Acne and Rosacea handout version Dr Elizabeth Ogden Associate Specialist in Dermatology 25.4.13
Acne Acne is the most common skin disease Affecting all races and ages Acne is most common in teenagers and young adults An estimated 85% of all people between the ages of 12 and 25 have acne outbreaks at some point Some people in their 30s, 40s and 50s continue to get acne - 15% of women and 5% of men
Lesions If sebum breaks through to the surface, the result is a whitehead. If the oil accumulates melanin pigment or becomes oxidized, the oil changes from white to black, and the result is a blackhead Blackheads are therefore not dirt and do not reflect poor hygiene.
History When started Sites involved Current treatment Previous treatments including over the counter Medical history Smoking For women period cycle, contraceptive history Family history of acne Other information job, studying etc Psychological impact
Examination Look at the face Look at the neck Look at the back Look for blackheads and whiteheads Look for papules and pustules Look for nodules and cysts Look for scarring Look for signs of picking and scratching
Types of Lesions Whiteheads (comedones): These are pimples that stay under the surface of the skin Blackheads: These pimples rise to the skin's surface and look black Papules: These are small pink bumps that can be tender Pustules: These pimples are red at the bottom and have pus on top Nodules: These are large, painful, solid pimples that are deep in the skin Cysts: These deep, painful, pus-filled pimples can cause scars
1. Comedonal acne Types of Acne 2. Mild - moderate papulopustular acne 3. Severe papulopustular acne, moderate nodular acne 4. Severe nodular acne, conglobate acne
Non-inflamed lesions Comedonal acne Open (blackheads) and closed comedones (whiteheads) Mid-facial distribution If very prominent early - is indicative of poor prognosis
Papulopustular acne Mixture of non-inflammatory and inflammatory lesions Papules and pustules May evolve into deep pustules or nodules in more severe disease Inflammatory macules represent regressing lesions that may persist for many weeks
Nodular/ conglobate acne Small nodules are defined as firm, inflamed lesions > 5 mm diameter, painful by palpation. Nodules are defined as larger than 5 mm, large nodules are > 1 cm in size. They may extend deeply and over large areas, frequently resulting in painful lesions, exudative sinus tracts and tissue destruction. Conglobate acne is a rare but severe form of acne found most commonly in adult males with few or no systemic symptoms.
Nodular/ conglobate acne Lesions usually occur on the trunk and upper limbs and frequently extend to the buttocks. In contrast to ordinary acne, facial lesions are less common. The condition often presents in the second to third decade of life and may persist into the sixth decade. Conglobate acne is characterized by multiple grouped comedones amidst inflammatory papules, tender, suppurative nodules which commonly coalesce to form sinus tracts. Extensive and disfiguring scarring is frequently a feature
Acne fulminans Other Variants of Acne Gram-negative folliculitis Rosacea fulminans Vasculitic Acne Mechanical acne Oil/ tar acne Chloracne Acne in neonates and infants Late onset and/or Persistent acne, sometimes associated with genetic or iatrogenic endocrinopathies.
Late Onset Acne A recent US study has shown that late onset acne in women is increasing 45% of women aged 21-30 had clinical acne 26 % aged 31-40 had clinical acne 12% of women aged 41-50 had clinical acne Another study has shown that Comedonal postadolescent acne (CPAA) is the most prevalent form of acne in adult women Also CPAA was frequently of late-onset and closely correlated with cigarette smoking.
