ADOLESCENT ACNE: EVALUATION AND MANAGEMENT · Comedomes-non-inflammatory Closed (whiteheads) Flesh...

BETSY PFEFFER MD

ASSOCIATE PROFESSOR PED IATR ICS

MORGAN STANLEY CHILDREN’S HOSP I TAL

OF NEW YORK PRESBYTER IAN

ADOLESCENT ACNE:EVALUATION AND

MANAGEMENT

ACNE:WHY DO WE CARE

Affects >80% of adolescents (M>F)

>40% of adults over 25

One of the top ten most prevalent diseases globally

ACNE:WHY DO WE CARE

Associated with:

Disfigurement

Pain, soreness

Loss of confidence & embarrassment

Depression, anxiety

Severity of acne and psychological impairment do not necessarily correspond

ACNE:WHY DO WE CARE

• Effects on quality of life

• Comparable to those suffering from

chronic diseases like asthma, seizures and

diabetes

• Body dysmorphic disorder

• 14% of patients with acne

PATHOPHYSIOLOGY

• Typically begins at puberty

• Genetics plays a role in severe acne

•Disorder of the pilosebaceous unit

(face, neck, chest, shoulders, back)

• Obstruction of the sebaceous follicle

• The primary pathologic event in acne

• Gives rises to the microcomedo, the

precursor of all acne lesions

PATHOPHYSIOLOGY

• Acne arises from the interaction of 4 factors:

• Increased androgen production leads to

increased sebum

• Abnormal keratinization and desquamation

obstructs the pilosebaceous duct

• Propionibacterium acnes proliferates in

excess sebum and breaks down sebum into

free fatty acids

• Proinflammatory mediators are activated

and result in inflammatory acne

EXTRINSIC INFLUENCES

• Friction and manipulation

• Can worsen acne and increase

inflammation and scarring

•Occlusive products

•Close fitting sports equipment

EXTRINSIC INFLUENCES

• Smoking

• Studies have suggested that severe acne

increases with smoking

• Evidence supporting this is controversial

•Medications:

• Steroids

• Antiepileptics

• Progestin only contraceptives

DIET

•Diet

• Diary, correlation between consumption

and acne (no randomized controlled

studies)

• High glycemic diet

• Randomized controlled trials show that a low

glycemic diet might improve acne

• Chocolate

• Well-recognized belief that chocolate causes or

exacerbates acne; limited evidence backing up

such a claim

STRESS & MENSES

• Stress• Acne among university students has been

associated with exam stress

• Hormones• 70% of females report mild premestrual

facial acne

• Acne is also common in girls who have polycystic ovary syndrome

CLINICAL FEATURES

Mild acne Comedomes-non-inflammatory Closed (whiteheads)

Flesh colored papules 1-3mm in size

Open (blackheads)

Contents of the comedome oxidizes upon expose to the light (tyrosine is oxidized to melanin)

Moderate acne Comedomes/Inflammatory Papules/Pustules

Severe acne Papules/Pustules/Nodulocystic lesions

CLOSED COMODOME

OPEN COMODOME

PAPULAR ACNE

PUSTULAR ACNE

NODULOCYSTIC ACNE

CONSEQUENCES OF ACNE

• Postinflammatory changes

• Risk of scarring

• Mild acne low risk

• Moderate acne medium risk

• Severe acne high risk of:

• Punctate depressions (ice-pick scars)

• Depressed scars (thumbprint scars)

• Atrophic scars

• Hypertrophic papular scars

• Keloids

ICE PICK SCAR

THUMBPRINT SCARS

ATROPHIC SCARS

HYPERTROPHIC SCARS

KELOIDS

RARE FORMS OF SEVERE ACNE

•Acne fulminans• Severe acne in young males in

association with fever, arthritis

•Acne conglobata• Comedomes, pustules, foul smelling cysts,

sinus tracts, atrophic and keloid scarring

• Treat with high dose steroids and isotretinoin

ACNE FULMINANS

ACNE CONGLOBATA

DIFFERENTIAL DIAGNOSIS

• Keratosis pilaris

• Perioral dermatitis

•Angiofibromas

• Pseudofolliculitis barbae

•Acne keloidalis nuchae

• Folliculitis

• Hidradentis suppurativa

KERATOSIS PILARIS

• Small perifollicular papules on the

extensor surfaces of the arms and legs,

cheeks and buttocks

•May be seasonal

•May improve w/ keratolytic moisturizers

containing ammonium lactate or urea

KERATOSIS PILARIS

PERIORAL DERMATITIS

• Idiopathic

• Sensation of stinging and burning.

