oral medication Works by affecting abnormal follicular keratinization

38 Topical treatment: Isotretinoin No effect on sebum production Effective in mild to moderate inflammatory and noninflammatory lesions Not available for use in the United State

39 Topical treatment: Salicylic acid Effective against comedones Effective against inflammatory lesions An exfoliant and chemical irritant

40 Topical treatment: Salicylic acid Adverse effects Cause skin irritation that presents as erythema, dryness and peeling

41 Topical treatment: Adapalene

42 Topical treatment: Adapalene A synthetic derivative of napthoic acid with retinoid-like activity A modulator of cellular differentiation, keratinization, and inflammatory processes Therapeutic role is both as a comedolytic agent as well as an anti-inflammatory agent Adapalene have been more erratic

43 Topical treatment: Tazarotene

44 Topical treatment: Tazarotene Newest topical agent Assumed to have a similar mechanism of action to retinoids Inflammatory and non-inflammatory lesions Especially with stubborn comedones

45 Topical treatment: Benzoyl peroxide

46 Topical treatment: Benzoyl peroxide Lipid solubility of benzoyl peroxide allows it to penetrate the PSD Reduce the concentration of two skin bacteria, P. acnes and S. epidermitis No effect on sebum production or composition comoedolytic anti-inflammatory bactericidal activity

47 Topical treatment: Benzoyl peroxide Most effective for inflammatory acne consisting of papules and pustules Mild cases of acne often can be treated with benzoyl peroxide alone Available without prescription in 2.5%, 5% and 10% lotions, creams, gels, and cleansers

48 Topical treatment: Benzoyl peroxide Side effect Dryness or peeling of skin Feeling of warmth Tingling Slight stinging About 3% of people are allergic and get an inflammation of the skin or severe crusting Benzoyl peroxide can bleach hair and fabric

49 Topical treatment: Antibiotics Main topical antibiotics used are erythromycin and clindamycin Comes in cream, lotion and gel Work by decreasing P. acnes

50 Topical treatment: Antibiotics Most useful in the treatment of mild inflammatory acne Can be the initial treatment modality or used as an adjunct to treatment with tretinoin or benzoyl peroxide Bacteriostatic antibiotics are thought to improve acne by decreasing the formation of by-products Reduce the production of chemotactic factors by P. acnes that play an important role in the disruption of microcomedones and the promotion of subsequent inflammation

51 Topical treatment: Antibiotics Papular and pustular acne respond best Topical antibiotics appear not to be as effective as their systemic counterparts; this is likely a reflection of the drug s distribution into the follicle Starting with the topical antibiotics first, reserving the oral medications for more severe cases that have failed topical therapy

52 Topical treatment: Antibiotics Side effect Dry skin Redness or irritation Peeling Oiliness Itching or burning About 10% of people have side effects

53 Systemic treatment: Oral antibiotics Decreasing P. acnes and levels of free fatty acid

54 Oral treatment: Tetracycline Usual Dose mg BID Adverse Effects GI upset Photosensitivity Vaginal candidosis Comments Best taken on empty stomach Highest incidence of GI upset Most widely prescribed antibiotic for acne Inexpensive

55 Oral treatment: Erythromycin Usual Dose 500 mg BID Adverse Effects GI upset Vaginal candidosis Comments Resistance emerging Safe in pregnancy

56 Oral treatment: Minocycline Usual Dose mg BID Adverse Effects Vestibular disturbances Blue-gray pigmentary changes in areas of cutaneous inflammation Vaginal candidosis Comments Relatively expensive Must take with meals

57 Oral treatment: Doxycycline Usual Dose 100 mg BID Adverse Effects GI upset Photosensitivity Vaginal candidosis Comments May take with meals Less expensive than minocycline

58 Oral treatment: Clindamycin Usual Dose mg BID Adverse Effects Pseudomembranous colitis Comments Highly effective

59 Oral treatment: Ampicillin Usual Dose 500 mg BID Adverse Effects Maculopapular rash Comments TCN alternative Efficacy with gram negative acne Safe in pregnancy

60 Oral treatment: TMP/SMX Usual Dose One DS tablet BID Adverse Effects Rash, hives Photosensitivity Comments Consider for resistant pustular acne Efficacy with gram negative acne

61 Oral treatment: Hormones Reduce the effect of the male hormones Testosterone Decrease the excess oiliness of the skin Called Dianette the trade name of a drug called cocyprindiol

62 Oral treatment: Hormones The active ingredient, cyproterone acetate, can damage the fetus The tablet also contains estrogen, which turn it into a contraceptive

63 Combination therapy Acne s multifactorial origins Most patients respond better if therapy encompasses more than one area of pathophysiology

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