Clinical Classifications 1. Comedonal acne 2. Mild - moderate papulopustular acne 3. Severe papulopustular acne, moderate nodular acne 4. Severe nodular acne, conglobate acne
Psychological effects Acne can lead to profound psychological effects on teenagers It is not proportional to the severity of the Acne DLQI Questionnaires
Prognostic factors of severe disease that should influence treatment choice Family history Course of inflammation Persistent or late-onset disease Hyperseborrhoea Androgenic triggers Truncal acne Psychological sequelae. Previous infantile acne may also correlate with resurgence of acne at puberty Early age of onset with mid-facial comedones Early and more severe seborrhoea Earlier presentation relative to the menarche
The influence of the assessment of scarring/ potential for scarring on disease management Scarring usually follows deep seated inflammatory lesions But can occur in more superficial inflamed lesions in scar prone patients In dermatology clinics acne scarring is seen in up to 90% of patients (some very mild) The presence of scarring should support more aggressive management and treatment early in the disease process
Differential Diagnosis Seborrhoeic Dermatitis look for scale in hair. Rash on body, scale in ears and eyebrows Perioral Dermatitis mostly women - papules around mouth and use of topical steroids Rosacea redness in the central face, fair skin no blackheads Contact or Irritant Dermatitis
Acne Scarring Urgent referral if acne scarring or Family History of Scarring Acne
Recommendations for comedonal acne High strength of recommendation None Medium strength of recommendation Topical retinoids Low strength of recommendation BPO Azelaic acid
Negative Recommendations for comedonal acne Topical antibiotics are not recommended Hormonal antiandrogens, systemic antibiotics and/ or systemic isotretinoin are not recommended Artificial ultraviolet (UV) radiation is not recommended
Mild to moderate papulopustular acne High strength of recommendation The fixed-dose combination adapalene and BPO is strongly recommended The fixed-dose combination clindamycin and BPO is strongly recommendedmedium strength of recommendation Medium strength of recommendation Azelaic acid, BPO, Topical retinoids For more widespread disease, a combination of a systemic antibiotic with adapalene
Mild to moderate papulopustular acne Low strength of recommendation Blue light monotherapy The fixed-dose combination of erythromycin and tretinoin The fixed-dose combination of isotretinoin and erythromycin Oral zinc can be considered In case of more widespread disease, a combination of a systemic antibiotic with either BPO or with adapalene in fixed combination with BPO
Negative recommendations for mild to moderate papulopustular acne Topical antibiotics as monotherapy are not recommended. Treatment of mild to moderate papulopustular acne with artificial UV radiation is not recommended. The fixed-dose combination of erythromycin and zinc is not recommended.
Negative recommendations for mild to moderate papulopustular acne Systemic therapy with anti-androgens, antibiotics, and/ or isotretinoin is not recommended. Open recommendation Due to a lack of sufficient evidence, it is currently not possible to make a recommendation for or against treatment with red light, IPL, Laser or PDT
Severe papulopustulo/moderate nodular acne High strength of recommendation Oral isotretinoin monotherapy is strongly recommended for the treatment of severe papulopustular acne. Medium strength of recommendation Systemic antibiotics*can be recommended for the treatment of severe papulopustular acne in combination with adapalene, with the fixed dose combination of adapalene/ BPO or in combination with azelaic acid *Doxycycline or lymecycline limited to 3 months treatment
Severe papulopustular/ moderate nodular acne Low strength of recommendation Oral anti-androgens in combination with oral antibiotics can be considered for the treatment of severe papulopustular acne. Oral anti-androgens in combination with topical treatment can be considered for the treatment of severe papulopustular acne Systemic antibiotics in combination with BPO can be considered for the treatment of severe papulopustular/ moderate nodular acne.
