acne

Dr. M. Goeteyn Dermatologie

AZ Sint-Jan Brugge-Oostende AV marleen.goeteyn@azsintjan.be

Why should you treat acne?

-Impact on the quality of life -scarring

What is acne?

Acne is an inflammatory disease of the pilosebaceous unit.

Primum movens: increased androgen production Abnormal proliferation and desquamation of epithelium of the acroinfundibulum Obstruction of the follicle Formation of a microcomedo(precursor)

Pathophysiology of acne

Activated sebaceous gland

Androgen driven activation of the sebaceous gland Obstructed follicles fill with lipid reach material Formation of comedones

Pathophysiology of acne

Sebum = substrate proliferation of P. acnes P. acnes = anaerobic bacterium (normal skin flora) P. acnes→chemical mediators→ Inflammation Traumatic rupture of comedones in surrounding dermis→ more inflammation

Pathophysiology of acne

Pathophysiology of acne

• Androgen driven abnormal keratinocytic proliferation and desquamation -> ductal obstruction

• Androgen driven increase in sebum production

• Proliferation of Propionibacterium acnes

• Inflammation

Acne in childhood

• Neonatal acne

• Infantile acne

• Mid-childhood acne

• Preadolescent acne

What is neonatal acne vulgaris?

- neonatal acne ≠ neonate with pustules - rare condition - acne triad - physiological raise in LH, testosterone - activation of the sebaceous glands -> comedo - > boys until 6 months of age

Neonatal cephalic pustulosis

-Little pustules - mainly cheeks, chin, forehead - colonisation Malassezia furfur - ketoconazole 2% cream

Neonatal sebaceous gland hyperplasia

- common - nose and cheek - term infants - multiple 1 à 2 mm yellow papules - maternal or endogenous androgenic stimulation of sebaceous gland - disappear spontaneously in 4-6 months

Infantile acne

-acne between 6 weeks and 16 months - androgen driven activation of sebaceous glands - usually boys - comedones, papules, pustules, nodules and cysts - scarring possible - more severe acne in puberty - mostly no associated endocrinological disease BUT -always assess growth, height and weight - look for signs of pubertas praecox - if clinical examination is abnormal start hormonal and endocrinological workup

Mid-childhood acne

-acne between 16 months and 7 years - no significant levels of adrenal and gonadal hormones - always workup by an endocrinologist

Childhood rosacea

• Rare condition

• Erythema, papules and pustules in the face

• Ocular involvement

Idiopathic facial aseptic granuloma

• Rare

• Chronic painless red to blue red mostly soft, elastic nodule in the centre of the face

• No inflammation

• Mostly solitary

• Chronic inflammatory granuloma with lymfocytes,histiocytes, neutrophils and foreign body giant cells

• Pathogenesis? Inflammatory reaction on an embryonic rest or epidermoid cysts granulomatous rosacea

• Spontaneous resolution

• Metronidazole per os

• excision

Preadolescent acne

-between 7 an 12 years

- normal onset of puberty

- comedones - few inflammatory lesions - forehead, centrofacial - comedones in the ears

- further workup unnecessary

The principles of acne treatment

• Morphology

• Severity

• Milder cases → topical treatment

• More severe cases → systemic treatment

• Target the precusor lesion (microcomedo)

