acne dr. jerald e. hurdle kennebec medical consultants
TRANSCRIPT
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Acne
Dr. Jerald E. Hurdle
Kennebec Medical Consultants
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Learning Objectives
To manage the patient with acne vulgaris,
To review the clinical presentation and management of Acne Rosacea, and
To recognize acneiform rashes & folliculitis.
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Case Study 1
• 28 yr old ♀
• Always had dandruff
• Using over the counter cream for facial rash
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Attends Primary Care
• PCP prescribes 2.5% HC Cream
• Initially improves then returns
• PCP stops HC and rash gets much worse
• Pt demands referral to dermatology
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Diagnosis: peri-oral dermatitis
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Acne Vulgaris
• Common
• Puberty onwards
• Disease of pilosebaceous unit
• Gets better with time
Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo
(whitehead); (D) papule; (E) pustule.
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Acne Vulgaris: pathogenesis
4 factors• Presence of hormones (androgens)
• Sebaceous gland activity (due to #1)
• P. acnes (bacteria) in the hair follicle (it lives on the oil and breaks it down to free fatty acids which cause inflammation)
• Plugging of the hair follicle (abnormal keratinization of the upper portion)
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Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
Mild Moderate Severe
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Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
Papules & Pustules
Nodules & Cysts
OpenComedones
ClosedComedones
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Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
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Acne Vulgaris: Rx
Patient Education • Diet
• Cleanliness
• Cosmetics
• Picking
• UV light
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Acne Vulgaris: Rx
Patient EducationTreatment Response & Time
Course
• Prognosis excellent
• All treatments take up to 3 months to see improvement
• No one ever becomes zit free for the rest of their life
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Gel, wash or cream• 5-10%• 1-2 x daily
Side effects: redness, dryness & bleaching
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Tretinoin (Retin-A)
0.025- 0.1% • 1 x Daily @ night
Adapalene (Differin)
0.1% gel or cream
1-2 x daily
SEs: dryness, redness & sun sensitivity
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Tretinoin (Retin-A)
0.025- 0.1% • 1 x Daily @ night
Adapalene (Differin)
0.1% gel or cream
1-2 x daily
SEs: dryness, redness & sun sensitivity
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
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Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Clindamycin
1% Gel, lotion & solution
2x Daily
Erythromycin
2% gel or sol, 2x daily
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
Minocycline• 50-100mg 1-2x daily• Hyperpigmentation
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
Minocycline• 50-100mg 1-2x daily• Hyperpigmentation
Doxycycline• 50-100mg 1-2x daily• Photosensitivity
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Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
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Acne Vulgaris: Rx Severe Disease
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Acne Vulgaris: Rx Severe Disease
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Isotretinoin• Refer to Dermatology• Women of childbearing potential need
adequate contraception• Check LFTS & fasting lipids• I-Pledge process bureaucratic: warn patient• Likely to require 6 months of Rx• Dry skin, cracked lips : inevitable side effects
Acne Vulgaris: Rx Severe Disease
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Photography
Useful for treatment monitoring
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Acne Variants: acne excoriee
• Predominantly in young women
• Comedones & papules excoriated +++
• Often underlying psych component (anxiety, OCD or personality disorder)
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Acne Variants: peri-oral dermatitis
• Commoner in women• Eczematous patches
and papules around mouth
• Occasionally around eyes
• Exacerbated by topical steroids
• Treat as acne vulgaris & stop steroids
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Case 2
• 33-year-old female complains of red cheeks
• Homeless, chronic alcoholic
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Case 2: Physical Exam
• Red Cheeks
• Papules and pustules on the central face and nose
• NO Comedones
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Case 2: Diagnosis?
• A. Systemic Lupus Erythematosus
• B. Bacterial Folliculitis with cellulitis
• C. Acne Rosacea
• D. Pellagra from nutritional deficiency
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Case 2: Diagnosis?
• A. Systemic Lupus Erythematosus (no pustules)
• B. Bacterial Folliculitis with cellulitis(acute and systemic symptoms)
• C. Acne Rosacea
• D. Pellagra from nutritional deficiency (scale, diarrhea, but no pustules)
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Case 2: Acne Rosacea
• Chronic inflammatory condition of the “flush” areas of the face (nose, cheeks > brow, chin)
• F > M
• Middle age (30-50)
• Affected persons blush easily
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Case 2: Question 2
• Which of the following might trigger this patient’s rosacea? A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above
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Case 2: Question 2
• Which of the following might trigger this patient’s rosacea?
A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above
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Acne Rosacea: triggers
• Alcohol
• Sunlight
• Hot Beverages (heat)
• Hot, Spicy food
• If it makes you flush it can flare rosacea
• Rosacea is NOT related to androgens!!
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Acne Rosacea: clinical features
• Erythema and Telangiectasias
• Papules and Pustules (NO COMEDONES!)
• Rhinophyma (W.C. Fields nose)
• Ocular Rosacea (keratitis, blepharitis, conjunctivitis)
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Acne Rosacea
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Acne Rosacea
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Acne Rosacea
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Acne Rosacea
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Acne Rosacea
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Acne Rosacea Treatment
• Medical treatment only effective for the papular and pustular component
• Topical Antibiotics (metronidazole)
• Topical Sulfur
• Oral Antibiotics (tetracyclines)
• Therapy is suppressive and may be required lifelong
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Acne Rosacea: Surgical Treatment
• Laser therapy can help the telangiectasias and the rhinophyma, once the papulopustular component is controlled.
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Steroid Rosacea
• Topical Steroids may exacerbate or induce an acneiform eruption resembling rosacea
• Treatment: Stop the topical steroids; give oral tetracyclines.
• Never treat central facial papular eruptions with topical steroids. It may be rosacea which will flare severely when the topical steroids are stopped
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Case 3
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Acneiform Eruptions: Drugs
• Systemic/topical steroids
• Anabolic steroids
• Lithium
• Phenytoin (Dilantin®)
• Epidermal growth factor receptor inhibitors
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Acneiform Eruptions: Acne Keloidalis Nuchae & Pseudofolliculitis Barbae
• Predominantly affects men of African descent
• Due to ingrowing hairs
• Avoid shaving
• Treat as acne
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Folliculitis
• Confined to hair follicles• No comedones• Lesions tend to
monomorphic• Often itchy• Common causes Staph,
Pityriasporum
• If HIV positive, consider eosinophilic folliculitis
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Learning Objectives
To manage the patient with acne vulgaris,
To review the clinical presentation and management of Acne Rosacea, and
To recognize acneiform rashes & folliculitis.