Negative recommendation Severe papulopustulo/moderate nodular Acne Single or combined topical monotherapy is not recommended. Oral antibiotics as monotherapy are not recommended. Oral anti-androgens as monotherapy are not recommended. Visible light as monotherapy is not recommended. Artificial UV radiation sources is not recommended
Treatment nodular/ conglobate acne High strength of Recommendation Oral isotretinoin is strongly recommended as a monotherapy for the treatment of conglobate acne
Treatment nodular/conglobate acne Medium strength of recommendation Systemic antibiotics can be recommended in combination with azelaic acid Low strength of recommendation Oral anti-androgens in combination with oral antibiotics Systemic antibiotics in combination with adapalene, BPO or the adapalene-bpo
Negative Recommendations Treatment nodular/ conglobate acne Topical monotherapy is not recommended Oral antibiotics are not recommended as monotherapy Oral anti-androgens are not recommended as monotherapy Artificial UV radiation sources are not recommended Visible light as monotherapy is not recommended
Summary of therapeutic Comedonal Acne recommendations Mild-to-moderate papulopustular acne Severe papulopustular/ moderate nodular acne Severe nodular/ Conglobate acne High strength of recommendation Adapalene + BPO or BPO + Clindamycin Isotretinoin Isotretinoin Medium strength of recommendation Topical Retinoid Azelaic acid or BPO or Topical retinoid or systemic antibiotic + Adapalene Systemic antibiotics + adapalene or Systemic antibiotics + azelaic acid or Systemic antibiotics + adapalene + BPO Systemic antibiotics + azelaic acid
Summary of therapeutic recommendations Comedonal Acne Mild-to-moderate papulopustular acne Severe papulopustular/ moderate nodular acne Severe nodular/ Conglobate acne Alternatives for females Hormonal antiandrogens + topical treatment Or hormonal antiandrogens + systemic antibiotics Hormonal antiandrogens + systemic antibiotics
Factors which make Acne worse Cosmetic agents and hair pomades Medications -steroids, lithium, some antiepileptics and iodides. Polycystic Ovary Disease, Congenital Adrenal Hyperplasia causing androgen increase/ sensitivity Pregnancy may cause a flare-up. Mechanical occlusion with headbands, shoulder pads, back packs, or under-wire bras can be aggravating factors Excessive sunlight may either improve or flare acne
Food Parents often tell teens to avoid pizza, chocolate, greasy, fried foods, and junk food. While these foods may not be good for overall health, they don't cause acne or make it worse BUT there is concern about excessive intake of milk especially skimmed milk Good advice about diet may help acne - eating more low glycaemic index foods and more foods rich in omega 3 - whole grains, fresh fruits and vegetables, fish, olive oil and garlic
Late Onset Acne A recent US study has shown that late onset acne in women is increasing 45% of women aged 21-30 had clinical acne 26 % aged 31-40 had clinical acne 12% of women aged 41-50 had clinical acne Another study has shown that Comedonal postadolescent acne (CPAA) is the most prevalent form of acne in adult women Also CPAA was frequently of late-onset and closely correlated with cigarette smoking.
Combined Oral Contraceptives Recent US survey showed that combined oral contraceptives were used infrequently for women with acne - 3.3% on initial consultation Non enzyme inducing antibiotics NO ADDITIONAL CONTRACEPTIVE PRECAUTIONS NEEDED NOW Any COC can make acne better but cocyprindiol and drospirenone are the two best progestogens (least androgenic)
Acne When to Refer Most patients with acne can be managed in primary care. However, referral to a specialist service is advised if they: have a very severe variant such as fulminating acne with systemic symptoms (acne fulminans) have severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin have severe social or psychological problems, including a morbid fear of deformity (dysmorphophobia) are at risk of, or are developing, scarring despite primary care therapies have moderate acne that has failed to respond to treatment which should generally include several courses of both topical and systemic treatment over a period of at least 6 months. Failure is probably best based upon a subjective assessment by the patient are suspected of having an underlying endocrinological cause for the acne such as polycystic ovary syndrome that needs assessment
Rosacea Thought to be a disease of the fair skinned but not exclusively so Typically starts 30s to 60s develops gradually Incidence in Swedish study 10% Higher incidence in the fairer skinned
Causes It is felt to be caused by a combination of factors vascular, environmental and inflammatory The skin's innate immune response appears to be important - antimicrobial peptides such as cathelicidins promote an inflammatory reaction. Hair follicle mites Dermodex are sometimes found in greater numbers within rosacea papules but their role is unclear.
