acne Dr. M. Goeteyn Dermatologie AZ Sint-Jan Brugge-Oostende AV marleen.goeteyn@azsintjan.be
Why should you treat acne? -Impact on the quality of life -scarring
What is acne? Acne is an inflammatory disease of the pilosebaceous unit.
Pathophysiology of acne Primum movens: increased androgen production Abnormal proliferation and desquamation of epithelium of the acroinfundibulum Obstruction of the follicle Formation of a microcomedo(precursor)
Pathophysiology of acne Activated sebaceous gland Androgen driven activation of the sebaceous gland Obstructed follicles fill with lipid reach material Formation of comedones
Pathophysiology of acne Sebum = substrate proliferation of P. acnes P. acnes = anaerobic bacterium (normal skin flora) P. acnes chemical mediators Inflammation Traumatic rupture of comedones in surrounding dermis more inflammation
Pathophysiology of acne Androgen driven abnormal keratinocytic proliferation and desquamation -> ductal obstruction Androgen driven increase in sebum production Proliferation of Propionibacterium acnes Inflammation
Acne in childhood Neonatal acne Infantile acne Mid-childhood acne Preadolescent acne
What is neonatal acne vulgaris? - neonatal acne neonate with pustules - rare condition - acne triad - physiological raise in LH, testosterone - activation of the sebaceous glands -> comedo - > boys until 6 months of age
Neonatal cephalic pustulosis -Little pustules - mainly cheeks, chin, forehead - colonisation Malassezia furfur - ketoconazole 2% cream
Neonatal sebaceous gland hyperplasia - common - nose and cheek - term infants - multiple 1 à 2 mm yellow papules - maternal or endogenous androgenic stimulation of sebaceous gland - disappear spontaneously in 4-6 months
Infantile acne -acne between 6 weeks and 16 months - androgen driven activation of sebaceous glands - usually boys - comedones, papules, pustules, nodules and cysts - scarring possible - more severe acne in puberty - mostly no associated endocrinological disease BUT -always assess growth, height and weight - look for signs of pubertas praecox - if clinical examination is abnormal start hormonal and endocrinological workup
Mid-childhood acne -acne between 16 months and 7 years - no significant levels of adrenal and gonadal hormones - always workup by an endocrinologist
Childhood rosacea Rare condition Erythema, papules and pustules in the face Ocular involvement
Idiopathic facial aseptic granuloma Rare Chronic painless red to blue red mostly soft, elastic nodule in the centre of the face No inflammation Mostly solitary Chronic inflammatory granuloma with lymfocytes,histiocytes, neutrophils and foreign body giant cells Pathogenesis? Inflammatory reaction on an embryonic rest or epidermoid cysts granulomatous rosacea Spontaneous resolution Metronidazole per os excision
Preadolescent acne -between 7 an 12 years - normal onset of puberty - comedones - few inflammatory lesions - forehead, centrofacial - comedones in the ears - further workup unnecessary
The principles of acne treatment Morphology Severity Milder cases topical treatment More severe cases systemic treatment Target the precusor lesion (microcomedo) Treat the active inflammatory lesions
Treatment of acne Topical treatment Retinoids Benzoyl peroxide Topical antibiotics Systemic treatment Antibiotics Isotretinoin Hormonal therapy Azelaic acid Combination products
Retinoids Mode of action Vitamine A derivates Normalisation of keratinocyte desquamation and adhesion Available products Adapalene Differin Tretinoin 0.05% in hydrophilic cream Comedolysis Prevention of microcomedones
Benzoyl peroxide Mode of action Bactericidal Weakly comedolytic Acts on inflammatory lesions Prevents the development of antibiotic resistance Available products Benzac Pangel Pharmaceuticaly compounded Bleaching effect
Topical antibiotics Mode of action Bacteriostatic Anti- inflammatory Antibiotic resistance Available product Clindamycin - Dalacin - Zindaclin - pharmaceuticly compounded Eryrthromycin - Erycine - Inderm - Zineryt (+ zinc ) - pharmaceuticly compounded
Azelaic acid Mode of action Comedolytic Antimicrobial Anti-inflammatory < effective than retinoids > tolerated Skinoren
Topical combination products Available combination products Benzoyl peroxide + adapalene Benzoyl peroxide + erythromycin Benzoyl peroxide + miconazol Tretinoin + clindamycin on the Belgian market Epiduo Benzadermine Acneplus Treclinax
Hormonal therapies combined oral anticonceptives suppress ovarian androgen production Androgen receptor blockers (cyproteron acetate) Decrease androgen mediated effects on the sebaceous gland
Systemic antibiotics Doxycycline, minocycline, lymecycline,tetracycline, erythromycin Lack of comparative data on the efficacy of the different antibiotics None of the tetracyclines can be used in children < 8 à 12 y Choice driven by side effect profiles Doxycycline : photosensitivity Minocycline: rare cases of drug induced systemic LE rare cases of DRESS and serum sickness rare cases of skin hyperpigmentation tetracycline and erythromycin: increased resistance of P.acnes
Antibiotic resistance P. acnes more resistant to erythromycin and clindamycin Efficacy of treatment is less when resistant strains are present Doxycycline and minocycline: mic of P.acnes Staphylocci and Streptococci may also develop resistance
Preventing antibiotic restistance Avoid antibiotic monotherapy Avoid antibiotic maintenance therapy Use combination with retinoids to enhance treatment efficacy Use combination with benzoyl peroxide (bactericidal properties) Limit antibiotic treatment duration to 3 à 4 months Avoid combination of an oral and a topical antibiotic
Isotretinoin Optimal dose: between 0.3 and 0.5 mg/kg/d (max 1 mg/kg/d) The treatment duration varies between 4 and 6 months. Monotherapy Isotretinoin can be used in young children for severe acne* Only in severe forms: total cumulative dose of 120-150 mg/kg Effects are usually not seen before one to two months Half of the patients are permanently cured after one course Highly teratogenic: neg pregnancy test and reliable anticonception Most reported side effects: dry skin and mucosae, epistaxis, myalgias Transient alterations in serum lipids and transaminase concentrations *Iben M.M et al: Infantile Acne Treated with Oral Isotretinoin. Ped Dermatol sept/oct 2013 vol 30 nr 5
Treatment recommendations for mild pediatric acne* Initial treatment BP OR Topical retinoid OR Topical combination therapy BP + antibiotic If inadequate response Add BP or retinoid, if not already prescribed OR Change topical retinoid concentration, type, and/or formulation OR Change topical combination therapy OR Retinoid + BP OR Retinoid + antibiotic + BP *adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:s163-86
Treatment recommendations for moderate pediatric acne* Initial treatment Topical combination therapy: Retinoid + BP OR Retinoid + (BP + Antibiotic) OR (Retinoid + Antibiotic) + BP OR Oral antibiotic + Topical retinoid + BP If inadequate response Change topical retinoid concentration, type, and/or formulation AND/OR Change topical combination therapy AND/ OR Add or change oral antibiotic Consider hormonal therapy for female patients OR Consider oral isotretinoin * adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:s163-86
Treatment recommendations for severe pediatric acne* Initial treatment Combination therapy Oral antibiotic + Topical retinoid + BP If inadequate response Consider changing oral antibiotic AND Consider oral isotretinoin Consider hormonal therapy for female patients * adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:s163-86