Itching is rare

•May occur after use of topical steroids

• Treatment:

• Discontinue steroid use

• Topical benzoyl peroxide

• Topical and/or oral antibiotics

PERIORAL DERMATITIS

ANGIOFIBROMAS

• Tuberous sclerosis

• Rubbery papules/plaques

• Flesh colored to brownish

• Seen on nasolabial folds

• Begin in childhood

• Treat with pulsed dye laser therapy or

carbon dioxide laser resufacing

ANGIOFIBROMAS

SHAVING

• Pseudofolliculitis barbae• Beard hair, when shaved closely, causes

inflammation, papules and nodules

•Acne keloidalis nuchae• Papules and nodules on the nape of the

neck

•Avoid close shaves, use depilatories, topical retinoids, benzoyl peroxide

PSEUDOFOLLICULITIS BARBAE

ACNE KELOIDALIS NUCHAE

FOLLICULITIS

• Papules/pustules on the face, back

buttocks

• Typically staph aureus

• Treatment

• Anti-bacterial wash like benzoyl peroxide

(Clearisil, Proactiv), chlorhexidine (Hibiclens), or

Phisoderm twice a day

• Topical antibiotics

• Best results may be achieved with combination

therapy using topical products and antibacterial

washes

FOLLICULITIS

HIDRADENITIS SUPPURATIVA

•Disease of the follicle

•Deep tender nodules in the groin,

axilla, buttocks

•Difficult to treat

•May respond to Accutane

HIDRADENITIS SUPPURATIVA

ACNE TREATMENT

Basic skin careNo scrubbing or picking

Cleanse with a gentle soap, may contain salicylic acid, glycolic acid or benzoyl peroxide

If moisturize use noncomedogenic agent

ACNE TREATMENT

• Acne treatments work by preventing new

lesions

• Response may not appear for many weeks

• Mild comedomal acne

• Topical retinoids

• Mild papulopustular acne

• Topical retinoids

• Antibacterial

• Benzoyl peroxide, topical antibiotics or azelaic

acid

ACNE TREATMENT

•Moderate acne

• Systemic drugs

• Oral antibiotics, hormonal therapy, oral retinoids

• Systemic therapy should be considered in

diseases with tendency for

physical/psychological scarring, post-

inflammatory hyperpigmentation,

widespread disease

• Sever acne

• Isoretinoin

TOPICAL RETINOIDS

Tretinoin (Retin A), Adapalene (Differin), Tazarotene (Tazorac)Excellent choice for comedomal and

inflamatory acne, targets the microcomedo

Improves follicular desquamation

Retinoids are the most effective comedolyticagents Eliminate mature comedones and inhibit the

formation of new ones

Use at night over entire face, may increase concentration over time

Results in six to eight weeks

TOPICAL RETINOIDS

• Anti-inflammatory action (Adapalene best)

• Degraded by prolonged exposure to the

sun and when used with benzoyl peroxide

• AdapaleneMost photostable so does not have to

be used at night

• Enhances the penetration of other topical

agents

• Adapalene

• Can be used in combination with benzoyl

peroxide

TOPICAL RETINOIDS

•Adverse affects

• Irritant potential (Tretinoin most irritating,

Adapalene least)

• Sun sensitivity

• Pustular eruption after 3-4 weeks

• Potential hyper/hypopigmentation in black

and Asian patients

• Contraindicated in pregnancy

TOPICAL ANTIBIOTICS

• Erythromycin and Clindamycin • Decrease P.acnes and percentage of free

fatty acids

• Slow to act

• Resistance often develops over time

• Best used in combination with topical retinoids/benzoyl peroxide

• Rare cases of pseudomembranous colitis w/topical clindamycin

BENZOYL PEROXIDE

• Bacteriocidal effect on P.acnes & no evidence of resistance

• Mild comedolytic action

• Helps decrease the presence of antibiotic resistent P. acnes when combined with a topical antibiotic

• Adverse effects

• Irritation, will decrease in most cases

• Bleaches clothing and hair

• Allergic contact dermatitis

TOPICAL DAPSONE

•Not first line therapy

•A synthetic sulfone

•Anti-inflammatory and antimicrobial

properties

• Used for mild/moderate acne

•More effective in reducing

inflammatory lesions compared to

non-inflammatory lesions

AZELAIC ACID

• Not first line therapy

• Dicarboxylic acid

• Bacteriostatic against P.acnes and normalizes

keratinization

• Most effective when used with other agents

• Side affects uncommon

• Use in caution in teens w/dark complexions

due to potential risk of hypopigmentation

OVER THE COUNTER PRODUCTS

• Alpha hydroxy acid (glycolic acid and lactic

acid)

