DIFFICULTIES IN TREATING ACNE

Acne vulgaris is a disorder of pilosebaceous unit characterized by the formation of comedones, papules, pustules, nodules and cysts.

It is the most common disorder encounter in day to day practice by dermatologists

Although generally considered to be a benign, self limiting condition, but it may sometime cause severe psychological upset or disfiguring scars

Treatment of Acne Good Responders 85-90% Poor Responders 10-15%

Poor response despite proper management

Genuine poor responders Patients with problematic side effects Patients with Acne variants and cystic

acne Patients with scars Miscellaneous

Poor responders To Antibiotics To Isotretinoin

Poor Responders

Antibiotics - Causes Resistant P. Acnes Gram (-) folliculitis Very high SebumExcretion Rate

P. Acnes Resistance

Prevalence of P. Acnes resistance on the skin of acne patients. 10 year surveillance date:

1991 34.5% to one or more used anti-acne antibiotics 1997 55.5% to one or more used anti-acne antibiotics 2000 64% to one or more used anti-acne antibiotics Coates P, Cunliffe W et al. Br J Derm. 146 (5): 840 (2002)

Main reason for increasedP. Acnes resistance

The extensive use of topical formulations of Erythromycin and Clindamycin

Eady E et al. Dermatology 206(1): 54 (2003)

P. Acnes Resistance

Erythromycin ……………………High Clindamycin .……………………High Tetracycline ……………………..Medium Doxycycline ……………………..Medium Trimethoprin …………………….Medium Resistance to Minocycline ……..Very rare Management: Isotretinoin – Minocycline

J. Ross, I. Snelling, A Katsambas et al. Br J Derm 148: 467—478 (2003)

Guidelines to avoid P.Acnesresistance

Limit antibiotics to shorter period Avoid concomitant use of oral and topical

dissimilar antibiotics (e.g. Tetra PO, Ery topical) Use topical retinoids to speed up improvement Avoid long-term antibiotics for maintenance If re-treatment is necessary, use the same

antibiotic (if it was effective)

Gollnick H., Cunliffe W et al. JAAD 49(1): Suppl. July 2003

Guidelines to avoid P.Acnesresistance

Topical antibiotics should not be used as monotherapy

Combine topical antibiotics with B.Peroxide Topical antibiotic therapy should be

discontinued once improvement is seen If no improvement with 6-8 weeks discontinue

Eady E.A. et al. Deramtology 206:54-56; 2003

Gram (-) Folliculitis

Sudden onset of many follicular pustules Sudden deterioration of acne Localised perioral &

perinasal location Management: Dicontinuation of

current antibiotics Isotretinoin (1mg/kg) Ampicilin (250mg qid)

Very high Sebum Excretion Rate

The excess of sebum dilute the antibiotic and produce lower and ineffective concentration of the antibiotic in the pilosebaceous unit.

Management: Double dose of antibiotic

(Minocycline 200mg/d)

(Doxycyclin 200mg/d) Isotretinoin Estrogen + Anti-androgens (Diannette)

Antibiotics Cause Management Resistant P. Acnes: Isotretinoin-Minocycline Gram (-) folliculitis : Isotretinoin - Ampicilin Very high Sebum Excretion Rate

Isotretinoin

Cypr. Acetate + Estrogens

Minocylcin 200mg/d

Doxycycline 200mg/d

Treatment of Acne : Poor respondersIsotretinoin

Patients with many macrocomedones –microcysts

Women with endocrine problems

- Polycystic Ovarian Syndrome Patients who have received total

cumulative dose less than 120mg/kgr

Patients with many macrocomedones –microcysts

Management: Gentle excision or cautery under topical anesthesia before isotretinoin treatment

Cunliffe W et al. Dermatology 206 (1) 11:6 (2003)

Isotretinoin: Women with endocrine problems

Management: Oral estrogens alone or with antiandrogens given together or after ISO treatment

Ethinylestradiol (EE) 35mg + Cyproterone Acetate (CPA) 2mg

EE 25mg + CPA 50mg EE + drospirenone Spironolactone 25-50 mg/d Prednisone 2.5-5 mg/d Indefinitely

