Acne

    Table of contents

    Intro

    • Problem with the pilosebaceous unit
    • Types of lesions:
      • Non-inflammatory Lesions
        • Comedones
          • Open Comedones (black heads)
          • Closed Comedones (white heads)
      • Inflammatory lesions
        • Papules, pustules, nodules
      • Acne scars:
        • Ice pick, boxcar scars

     

    History/Physical

    • Hx:
      • Drugs
      • Cosmetic products used
      • Occupation
      • Symptoms of hormonal acne (irregular menses, obesity, hirsuitism, prior tx)
    • Px:
      • Lesion type, severity, skin type, color, distribution, scar.
    • Labs:
      • If Hormonal suspected: free/total testosterone, DHEAS, prolactin, LH/FSH, am cortisol
        • If DHEAS - if really high, may suggest adrenal tumor
        • If high testosterone & LH/FSH >2 - suggest PCOS
        • If very high testosterone - androgen producing tumor?

     

    Types of Acne

    • Acne vulgaris - common type
    • Acne conglobata - Severe, nodular acne WITHOUT systemic symptoms.
      • Often on trunk in males.
    • Acne fulminans - Severe, explosive, inflammatory, and nodular acne WITH systemic symptoms (fever, arthralgias, myalgias, etc).  Usually on chest + back.
    • Acne mechanica - from repetitive rubbing (helmet strap, collars)
    • Acne cosmetica - from greasy occlusive products (vaseline on face)
    • Drug induced - (steroids, lithium, bromides/iodides, isoniazide, etc.)
    • Acne excoriee des jeunes filles - women, anxiety disorder
    • Occupational acne - petroleum-based products, coal, tar etc..
    • Chloracne - chlorinated aromatic hydrocarbons etc..
    • Neonatal acne - 20% newborns, possibly Malassezia sppˆ  yeast.  Appear 2 wks, clear by 3 mo
    • Infantile acne - present 3-6mo, usually hormonal problem
    • Hormonal acne - androgens (PCOS, CAH, Cushings, steroids)

     

    Treatment

    • See Acne Infographic on a detailed escription of treatments
    • Classify into:
      • Mild (20 comedones or <15 inflammatory papules).
      • Moderate  (15-50 papules & pustules with comedone, cysts rare, total lesion count 30-125).
      • Severe (Primary nodules and cysts.  Total lesion count >125, scarring).
    • Oily skin --> Use Solution or Gel
    • Dry skin --> Use Cream and Lotion
    • General Approach:
      • 1. First Line
        • General Measures:
          • D/C acnegenic moisturizes/substances.  Use oil-free makeup.
          • D/C manual lesion manipulation.  Avoid stress, scrubs.
          • Shaving: Shave lightly, only once & follow grain of hair growth.
          • Wash Face: Once daily, no more than BID with mild soap (Glycerin Bar, Petrophyllic, Pears, Dove & Olay)  or soapless cleanser (Cetaphil, Spectro Jel)
          • Discontinue drying agents.
          • Moisturizers - in dry seasons.
          • Sunlight: Evidence lacking.  Helps, but incr skin cancer.
          • Diet: Chocolate = MYTH.   Greasy foods = MYTH
        • Benzoyl Peroxide (BP) 2.5-5%
          • H2O-based gel (Panoxyl Aquagel) or 4% Solugel  (Better tolerated, less irritation)
          • Acetone or alcohol-based for oily skin.  (More irritation, but better for oily skin).
      • 2. Second Line
        • Papulopustular (inflammatory) +/- comedonal
          • Add topical ABX to BP (May need to lower BP strength to decr dryness). +/- retinoid
          • i.e. Cobo agents (Benzamycin, clindoxyl/Benzaclin) +/- retinoid OR Stievamycin (Mild 0.01%/Ery 4%, Regular 0.025%/Ery 4%, Forte 0.05%/Ery 4%).
          • To maintain step down to retinoid only.
        • If comedonal (white-blackheads, minimal inflammation):
          • Start topical retinoid (tretinoin 0.025-0.05% cheaper, but adapalene is less irritating). May add to BP. 
      • 3rd Line:
        • Women: OCP, Diane 35 {spironolactone may be alternative}. +/- topicals.
        • Systemic abx (Resistance concerns, pulse therapy may help)
          • I.e. Tetracycline, doxy, minocycline, erythromycin, trimethoprim, etc..
      • 4rth Line:
        • Isotretinoin (Accutane, Clarus)  --> avoid topicals with this, too much irritation/drying
    • Topical
      • Benzoyl peroxides (2.5-10%)
        • First line     
      • Azelaic Acid
      • Antibiotics: Erythromycin, clinda
      • Topical Retinoids.  
        • Available in Cream, gel, liquid forms
        • Oxidized by UV light and benzoyl peroxide - don't apply with benzoyl
        • Irritation is a common concern, so start with low doses.
        • No consensus on use in pregnancy.  Study in 1998: transdermal absorption below endogenous levels, but still not used in prengnacy due to fear.
    • Systemic (oral)
      • Antibiotics (tetracycline, minocycline etc..)
      • Hormonal:
        • OCP
        • Spironolactone (androgen blocker), watch hyperkalemia & pregnancy
        • Cyproterone acetate: androgen blocker
        • Flutamide: androgen blocker, hepatotoxic, monitor LFTs
      • Isotretinoin (Accutane)
        • Teratogenic - must be on OCP, and negative pregnancy tests.
    • Other Therapies
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