• Remove dead skin

• Reduce inflammation

• May stimulate growth of new smoother skin

• Salacytic Acid

• Salacytic acid comedolytic properties that are

less potent than retinoids

• Promotes exfoliation

• Few well designed trials of its efficacy exist

OVER THE COUNTER PRODUCTS

• Sulfur, sodium sulfacetamide, and

resorcinol are active ingredients in several

OTC products

• Sulfur has mild antibacterial and

keratolytic properties

• Sulfur has an odor

• Often combined with sodium sulfacetamide

to mask the scent

SYSTEMIC ANTIBIOTICS

• Decreases P.acnes and reduces amount of

free fatty acids

• Preferred agents:

• Minocyclin most effective, Doxycycline,

Tetracyclin least effective

• High rates of resistance to Erythromycin

• Discontinue or taper within 1-2 months after

new inflammatory lesions have stopped

emerging (can take several months)

HORMONAL CONTROL

• Oral contraceptive pills in females

• Increases production of sex hormone binding globulin leading to a decrease of circulating androgens

• Decreases ovarian androgen production

• Orthotri-cyclen, Estrostep, Yaz FDA approved for the treatment of acne

• Oral antiandrogens (spironolactone) can be useful

• Oral corticosteroids, short course for patients with severe inflammatory disease

ISOTRETINOIN

• Systemic retinoid used for nodulocystic acne• Reduces sebum production

• Normalizes follicular keratinization

• Decreases inflammation

•Most effective treatment with remission in 60% after single course (15-24 weeks)

ISOTRETINOIN

• Baseline CBC, LFT’s, lipids (repeat in 1-2 months)

• Pregnancy test (repeat monthly)

• Post pubertal females must be on contraception and have two sequential negative pregnancy tests before starting

ADVERSE EFFECTS ISOTRETINOIN

Teratogenic and retinoid embryopathy can occur with a single exposure during gestation

Drying/chapping of skin and mucous membranes

Myalgias/Arthralgias

Photosensativity

GI effect: transaminitis, lipid abnormalities, pancreatitis, IBD (?)

Hematologic: leukopenia, elevated platlets and ESR

ADVERSE EFFECTS ISOTRETINOIN

Renal Protienuria, Hematuria

Neurologic Pseudotumor Cerebri

Mood disorders Depression, suicidal ideations and suicides

No causal relationships have been established

MISCELLANEOUS THERAPY

• Comedome removal

• May be helpful if comedomes are resistent to other treatments

• Chemical peels

• Little evidence supporting efficacy

• Intralesional steroids

• Used for large inflammatory nodules/cysts

• Can be associated with local atrophy

• Topical tree oil

• One clinical trial documented effectiveness

ACNE SCARS

• Facial scarring from acne affects up to

20% of teenagers

• Treatment

• Subcision

• Punch excision

• Laser resurfacing

• Demabrasion

• Chemical peels

• Fractionated laser treatments

MANAGING ADOLESCENTS

• Remember adolescents are impatient

• Empower the patient to take control of

their care

• Can improve adherence

•Give reasonable expectations

• Treatment takes time

• Acne may worsen initially

• Irritation may occur but tends to improve

RESOURCES

1. Current concepts in acne management.

Yan AC - Adolesc Med Clin - 01-OCT-2006; 17(3): 613-37

2. Guidelines of care for acne vulgaris management.

Strauss JS - J Am Acad Dermatol - 01-APR-2007; 56(4): 651-63

3. High school dietary dairy intake and teenage acne.

Adebamowo CA - J Am Acad Dermatol - 01-FEB-2005; 52(2): 207-14

4 Acne : Clinical Review Purdy,S-BMJ-04-NOV-2006;333:949-953.

5. Acne vulgaris, Hywel C et a Lancet 2012

6. Guidelines of care for acne vulgaris management

Work Group : John S. Strauss,et al J AM ACAD DERMATOL APRIL 2007

7 The relationship of diet and acne

A review Dermato-Endocrinology 1:5, 262-267; September/October 2009

8. Nutrition and acne F. William Danby, MD⁎ Clinics in Dermatology (2010)

9. The epidemiology of acne vulgaris in late adolescence The Dove Press

Lynn DD et al Published 19 January 2016 Volume 2016

10. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental

Indian and African American women. Perkins AC et al. J Eur Acad DermatolVenereol 2011

11. Guidelines for Treating Acne ANDREAS. D. KATSAMBAS, MD Mild Comedonal Acne

Clinics in Dermatology Y 2004

12. Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne

Lawrence F. Eichenfield, MD et al, PEDIATRICS Volume 131, Supplement 3, May 2013

13. Epidemiology of acne vulgaris K. Bhate et al, British Association of Dermatologists 2013

14. Guidelines for Treating Acne ANDREAS. D. KATSAMBAS, MD, Clinics in Dermatology, 2004