Causes No good evidence Helicobacter pylori plays a role Rosacea may be aggravated by facial creams or oils, and especially by topical steroids Sun damage is an important factor in rosacea - hence the distribution
Signs Early signs - easy blushing and flushing Often are stingers burning and stinging from cosmetics and medications Patients with rosacea also have defective barrier function
Signs Redness affecting the nose, the cheeks and chin this is the most important sign will be worse when hot, when eating and with alcohol. Scattered pustules and papules in the same areas Neck, back and chest spared
Differential Diagnosis Seborrhoeic Dermatitis - look for scaling on scalp, naso labial creases, eyebrows and ears Keratosis Pilaris look at upper arms and thighs Acne look for blackheads. Check chest and back Lupus Erythematosus follicular plugging, look in the ears
4 main subtypes Erythematotelangiectatic (vascular) Inflammatory (papulopustular) Phymatous (sebaceous) Ocular
Ocular Rosacea Between 20% to 50% of rosacea sufferers can have ocular involvement No correlation exists between the severity of ocular disease and the severity of facial rosacea Symptoms vary from minor irritation, dryness, and blurry vision to potentially severe ocular surface disruption and inflammatory keratitis Blepharitis and conjunctivitis are commonest
Ocular Rosacea Other ocular findings include lid margin, conjunctival telangiectasias, eyelid thickening, eyelid crusts and scales, chalazia, hordeolum, punctate epithelial erosions, corneal infiltrates, corneal ulcers, corneal scars, and vascularization. Sight-threatening disease is rare with rosacea; however, keratitis can result in sterile corneal ulceration and eventual perforation if not treated aggressively
Other rarer facial problems that can be confused with Rosacea Tuberous Sclerosis Birt-Hogg-Dube syndrome Sebaceous Hyperplasia Acne excoriée
Advice to Rosacea Sufferers Where possible, reduce factors causing facial flushing. Avoid oil-based facial creams. Use water-based make-up Never apply a topical steroid to the rosacea. Protect the skin from the sun using light oil-free facial sunscreens Keep the face cool: minimize exposure to hot or spicy foods, alcohol, hot showers and baths and warm rooms Green based make up can help disguise the redness
Treatment Topical Treatment Metronidazole cream or gel can be used intermittently or long term on its own for mild cases and in combination with oral antibiotics for more severe cases. Azelaic acid cream or lotion is also effective, applied twice daily to affected areas. Can be used in pregnancy
Treatment oral treatment 6-12 weeks of lymecycline, doxycycline or minocycline reduce inflammation, the redness, papules, pustules and eye symptoms. Low doses can be used there is 40mg low dose doxcycycline Further courses are often needed from time to time as the antibiotics don't cure the disorder. Sometimes co-trimoxazole or metronidazole are prescribed for resistant cases.
Other Treatments Isotretinoin - but not always successful (different to acne) Medications to reduce flushing such as clonidine (an alpha 2 receptor agonist) may reduce the vascular dilatation. Does have side effects. Anti-inflammatory agents Oral non-steroidal antiinflammatory agents such as diclofenac may reduce the discomfort and redness Tacrolimus ointment and pimecrolimus cream are reported to help some patients with rosacea.
Treatment of Ocular Rosacea Lid hygiene - Hot compresses, Mild, non irritating cleaning solutions, such as dilute baby shampoo or commercially preparations. Light pressure applied to the eyelids can aid in gland expression. Artificial tears - used often and ointment at night. Antibiotics -Tetracyclines (eg, tetracycline, doxycycline, minocycline) for antibiotic effect, and, once the disease has come under control, the dose may be tapered to a lower, suppressive dose and maintained indefinitely. The 40mg low dose doxcycycline is useful for maintenance.
Telangiectic Rosacea The papular part of the rosacea is relatively easy to help but the persistent redness doesn t go away easily with topicals especially if of long standing Vascular laser - persistent telangiectasia can be successfully improved with vascular laser or intense pulsed light treatment
Treatment IPL treatment to reduce redness Protect from the Sun Green based foundation Make up to help redness