Acne Vulgaris and

Rosacea

Dr. Lyn Guenther

University of Western Ontario

Objectives

• State the incidence of acne • Discuss the psychosocial impact of acne & scarring • Discuss the pathophysiology of acne • Differentiate acne vulgaris from rosacea • Elicit a history and perform a relevant examination • Give an approach to acne and rosacea treatment from mild to severe

Acne vulgaris

• Incidence: 95%

• Scarring - In 95% seeing a dermatologist for the first

time

- Increased with: • Squeezing

• Inflammatory lesions

• Longer disease duration

Psychological Scarring

• QOL studies: - Social, psychological & emotional deficits

comparable to: • Asthma

• Epilepsy

• Diabetes Mellitus

• Back Pain

• Arthritis

Pilosebaceous Unit

• Sebaceous Gland

• Sebum

• Follicle

• Arrector Pili Muscle

900 glands/cm2 on face, back, chest <100 glands/cm2 on rest of body

Pathogenesis of Acne

• Abnormal Keratinization (genes)

• Androgens cause increased sebum production

• Propionibacterium acnes

• Inflammation

Acne Vulgaris Pathophysiology

Microcomedones Accumulation of Sebum

Closed/Open Comedones(non-inflammatory acne)

Proliferation of P. acnes Infiltration of neutrophils

Ruptured comedones

Papules, Pustules, Cysts (inflammatory acne)

Acne vulgaris - History

• Age of onset • Family history of acne • Location and severity of lesions • Scarring • Psychosocial impact • Menses/Contraceptive use • Moisturizer and foundation • Medications & Drug Allergies • Current and Past treatment including response and A/E’s

Physical Examination:

Scarring and Pigmentary Changes Scarring: depressed / ice pick / saucer / keloid

Excoriations Hyper / hypo-pigmentation

Lesion Morphology

Non-inflammatory Comedonal

Inflammatory Papules / pustules

Nodules / cysts

Acne Lesions

Comedones Papules & Pustules Cysts

Acne vulgaris - Why treat?

• Improve appearance • Minimize scarring • Eliminate discomfort of inflammatory lesions • Reduce psychological consequences

Acne vulgaris - Dispel myths

• Acne is NOT caused by: - Chocolate

- Fried or fatty food

- Too much or too little sex

- Dirt

- Wrong kind of soap

• Not contagious

Acne vulgaris - Aggravating Factors

• Stress

• Lack of sleep

• Tight headbands/helmets

• Grease-filled environments

• Heavy makeup while exercising

• Premenstrual in some

Acne vulgaris - Cleansing

• Wash BID

• Lukewarm water

• Mild cleanser

• No abrasives

• No scrubbing

• Don’t squeeze

Acne vulgaris Moisturizers and Foundation

• Non-comedogenic

• Non-acnegenic

Treatment Guidelines

Non-scarring acne

* Comedones: Retinoid * Tretinoin cream .01-.05% daily or * Tazarotene cream/gel or * Differin cream/gel

* Papules/Pustules * Topical antibiotic B.I.D. * Benzoyl peroxide 5% daily * Antibiotic/benzoyl peroxide * Oral antibiotics * Hormonal agents for women

desiring oral contraception

ANTIBIOTIC DOSE Tetracyclines

Tetracycline 500 mg B.I.D.

Minocycline 100 mg/day

Doxycycline 100 mg/day

Erythromycin 500 mg B.I.D.

Trimethoprim 100 - 200 mg/day

NOTES

*Avoid in pregnancy or children < 8 years *Take on empty stomach *G.I. irritation *May be taken with food *Dizziness may develop at higher dos es *Pigmentary changes *May be taken with food *Phototoxicity a potential problem *Safe in pregnancy and for children *May caus e G.I. Ups et *Useful in those resistant to other antibiotics

Hormonal Therapies for Acne

Diane-35® cyproterone acetate/ ethinyl estradiol

Ortho -Tricyclen® norgestimate/ ethinyl estradiol

Alesse® levonorgestral/ ethinyl estradiol

Yasmin ® drospirenone-ethinyl estradiol

Treatment Guidelines

Severe or

Scarring acne

Isotretinoin:

* 0.5mg/kg/day for the first 2-4 weeks

* 1 mg/kg /day for the next 4-5 months to a total cumulative dose of 120-150 mg/kg * 80% have long-term drug free remission

