By Theresa M. Schimmels, PA-C WAPA Fall CME 2012 Basic skin care Acne How to recognize How to treat I have no conflict of interest Composed of three layers epidermis dermis hypodermis or subcutaneous Glands sebaceous sweat Skin: made of three layers Works as a: Barrier Temperature controller Protects from UV light Sensory input Metabolism Remember that skin disease/rashes can often be signs of internal problems Rheumatologic and autoimmune disease Thyroid, diabetes, lupus, psoriasis Liver or kidney disease Internal cancer Hematologic problems Bathing- not too hot! Daily, every other day, once or twice a week Cleanse Gentle cleanser or soap Moisturize Lotions for oily skin Creams for drier skin Pat the skin dry after washing the immediately apply moisturizer while the skin is still damp Reapply as needed throughout the day 1
Sunscreen Broad spectrum SPF 30 or greater daily Wide brimmed hat Avoid the sun between 10-3 Fish oil Creams and lotions restore water and lipids to the epidermis Pick what the skin type needs: Gel for oilier skin Lotion for mild dryness Cream for widespread flaky dryness Ointment for extremely dry skin Acne vulgaris Primarily affects adolescents pores or hair follicles get infected and produce comedomes, papules, pustules, nodules, cysts P. Acnes is the primary bacteria involved Hyperkeratosis Increased sebum production Propionibacterium acnes present in the follicle Inflammation Affects face, neck, chest, upper back, upper arms Greatest number of sebaceous glands Scarring and hyperpigmentation may occur 2
Open comedo = blackhead Follicle is open and distended Dark color is due to melanin, lipids, and keratinocytes Closed comedo = whitehead h Progresses from microcomedo due to sebum production Acne tends to resolve in the 3 rd decade Due to DHEA decline Premenstrual flares are common in older women Rosacea is a different story We ll touch on that later Pustules (superficial), papules, nodules Develop when follicular contents rupture into surrounding dermis papules Androgens in general are the original culprit Leads to pubertal production of sebaceous glands and sebum Also, some androgens are active on the skin leading to increased metabolic activity in acneprone areas of the skin 3
Acne cosmetica Recommend water-based products Acne mechanica Mechanical trauma may lead to inflammatory lesions Sports induced Clothing can harm Patients with acne should avoid occlusive clothing Environmental factors Humidity & heavy sweating, halogenated hydrocarbons from industrial products (cutting oils, herbicides, chemical warfare) Dietary factors are usually not of concern?milk? Family history Age related? Teenager vs prepubertal Focus on type & location of lesions, scarring, & post-inflammatory pigment changes Check med list May be caused by androgens, corticosteroids, lithium, phenytoin, B vitamins, etc. If suspected do endocrine evaluation to rule out systemic causes PCOS hyperandrogenism Hirsutism or virilization warrants further lab & imaging studies Treatment is a control, not cure Patient must want to comply with therapy Takes 8-12 weeks to see full effect and may continue to improve for up to six months Long-term, consistent and continuous routine care of skin and medication usage 4
Moderate to severe papular, pustular and nodular acne (10-25 inflammatory lesions) Scars On chest or back Not typical age- greater than 21ish, less than 11-12 Due to medication use Medication failure Cleanse the skin warm water, soap, no vigorous scrubbing No, I do not recommend scrubs or mechanical devices Minimizing contributing factors avoid friction causing clothes no oil based cosmetics sun exposure don t pick or squeeze Mild comedolytic agent Surface keratolytic Apply 1-3 times daily Benzyl Peroxide Salicylic Acid Sulfur (w/ resorcinol) Bactericidal against P. acnes Increase sloughing of skin cells Prevents closure of orifice Use 1-2 times daily (4-6 weeks for full effect) Excessive dryness, peeling May bleach clothes, bedding Benzamycin BPO with erythromycin Benzaclin BPO with clindamycin Wash 5% or 10% Use in the shower daily 5
Side effects bleaches clothing, towels Can cause redness and irritation of the skin Differin Solution Gel Cream Retin A Solution Gel Lotion Cream Azelex Cream Comedogenic and antibacterial Tazorac Cream Gel Also used for psoriasis Cause irritation, drying scale Work great if patient can tolerate! May need to moisturize before use, always moisturize after use Erythromycin/Clindamycin/Tetracyclines All come in topical or orals Use once or twice daily Antibacterial resistance is an issue! Use topicals before you use oral antibiotics Oral Doxycycline 100 mg bid with food, no milk Calcium binds to the medication Can give ulcer Photosensitivity Minocycline 100 mg bid Only use if doxy not tolerated Risk of lupus-like syndrome Can cause bluish deposits in the skin Used for the worst acne Nodulo-cystic or pustulo-cystic Basically remodels the oil glands in the entire body, not just the face Need to be go through a certification process to be able to prescribe 6
Patient must be seen monthly and monitored for side effects- lots of bad side effects Causes dryness- common complaint Musculoskeletal aches Headaches (increases ICP) GI symptoms Visual changes Teratogenic- severe Women must be on two forms of birth control and must have two negative pregnancy tests prior to initiation of med Pregnancy is treated with abortion due to risk of fetus and mother Can cause severe anemia's, liver failure, pancreatitis, metabolic syndrome associated hypertriglyceridemia Liver function (ALT), triglycerides, and CBC must be checked once a month while patient is on the medication Very expensive! www.ipledgeprogram.com for more info Cause: Follicle related disease causing redness in the skin, papules and chronic inflammatory perivascular infiltrate Associated with Demodex folliculorum mite Can lead to thickening of the skin Rhinophyma- W.C. Fields nose Most common in people age 30-60 Cause of vascular dilation unknown Initial symptom is erythema of the face Treat symptoms topical antibiotics and benzyl peroxide most effective comedolytics & oral antibiotics for persistent sx Topical metronidazole Bid for 0.75% Topical sulfacetamide with or without sulfur Bid Topical azelaic acid Start once daily for a couple of weeks then twice daily 7
Oral antibiotics Tetracyclines Low dose or high dose Oracea (name brand) Sustained release low dose doxycycline 40 mg once daily Do not use topical corticosteroid creams!!! Milia cysts 1.0 to 2.0 mm, superficial, white-to-yellow, keratin-containing epidermal cyst. Can be located on the eyelids, cheeks, and forehead in pilosebaceous follicles and at sites of trauma (often the dorsal surface of the hands and over the knees). They are usually asymptomatic. Treatment consists of incision and expression of the white keratin plug. 8