ACNE, Ph.D.
Contents Definition Cause of acne Type of acne Acne grades Acne treatments
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
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.
What is acne? A normal follicle
What is acne? Follicles sometimes get blocked and bacteria begins to grow Both whiteheads and blackheads start out as a microcomedone
Types of acne Non-inflammatory acne Whitehead Blackhead Inflammatory acne Papule Pustule Nodule Cyst
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
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
Papule Occurs when there is a break in the follicular wall White blood cells rush in The pore become inflamed
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
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
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
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
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
1. Hyperactive sebaceous gland Sebaceous gland locate Located all over body: most numerous in face, back, chest and shoulders
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)
1. Hyperactive sebaceous gland Imbalance between sebum production and secretion sebum blockage in hair follicle then get inflammation
2. Hyperkeratosis Stages of acne Normal process of keratinocytes occur (like on skin s surface) Keratinocytes slough into the hair follicle
2. Hyperkeratosis Stages I: Comedogenesis The sloughed cell stick together inside the hair follicle Resulting in a clogged pore or comedone
2. Hyperkeratosis Stages II The clogged pore is a great nutritional source for bacteria Bacterium acnes gravitate to the blocked pore
2. Hyperkeratosis Stages III Inflammation continues with increased redness and pus
2. Hyperkeratosis Stages IV Continued inflammation lead to so much inflammation Hair follicle rupture Bacteria and debris are released into the dermis
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
Acne treatment 1. Reduce abnormal keratinization 2. Inhibit sebum production 3. Limit the production and activity of P. acnes
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
Acne treatment Systemic treatment for severe and recalcitrant acne will require systemic medication Oral antibiotics Hormonal therapy
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
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
Topical treatment: Azelaic acid Side effect Itching Burning Stinging Tingling About 1-5% of people have side effects
Topical treatment: Retinoids A chemical compounds that related to vitamin A Come in cream, gel Usal dose 0.025-0.05%
Topical treatment: Retinoids Reduce abnormal growth and development of keratinocytes Inhibits microcomedone formation Reduces the number of comedones Reduces the inflamed lesions
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
Topical treatment: Retinoids Comment not used during pregnancy or by women of childbearing age who are not taking adequate contraceptive precautions
Topical treatment: Tretinoin The acid form of vitamin A Knownasall-trans retinoic acid or ATRA Comedolytics Antibacterials
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
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
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
Topical treatment: Salicylic acid Effective against comedones Effective against inflammatory lesions An exfoliant and chemical irritant
Topical treatment: Salicylic acid Adverse effects Cause skin irritation that presents as erythema, dryness and peeling
Topical treatment: Adapalene
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
Topical treatment: Tazarotene
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
Topical treatment: Benzoyl peroxide
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
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
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
Topical treatment: Antibiotics Main topical antibiotics used are erythromycin and clindamycin Comes in cream, lotion and gel Work by decreasing P. acnes
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
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
Topical treatment: Antibiotics Side effect Dry skin Redness or irritation Peeling Oiliness Itching or burning About 10% of people have side effects
Systemic treatment: Oral antibiotics Decreasing P. acnes and levels of free fatty acid
Oral treatment: Tetracycline Usual Dose 250-500 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
Oral treatment: Erythromycin Usual Dose 500 mg BID Adverse Effects GI upset Vaginal candidosis Comments Resistance emerging Safe in pregnancy
Oral treatment: Minocycline Usual Dose 50-100 mg BID Adverse Effects Vestibular disturbances Blue-gray pigmentary changes in areas of cutaneous inflammation Vaginal candidosis Comments Relatively expensive Must take with meals
Oral treatment: Doxycycline Usual Dose 100 mg BID Adverse Effects GI upset Photosensitivity Vaginal candidosis Comments May take with meals Less expensive than minocycline
Oral treatment: Clindamycin Usual Dose 75-150 mg BID Adverse Effects Pseudomembranous colitis Comments Highly effective
Oral treatment: Ampicillin Usual Dose 500 mg BID Adverse Effects Maculopapular rash Comments TCN alternative Efficacy with gram negative acne Safe in pregnancy
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
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
Oral treatment: Hormones The active ingredient, cyproterone acetate, can damage the fetus The tablet also contains estrogen, which turn it into a contraceptive
Combination therapy Acne s multifactorial origins Most patients respond better if therapy encompasses more than one area of pathophysiology