• Treat the active inflammatory lesions

Treatment of acne

Topical treatment

• Retinoids

• Benzoyl peroxide

• Topical antibiotics

• Azelaic acid

• Combination products

Systemic treatment

• Antibiotics

• Isotretinoin

• Hormonal therapy

Retinoids

Mode of action

• Vitamine A derivates

• Normalisation of keratinocyte desquamation and adhesion

• Comedolysis

• Prevention of microcomedones

Available products

• Adapalene Differin®

• Tretinoin 0.05% in hydrophilic cream

Benzoyl peroxide

Mode of action

• Bactericidal

• Weakly comedolytic

• Acts on inflammatory lesions

• Prevents the development of antibiotic resistance

• Bleaching effect

Available products

• Benzac®

• Pangel®

• Pharmaceuticaly compounded

Topical antibiotics

Mode of action

• Bacteriostatic

• Anti- inflammatory

• Antibiotic resistance

Available product

• Clindamycin - Dalacin®

- Zindaclin® - pharmaceuticly compounded

• Eryrthromycin - Erycine®

- Inderm® - Zineryt® (+ zinc ) - pharmaceuticly compounded

Azelaic acid

Mode of action

• Comedolytic

• Antimicrobial

• Anti-inflammatory

• < effective than retinoids

• > tolerated

• Skinoren®

Topical combination products

Available combination products

• Benzoyl peroxide + adapalene

• Benzoyl peroxide + erythromycin

• Benzoyl peroxide + miconazol

• Tretinoin + clindamycin

on the Belgian market

• Epiduo®

• Benzadermine®

• Acneplus®

• Treclinax®

Hormonal therapies

• combined oral anticonceptives suppress ovarian androgen production

• Androgen receptor blockers (cyproteron acetate)

• Decrease androgen mediated effects on the sebaceous gland

Systemic antibiotics

• Doxycycline, minocycline, lymecycline,tetracycline, erythromycin

• Lack of comparative data on the efficacy of the different antibiotics

• None of the tetracyclines can be used in children < 8 à 12 y

• Choice driven by side effect profiles

• Doxycycline : photosensitivity

• Minocycline: rare cases of drug induced systemic LE rare cases of DRESS and serum sickness rare cases of skin hyperpigmentation

• tetracycline and erythromycin: increased resistance of P.acnes

Antibiotic resistance

• P. acnes more resistant to erythromycin and clindamycin

• Efficacy of treatment is less when resistant strains are present

• Doxycycline and minocycline: mic of P.acnes ↗

• Staphylocci and Streptococci may also develop resistance

Preventing antibiotic restistance

• Avoid antibiotic monotherapy

• Avoid antibiotic maintenance therapy

• Use combination with retinoids to enhance treatment efficacy

• Use combination with benzoyl peroxide (bactericidal properties)

• Limit antibiotic treatment duration to 3 à 4 months

• Avoid combination of an oral and a topical antibiotic

Isotretinoin

• Optimal dose: between 0.3 and 0.5 mg/kg/d (max 1 mg/kg/d)

• The treatment duration varies between 4 and 6 months.

• Monotherapy

• Isotretinoin can be used in young children for severe acne*

• Only in severe forms: total cumulative dose of 120 -150 mg/kg

• Effects are usually not seen before one to two months

• Half of the patients are permanently cured after one course

• Highly teratogenic: neg pregnancy test and reliable anticonception

• Most reported side effects: dry skin and mucosae, epistaxis, myalgias

• Transient alterations in serum lipids and transaminase concentrations *Iben M.M et al: Infantile Acne Treated with Oral Isotretinoin. Ped Dermatol sept/oct 2013 vol 30 nr 5

Treatment recommendations for mild pediatric acne*

• Initial treatment BP OR Topical retinoid OR Topical combination therapy BP + antibiotic OR Retinoid + BP OR Retinoid + antibiotic + BP

*adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:S163-86

If inadequate response Add BP or retinoid, if not already prescribed OR Change topical retinoid concentration, type, and/or formulation OR Change topical combination therapy

Treatment recommendations for moderate pediatric acne*

• Initial treatment

Topical combination therapy: Retinoid + BP OR Retinoid + (BP + Antibiotic) OR (Retinoid + Antibiotic) + BP OR Oral antibiotic + Topical retinoid + BP

* adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:S163-86

• If inadequate response

Change topical retinoid concentration, type, and/or formulation AND/OR Change topical combination therapy AND/ OR Add or change oral antibiotic Consider hormonal therapy for female patients OR Consider oral isotretinoin

Treatment recommendations for severe pediatric acne*

• Initial treatment

Combination therapy Oral antibiotic + Topical retinoid + BP

* adapted from Eigenfield LF, Krakowski AC, Pigott C et al. Evidence-based

recommendations for the diagnosis and treatment of pediatric acne. Pediatrics.2013 May suppl3:S163-86

• If inadequate response

Consider changing oral antibiotic

AND Consider oral isotretinoin Consider hormonal therapy for female patients