Acne. Objectives. Conflicts of Interest. Acne 05/18/2015

Transcription

1 Objectives Acne Jonathan A. Dyer, MD Associate Professor of Dermatology and Child Health University of Missouri Discuss acne pathogenesis Recognize common acne subtypes Implement a treatment plan based on acne subtype and current evidence based guidelines Explore ongoing concepts and controversies in acne None Conflicts of Interest Acne million patients/ year Cost of ~$2.5 billion/yr in US 85% between y/o Earlier onset - developed countries Common in 7-11 y/o; first sign of puberty May not outgrow it: 12% of women and 3% of men have acne into their 40s 1

2 Acne doesn t care who you are Acne Nearly universal 4 interrelated factors: Altered keratinization of pilosebaceous duct Comedo formation Propionibacterium acnes colonization of follicle Increased sebum production Inflammatory mediators form around pilosebaceous units 4 pillars of acne pathogenesis Pathogenesis of Acne Vulgaris: it all begins with the comedo 2

3 Diet and acne Multiple randomized controlled trials support a low glycemic index/load diet as beneficial for acne patients *** Observational studies suggest frequent milk consumption increases risk of acne Randomized controlled trials necessary before dietary recommendations can be made» J Am Acad Dermatol 2014;71:1039.e1-12 Psychosocial effects are profound Suicidal ideation Bad acne appears to be a risk factor Depression Social problems Psychological problems» Journal of Investigative Dermatology (2011) 131, Anxiety Assessing the acne patient Acne in children How old are they? Neonatal acne Up to 20% newborns Differential NCP Yeasts? TNPM Hyperpigmentation Infantile acne ~6wks 6+mo Boys Eval for +androgen Mid-childhood acne 1-7 yo r/o endocrine abnormality Preadolescent acne 7-12 yo; Common May be first signs of puberty Comedonal T-zone 3

4 Infantile acne Assessing the acne patient Acne vulgaris Comedonal Inflammatory Nodulocystic 4

5 13 yo male Active in sports Presents with these lesions Has tried some face wash without great benefit. Patient 1 Diagnosis? Comedonal acne Treatment? Topical OTC agents Benzoyl peroxide Retinoid Keep things simple Consider combining therapies OTC agents Cleansers Aggressive cleansing not necessary Make up not usually the culprit Sulfur-sodium sulfacetamide Mild Can be helpful OTC agents Salicylic acid OK but BPO better Benzoyl peroxide (BPO) Broadly antimicrobial Higher % does not = better efficacy Decreases bacterial resistance Complicating factors: Risk of allergic dermatitis Bleaches Irritating» British Journal of Dermatology (2014) 170, pp

6 Acne Treatment Topical retinoids adapalene (Differin) Tretinoin (Retin-A/Retin-A micro) Tazorotene (Tazorac) Topical antibiotics = inflammation Erythromycin Clindamycin Benzoyl Peroxide direct toxic effect Combination Products Clindamycin/Benzoyl Peroxide (Benzaclin/Duac) Retinoids Topical First line for comedonal lesions Useful in almost all forms of acne therapy Less helpful for purely inflammatory acne Slower onset than BPO» British Journal of Dermatology (2014) 170, pp Comedonal acne Caveats No indication for antibiotics ABX =Inflammation Watch for ice-pick scarring!!! 6

7 TAKE HOME POINTS Comedones = Topical therapy Balance irritation (SE) with efficacy Antibiotics only for inflammatory lesions If using antibiotics of any type you MUST try and also use BPO Never antibiotic monotherapy Pediatrics 2013;131: S163 S yo female Worsening acne lesions Flare with menstrual cycle but present continually Painful at times Picks at lesions Patient 2 Diagnosis? Inflammatory acne Treatment? Topical ALWAYS a part of therapy Benzoyl peroxide Retinoid Inflammation often indicates need for additional agents 7

8 Inflammatory acne Anti-inflammatory agents Antibiotics Topical Oral Female patients: Hormonal modulation Oral contraceptives Spironolactone Oral antibiotics Optimal length of antibiotic therapy is unknown limit to 3-6 months improvement from PO antibiotics occurs in 6-8 wks After 3 mo >50% have sustained benefit at wks (74-85% with topical retinoid; 46-64% with vehicle control) Short ABX courses may have longer lasting effects Recent study suggests overall course length is decreasing but still ~ 9 months Topical retinoids underused» J Am Acad Dermatol 2014;71:70-6.» J Am Acad Dermatol 2015;72:822-7 Acne tx, cont d. Oral Antibiotics Doxycycline Minocycline Less often Amoxicillin, Bactrim, cephalexin Low-dose doxycycline (Periostat, 20 mg) Below MIC; no resistance concerns Pediatrics 2013;131: S163 S186 8

9 Why oral antibiotics? Oral contraceptives (OCPs) Oral antibiotics may exhibit more improvement at 3 mos OCPs are equivalent by 6 mos May be better first-line choice for long-term acne management in women» J Am Acad Dermatol 2014;71:450-9 Recs are not to start until at least one yr after onset of menstruation?spironolactone Oral contraceptives (OCPs) Yaz, Orthotricyclin and Yasmin FDA approved for acne All are effective New antiandrogenic progestins (eg, drospirenone) are superior in some trials Newer progestins like drospirenone (derived from spironolactone) are less androgenic Superior to triphasic norgestimate/ethinyl estradiol (EE) and nomegestrol acetate/ 17b-estradiol» Med Clin N Am 99 (2015)

10 TAKE HOME POINTS If using antibiotics of any type you MUST try and also use BPO Never antibiotic monotherapy OCPs can mitigate need for ABX Gentle cleansers Follow manufacturer recs 16 yo female Has tried a variety of treatments Washes Topical prescription agents Acne worsening Painful lesions Patient 3 Diagnosis? Nodulocystic acne Treatment? Oral therapy absolutely necessary Antibiotics OCPs Must consider oral retinoid Referral Why do we care about bad acne? 10

11 Acne scarring Bad acne = A Big Deal Journal of Investigative Dermatology (2011) 131,

12 Pediatrics 2013;131: S163 S186 Isotretinoin Used for nodulocystic acne/scarring acne Vitamin A derivative Oral therapy Affects all 4 mechanisms of acne development Offers potential cure of acne 50-60% cure after full course ( mg/kg) of therapy Isotretinoin Side effects Xerosis/Nosebleeds Myalgias Headache(pseudotumor) Delayed wound healing Teratogenicity ipledge Others 12

13 What about IBD? IBD incidence: Exposed 0.9% Nonexposed 2.6%; P =.03 Negative association remained after adjusting for sex (OR, 0.28; 95% CI, ; P =.02) And for sex and nonacne indication (OR, 0.28; 95% CI, ; P =.02)» JAMA Dermatol. 2014;150(12): Don t underestimate the impact or importance of acne! Don t underestimate acne! Appropriately treating acne can dramatically alter a patient s life 13

14 Thank you for attending! Please contact me should you have any questions. Jon A. Dyer, MD Associate Professor of Dermatology and Child Health University of Missouri - Columbia 1 Hospital Drive; Room MA111 Columbia, MO phone: fax: [email protected] 14