Leyden J et al JAAD 47 (3) 399: 2002

Huber J and Waltz K. Contraception 73(1): 23-9; 2006

Patients who have received total cumulative dose less than 120mg/kg

Repeat the treatment with the proper dose

Patients with problematic side effects

Drug: Topical (Retinoids – Benzoyl Peroxide) Side effects: Irritant Dermatitis

Temporary exacerbation of acne Management: Inform patient about temporary nature of side effects Use on alternate evenings Use moisturizers and even hydrocortisone cream in the morning Use less irritant topical retinoid (Adapalene – tretinoin gel

microsphere)

Nighland M et al. Cutis 77(5): 313-6; 2006

Adapalene gel is equally effective and significantly better tolerated than tretinoin cream and tretinoin microsphere gel in the treatment of acne.

Katsambas A, Papakonstantinou C. Clinics in Derm. 22:439-444; 2004

Thiboutot DM et al. Arch Derm 142(5): 597-602; 2006

Drug: Minocycline Side effects: Management: Benign intra-cranial Lower dose

hypertension Change to Doxycycline (Dizziness – headache)

Hyperpigmentation Discontinuation

Change toDoxycycline

Katsambas A. et al. Clinics in Derm. 22:412-418; 2004

Drug: Isotretinoin Side effects: Management: Dermatitis&Cheilitis Moisturizers&HC

Cream Arthralgia &Myalgia Lower dose NSAID S. Aureous Boils Erythromycin Depression Discontinuation

Acne Variant

Acne conglobata Pyoderma faciale Acne Fulminans Cystic Acne

Acne conglobata

Most commonly in adult males with no or little systemic upset.

Lesions usually occur on the trunk and upper limbs and frequently extend to the buttocks.

facial lesions are not common. Long-term highdose antibiotics,

dapsone, ciclosporin and/or

colchicine in conjunction with

topical retinoids and antimicrobial therapy . Oral isotretinoin (1 mg/kg/day) for 4–6 months is the

treatment of choice.

Pyoderma faciale

Women 25-40 yr Sudden development of inflammatory pustules and nodules Management: Treatment with prednisolone

at 1 mg/kg/day, before Adding isotretinoin

0.2–0.5 mg/kg/day. The steroid was tapered

off over 2–3 weeks and the

isotretinoin continued for

3–4 months

Acne Fulminans

Severe truncal acne in males Fever and polyarthropathy Management: Oral prednisolone therapy should be commenced first line (0.5– 1.0 mg/kg/day) and decreased slowly over 2–3 months oral salicylates or NSAID Low-dose oral isotretinoin

(0.25–0.5 mg/kg/day)

should be cautiously introduced

after 3–4 weeks of steroids

and gradually increased as tolerated

, according to clinical response.

Cystic Acne

Giant whiteheads Extraction & light cautery

Inflammatory cysts Isotretinoin 1mg/d

TriamcinoloneAc.(I/L)

or

Liq. Nitrogen

(more than 3 week

duration)

Patients with Scars

Atrophic scar

Treatment:

1. Laser resurfacing

(CO2 – Er-Yag)

2. Chemical Peel

3. Dermabrasion

4. Excision of the scar

5. Injection of fillers

Keloid Scars Treatment:

1. Potent topical steroids

2. Triamcinolone AC injections

3. Liq. Nitrogen + Triamcinolone Ac injections

Hyperpigmented Acne scars

Management:

a. Prevention

b. Treatment Prevention of Hyperpigmented scars : Initiation of the proper treatment as soon as possible

in order to minimize the risk of inflammation and the subsequent hyperpigmentation.

Photo-protection, especially during the periods of treatment when inflammation exists

Minimization of the inflammation caused by potent anti-acne drugs.

Treatment of hyperpigmented scars Topical Retinoids Hydroquinone Kojic Acid Azelaic Acid Chemical peels Lasers

Miscellaneous

Acne Excoriee Over expectant patients (Over-concerned

about Appearance) Dysmorphobic patients (Over-complaining

about a few spots)

FINAL REMARK

All acne cases can be adequately controlled if the relationship between doctor and patient has been built on trust and confidence

THANKS