Acne

Acne

Bill V. Way, D.O.

Dermatology Residency

Program Director

What is Acne? Acne is a skin disorder resulting from

the action of hormones on the skin’s oil glands (sebaceous glands) which leads to plugged pores and outbreaks of the lesions of papules, pustules, comedones, inflammatory cysts commonly called pimples or zits.

Acne

Over 17 million people in the US have acne today. It is the most common skin disease.

Not a serious health threat, but severe acne can lead to disfiguring, permanent scarring, low self esteem.

Acne

The disease of the pilosebaceous units of the skin.

Most commonly on the face, neck, chest, back and shoulders were more of the pilosebaceous units are located.

Acne

The basic acne lesion is called the comedo (KOM-e-do), simply an enlarged and plugged hair follicle.

If it remains below the surface it is called a closed comedo and produces a whitish bump called a whitehead, this is not a milium.

Acne: Comedo

If the comedo reaches the surface, it is called an open comedo or blackhead

The black color is not dirt, but is from the oil oxidizing when it reaches the surface of the skin

Acne: Papule

Inflammed lesions that usually appear as small pink bumps on the skin and may be tender to the touch

Acne: Pustule

Inflammed papules with a pustule on the top that may be red at the base and usually tender. (Pimple)

Acne: Nodules

Large, painful, solid lesions that are lodged deep within the skin

Acne: Cysts

Deep,painful, pus-filled lesions that can cause scarring

What causes Acne?

Exact cause of acne is unknown. Several factors may play a role.

One important factor is an increase in androgens (male hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.

What causes Acne?

Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing

Hormone changes related to pregnancy or starting and stopping birth control pills can also be a cause of acne.

What causes Acne?

Propionibacterium acnes (P.acnes) are the anaerobic bacteria responsible for causing acne.

Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing

Hormone changes related to pregnancy or starting or stopping birth control pills can also be a cause of acne.

Propionibacterium acnes

Anaerobic bacteria in hair follicle. These bacteria use the sebum as food and

break the sebum down into irritating substances, which cause inflammation.

The abnormal flaking of the cells inside the hair follicle and the irritating substances lead to a plug formation and the to follicle swelling and then rupturing and developing into the papule then to the pustule.

What can make Acne worse?

Changing hormone levels in adolescent girls and adult women 2-7 days before their menstrual period starts

Friction by leaning or rubbing skin Pressure from helmets, backpacks Environment: pollution and high humidity Squeezing or picking at pimples Hard scrubbing of the skin

Myths about causes of Acne

Foods; chocolate, greasy or fried foods. No foods cause acne.

Dirt. Acne is not the result of uncleanliness or infrequent washing.

Stress. Just the opposite, Acne may cause the patient more stress.

Sunlight or tanning clears acne. No tanning will lead to sundamaged skin, wrinkles and skin cancers.

Skin must be scrubbed. No, too much scrubbing may actually make acne worse.

Who gets Acne?

People of all races and ages. Most common in adolescents and

young adults 85% between ages 12-25 Resolves with time around age 25-30 Few patients may have persistent acne

into their 40’s and 50’s

Who should be treating Acne?

Family Practice Pediatrics Internal Medicine Dermatology

What are the goals in treating Acne? Heal existing lesions Stop new lesions from forming Prevent scarring Minimize the psychological stress and

embarrassment, thus improving self-esteem and self-confidence and avoiding depression

Teach the patient what acne is, how to treat their acne and what to expect from treatment

Acne Treatment

Medical treatment is aimed at reducing several problems that play a role in causing acne; abnormal clumping of cells in the follicles, increased oil production, bacteria and inflammation.

Grading Acne

Scale 0-4 0 – no acne, clear +1– mild acne, comedos, papules, few

pustules +2 – moderate acne, comedos, multiple

papules and pustules +3 – moderately severe, multiple comedos,

papules and pustules, mild scarring +4 – severe, multiple comedos, papules,

pustules, inflammatory cysts, nodules, scarring

Treatment for Blackheads, Whiteheads and mild inflammatory Acne OTC or Rx Benzoyl peroxide, resorcinol, salicyclic

acid and sulfur Benzoyl peroxide products kill P.acnes

and may reduce oil production Resorcinol and salicyclic acid and sulfur

help break down blackheads and whiteheads

OTC Treatment

Benzoyl peroxide washes and gel Salicyclic Acid washes Must be used twice daily regularly for 8-