* 20% require a second course

* patients unable to take isotretinoin should be given topical therapy combined with systemic antibiotics or hormonal agents

Isotretinoin

Sebaceous follicles

• Decreases sebum production within 2 weeks

• Corrects follicular hyperkeratinization

• Decreases growth of P. acnes • Decreases inflammation

Pre-Accutane On Accutane

Isotretinoin Contraindication:

Absolute: • Pregnancy (see Pregnancy Prevention Program™)

Relative:

• History of pre-morbid depression

• History of hypertriglyceridemia/ hypercholesterolemia

• Pre-existing liver disease

Accutane use and pregnancy

• Isotretinoin is a potent teratogen - >25% risk of fetal malformation.

• Reported pregnancy rate on Accutane<1%

- Average age: 26 years.

• Reasons for these pregnancies: - abstinence unsuccessful

- use of ineffective method of contraception

- contraceptive used inconsistently

- unexpected sexual activity

- failure of contraceptive method

Pregnancy Prevention Program™

• Two negative pregnancy tests required before starting Accutane

- Initial visit & day 2-3 of next period

• Two effective forms of birth control

- one primary and one secondary

• Begin therapy on 2nd or 3rd day of next menses

Pregnancy Prevention Program™

• One month prescription only

• Monthly pregnancy testing

• Monthly contraceptive counseling

• Initial Consent form

• Patient Information booklet

Effective Forms of Contraception

Primary

• Tubal ligation

• Partner’s vasectomy

• Birth control pills

• Injectable/implanted hormones

• IUD

Secondary

• Diaphragms with spermicide

• Latex condoms with spermicide

• Cervical caps with spermicide

Isotretinoin Adverse Events

• Cheilitis 96%

• Dermatitis 55%

• Dry nose 51%

• Eye irritation 11%

• Joint pain 13%

• Depression rare

• Elevated TG (25%) & cholesterol (7%)

• Elevated liver enzymes (15%)

Isotretinoin and Psychiatric Events

Depression Suicide/attempt

Isotretinoin Use

(1982-2000)

USA General Pop’n

(CDC 1980-92)

10-13 per 100,000 patients

20,000 per 100,000 patients

1-1.7 per 100,000 patients

20 per

100,000 patients

Isotretinoin

Mucutaneous adverse events: • Chapstick • Lubricants

Lab monitoring: • CBC, liver function and fasting lipids

• Pregnancy test

Case studies

Case 1

• Washes with apricot scrub

• Has tried numerous other cleansers

• Has stopped eating chocolate

• No other treatment

• Case 2

• Won’t socialize • Regular menses • Not sexually active • No prior treatment

Case 3

• Oily skin

• Seborrheic dermatitis

• Plucks facial hair

• Irregular menses

• Proactive-No help

Case 4

• Acne lesions hurt

• Tetracycline 500 mg BID for 6 months, then

• Minocycline 100 mg BID for 8 months

• Differin gel x14 months

Rosacea

• ~10% of Canadians affected

• Women: Men=2:1, but men more prone to rhinophyma

• Celtic descent - Uncommon in Africans & Asians

• Onset usually after age 30 - Peak: 4th to 7th decade

- Rarely in children

Konshik PC et al. Dermatol Clin 1992;10(3):533-47

Rosacea Pathophysiology • Genetic

• Abnormalities of cutaneous vasculature - Dysregulation of thermal mechanisms

• Dermal matrix degeneration - Poor connective tissue support for cutaneous vessels

• Infectious organisms - Demodex

- Helicobacter pylori

• Excess of canthelicidins and protease stratum corneum tryptic enzyme (STCE) in facial skin

Yamaski K et al. Nat Med 2007;13:975-80

Rosacea Pathophysiology

• Murine model: - Injection of cathelicidins found in rosacea or addition of SCTE → skin inflammation - Deletion of the serine protease inhibitor gene Spink5 →

protease activity → skin inflammation - TCN + Minocycline indirectly inhibit serine proteases and work even in the face of bacterial resistance Hypothesis: Increase in local antimicrobial peptide expression may change the normal skin microflora in

rosacea

Yamaski K et al. Nat Med 2007;13:975-80

Rosacea affects QOL

• Recent Canadian Survey (n=1271): - Social life affected in 36%

• 16% of all respondents declined a social invitation due to rosacea symptoms

• Lower self esteem

• Affects professional interactions

Rosacea: Skin changes

• Symmetric over convexities of central face - nose, cheeks, chin, central

forehead • Occ. on neck, scalp, chest • Very rarely on back and limbs

Rosacea: Skin changes

• Primary features: - Flushing:

