Table of contents
- 1. Intro
- 2. History/Physical
- 3. Types of Acne
- 4. Treatment
Intro
- Problem with the pilosebaceous unit
- Types of lesions:
- Non-inflammatory Lesions
- Comedones
- Open Comedones (black heads)
- Closed Comedones (white heads)
- Comedones
- Inflammatory lesions
- Papules, pustules, nodules
- Acne scars:
- Ice pick, boxcar scars
- Non-inflammatory Lesions
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?
- If Hormonal suspected: free/total testosterone, DHEAS, prolactin, LH/FSH, am cortisol
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).
- General Measures:
- 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.
- Papulopustular (inflammatory) +/- comedonal
- 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
- 1. First Line
- 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.
- Benzoyl peroxides (2.5-10%)
- 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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