12 weeks, then reevaluate

Treatment of Moderate to Severe Inflammatory Acne Prescription topical and or oral

medications alone or in combination Recheck patient every 4-8 weeks for

results and to adjust acne treatment program

Treatment of Severe Nodular or Cystic Acne Should be seen and treated by a

dermatologist Failure to respond to a variety of topical

antibiotics, topical retenoids and oral antibiotics

Consider Accutane Therapy

OTC Topical Acne Cleansers

Neutrogena Acne Wash Cetaphil Facial Cleanser Oil of Olay Facial Cleanser Various Benzoyl Peroxide Cleansers,

Clearsil, Clean and Clear, others

Acne Treatment

Clean skin gently Avoid squeezing, pinching, picking or

scratching the acne lesions. Bleeding leads to scarring Shave carefully Avoid sunburn or suntan Choose cosmetics carefully, oil-free,

water based

OTC Acne Topicals

Benzoyl peroxide cleansers Sulfur products Salicyclic acid pads

Prescription Acne CleansersBenzoyl Peroxide Brevoxyl 4%, 8% Triaz 3%, 6%, 10% Benzac 5%, 10%

Prescription Cleanser

Plexion Cleanser: Sodium Sulfacetamide 10% & Sulfur 5%

Topical Antibiotics

Clindamycin: Solution,Gel, Lotion, Pads Erythromycin:Solution,Gel,Pads,

Ointment Combination: Benzoyl peroxide and

topical antibiotic Sodium Sulfacetamide and Sulfur

Topical Antibiotics

Cleocin T Solution, Lotion, Gel, Pads Erycette Pads Benzamycin Gel BenzaClin Gel Klaron Lotion Plexion SCT

Topical Retenoids

Retin A: gel, cream, microgel Differin: gel, cream, pad Generic Tretinoin: gel, cream

Retin A Microgel

0.04% and 0.1% 20gm and 45gm Apply at hs Recommend sunscreens in am

Oral Antibiotics

Tetracycline Minocycline Doxycycline Erythromycin Azithromycin

Oral Tetracycline

Generic Tetracycline is ok Must be taken correctly, 1 hour before

meal or 2 hours after meal with glass of water

Not to taken with milk Increased change of inducing vaginal

yeast infections

Oral Minocycline

Dynacin, Minocin, Adoxa, Generic Better absorption, less GI upset May be taken with food, minimal loss of

effect 1-2 times daily Avoid 100mg bid for it may induce a

blue gray hyperpigmentation in areas of cysts, bleeding or brusing

Oral Minocycline

Increased cost Very effective May be used long term

Oral Doxycycline

Doryx, Generic Good absorption, less GI upset May be taken with food, minimal loss 1-2 times daily Occasional photosensitivity, rare Increased cost, very effective, may be

used long term

Oral Erythromycin

Eryc 250mg 1 bid Effective for short times, then bacterial

resistance starts to develop Low cost, increased GI upset May have other drug interactions

Oral Azithromycin

Recommend use only by dermatologist due cost

Accutane (Isotrenoin)

10mg, 20mg, 40mg Used by itself Patients must be enrolled into the

SMART Program and rules and regulations must be followed exactly

Recommend patient be referred to dermatologist

Accutane (Isotretinoin)

Very effective Useful to help prevent scarring 15-20 weeks of therapy SMART Program Expensive Patient must be monitored very closely No other acne treatment needed

Accutane: Disadvantages

Can cause birth defects Female patients must not get pregnant

while on Accutane Depression, Irritability Loss of appetite, hair thinning, curling Dry eyes, mouth, lips, nose and skin,

itching, nosebleeds, muscle aches, sensitivity to sun, poor night vision

Accutane: Disadvantages

Changes in blood such as increase in triglycerides and choesterol or a change in liver function

Must monitor blood prior to starting and every 4 weeks while on Accutane

CBC, CMP, Lipid Panel, UA, Urine pregnancy test

Adjunct Derm Treatment

Acne Surgery Mild Chemical Peels Microdermabrasion New ClearLight treatment Dermabrasion or Laser tx for scarring Surgical scar revision Fillers for scars, fat transfer Intralesional steroid injections

How often should the Acne Patient be seen? Initially every 4-8 weeks Then every 8-12 weeks Then every 3-4 months Acne is monitored and treated for

several years from ages 12-25

Hormonally Influenced Acne

Increased excessive androgen levels in females may present as hirsutism, premenstrual acne flares, irregular menstrual cycles, elevated blood levels of certain androgens

Birth control pills with increased androgens will increase acne

Birth control pills with increased estrogens decrease acne

Recommend OrthoTri-Cyclen or Demulen Occasionally but rare use of low dose

corticosteroid drugs, prednisone or dexamethasone may be used to suppress the androgen production by the adrenal gland

Occasional use of spironolactone to reduce excessive oil production.

Web Sites on Acne

www. aad.org www.aocd.org www.niams.nih.gov www.derm-infonet.com/acnenet