• Usually lasts > 10 minutes • Sparing of periocular skin • Often assoc. with burning, stinging

- Persistent Erythema - Telangiectasia - Papules, pustules (follicular and non-

follicular) ……..NO COMEDONES

Rosacea: Skin changes

• Secondary features: - Burning or stinging - Lowered threshold for irritation from topical substances - Plaques - Dry appearance - Edema (e.g. periorbital, glabellar, malar)

• Acute, chronic recurrent, chronic persistent • Pitting or non-pitting

- Ocular - Peripheral location (neck, chest, scalp, ears, back)

Subtypes of Rosacea

1. Erythematotelangiectatic

2. Papulopustular

3. Phymatous

4. Ocular

Phymatous Variant

• Men • Erythematous, irregularly swollen, bulbous, dilated pores, telangiectasia

- Rhinophyma (nose) - Metophyma (forehead) - Gnathophyma (chin) - Blepharophyma (eyelids) - Otophyma (ears)

Aloi F et al. JAAD 2000;42:468-72

Rosacea-Ocular

• 50% of patients• 6th-7th decade (later than skin)

• Women=Men • Onset with skin:2

- 53% skin first - 20% eyes first - 27% together

• Strong correlation with flushing3

1. Barankin B, Guenther L. Can Fam Physician. 2002;48:721-4. 2. Borrie P. Br J Ophthalmol 1953:65:458. 3. Wilkin JK. Int J Dermatol 1983;22:393-400.

Rosacea-Ocular

• Dry, gritty eyes, itching, burning, tearing, blurry vision, photophobia

• Blepharitis (93%), conjunctival hyperemia (86%), conjunctivitis, keratitis, superficial punctate keratopathy (41%), keratoconjunctivitis sicca (up to 40%)

corneal vascularization ulceration and perforation, iritis (20%), chalazion (22%)

• ~ 60% of patients with chalasion have rosacea

Barankin B, Guenther L. Can Fam Physician. 2002;48:721-4.

Rosacea Triggers

• Food: - Hot food - Spicy food - Tomatoes - Chocolate - Yogurt, sour cream,cheese

• Alcohol • Hot and cold temperatures • Wind • Exercise • Stress

Rosacea Triggers

• Drugs:1

- Corticosteroids

- Amiodarone • Rosacea + multiple chalazia2

- Epidermal growth factor receptor inhibitors

- High dose vitamin B6 and B12

1. Crawford GH et al. JAAD 2004;51:327-412. Reifler DM et al. Am J Ophthalmol 1987;103:594-5

Rosacea Treatment

• Avoid triggers • Flushing:

- Clonidine 0.05 mg OD→BID - Green moisturizers

• Telangiectasia - Vascular lasers (e.g. pulsed dye, KTP, 532 and 810 light-emitting diode (LED), Alexandrite, Nd-TAG, IPL

alone or with PDT)

Rosacea Treatment: Topical

• Mild cleansers • Sunscreen: titanium dioxide & zinc oxide well tolerated

• Topical - Metronidazole - Azelaic acid 15% (Finacea) - Sodium sulfacetamide 10%/sulfur 5% - Clindamycin - Dapsone - Pimecrolimus/Tacrolimus - +/- BP, VAA (phymatous rosacea; may irritate)

• Eye: - Warm soaks, dilute baby shampoo - Topical steroids (ophthalmologist) - Artificial tears:

Rosacea Treatment: Oral

• Oral antibiotics (skin + eye) - Tetracyclines:

• Tetracycline • Minocycline • Doxycycline

- Others: • Erythromycin • Clarithromycin • Azithrmycin • Metronidazole • Dapsone

• Isotretinoin (skin including phymas + eye)

Rosacea Treatment: Rhynophyma

• Medical: Isotretinoin

• Surgical: - Ablative lasers

- Shave excision

- Cryosurgery

- Electrosurgical loops to shave off excessive

tissue, then fine tune with dermabrasion

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