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Acne
New Thoughts on Acne
-Resistance -Op6ons
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No Conflict of Interest
Defini6on: Acne is a disease of the pilosebaceous unit, appears in males and females who live in westernized socie6es and are near puberty, and in most cases acne becomes less ac6ve as adolescence ends. The intensity and dura6on of ac6vity vary for each individual.
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Mostpa.entswithacnecanbemanagedbycompetentcaringpediatricians,familyandgeneralprac..onersandinternist.
Incidence
~95%ofadolescentsinwesterncultures
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E6ology
Diseaseofpilosebaceousgland1. Increasesebumproduc.on2. Prolifera.onofpropionbacteriumacne3. Follicularplugging4. Allresul.ngininflamma.onofsebaceousgland
Pathogenesis • Acnemaybeaninheriteddiseasewithvariable
penetrance• Diet,ac.vity,andstressmayinfluenceacne
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Two non-westernized popula6on do not have acne in adolescents:
-Kit Ivan Islands of Papua, New Guinea
-Ache-hunter gathers on Paraguay
Dietary Management of Acne�
• www.acnemilk.com• www.thepaleodiet.com• www.godairyfree.org• www.glycemicindex.com• www.hs-founda.on.org
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Initial Evaluation of Acne
• Typeoflesion• Severityofacne
• Previoustreatmentregimes
• Skintype
• Cosme.cs• Tanning
Comedonal Acne
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Mild Inflammatory
Moderate-to-severe inflammatory acne
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Nodulocys6c Acne
Nodulocys6c Acne
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Topical Agents for Acne
• Benzoylperoxide• Adapalene• Re.noid• Azelaicacid
Benzoyl Peroxide
1) An.-bacterial2) OTCandRx3) Combina.onproducts-BP/Cleocin-BP/Erythromycin4) 2.5to10%5) OTC“proac.ve”6) 2%maydevelopcontactderma..s7) Bestusedinshower-30secondcontacttoarea-Rinsewell-Avoidsbleaching
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Retinoids: Reverse abnormal pattern of keratinization
• Tre.noin“re.n-a”-gel,cream• Tazorac“tazarotene”-gel,cream,foam• Peasizeamount,en.reface• Applymoisturizer• Maystarteveryothernight
Adapalene • Re.noidlikeac.vity• An.-inflammatoryac.vity• Di\erivgel/cream0.1-0.3%
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Azelaic Acid An.-kera.nizing,an.bacterialac.vityandan.-inflammatoryproper.ve
Topical Dapsone
• Aczonegel7.5%• Effec.ve• >12years• AvoidBactrimDS• AvoidBenzoylperoxide• CategoryC
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Topical An6bio6cs
• Erythromycin• Cleocin• Combina.onproducts
Alltopicalacneprepara.ons
drying,besuretousemoisturizersregularlyanddose.Accordingto
pa.entsskintype
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Systemican,bio,cs:• Majorproblemisresistance!!!• Limitusefor3to6months• An.bio.cshavebeenusedfor>40years
Common Systemic
An6bio6c
Doxycycline50-100mg,photosensi.vityMinocycline50-100mgo MinocinSyndrome-fever,rash,jointpain,lupus-likereac.on,headache,eyepain,visualchanges,orbluishpigmenta.ontoskin.
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Systemic An6bio6cs
• Clindamycin75-100mg-severepseudomembranouscoli.s,C.Diff
• Ampillicn/Amoxicillin-Ampillicnokduringpregnancy
• Trimethoprim/sulfametoxazole-Bactrim/Septra
• Macrolides-Erythromycin
Anypa.entonasystemican.bio.cshould/mustbeadvisedofcommonsideeffects.
• Photosensi.vity-doxycycline
• Erythemia-bactrim• Bluishdiscolora.on-minocycline
• Diarrhea-clindamycin
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Allpa.entsonansystemican.bio.cshould:• Avoidtanningbeds• Eatyogurtortakeacrdophiluscapsule2-4x/wk
HormonalTherapy
Birthcontrolpillsareeffec.veformanywomen,slowac.ngwhencomparedto
systemican.bio.cs
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Acne in women may be a marker for underlying diseases
Polycys.cOvarianSyndrome
1Anovula.on
2Cushing’sdisease
3Androgen-secre.ngtumor
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Hormonal treatment
Spironolactone25-200mg/day
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Women Best Suited for Hormonal Treatment
MostlikelytorespondtoHormonalTreatment:- Increasedfacialoiliness(seborrhea)- Premenstrualacneflare-ups- Inflammatoryacneonmandibularlineandneck
INDICATIONS
1. Adultwomenwithinflammatoryfacialacne2. Hormonalinfluencesuggestedbya)Premenstrualflaresb)Onseta\erage25yearsc)Distribu.ononthelowerface,includingthe
mandibularlineandchind)Increaseinoilinessonthefacee)Coexistentfacialhirsu.sm3.Inadequateresponseorintolerancetostandardtreatmentwithtopicaltherapies,systemican.bio.cs,orisotre.noin4.Presenceofcoexis.ngsymptomssuchasirregularmenses,premenstrualweightgain,orothersymptomsofpremenstrualsyndrome
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Whenpa.entsdonotrespondby3monthstheyareontopicalbenzoylperoxide,atopicalre.noid,andsystemicconsider:
1. Changingan.bio.cs2. ForwomenaddBCP
3.Star.ngisotre.noin/Accutane
Isotretinion
• Approved1982• Indica.on
-Severe,recalcitrantcys.cacne-Severe,recalcitrantnodularand inflammatoryacne-Moderateacneunresponsiveto conven.onaltherapy-Pa.entswhoscar-Excessiveoiliness-Severlydepressedordysmorphicpa.ents
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Enroll in the I-pledge system
Dosage0.5-1.0mg/kgfor4-8monthsRelapse39%(usuallywithin3years,mostwithin18months)23%requirean.bio.cs16%requireaddi.onalisotre.noin
TEST COMMENTSPregnancy SeeiPLEDGEprogram
guidelinesTriglyceridelevel Performedduring
pretreatment,a\er2- 3weeksof
treatment, andthenat4-week intervals.Stopisvalue exceeds700-800 mg/dltoreducerisk ofpancrea..sCompletebloodcellcount Performedbefore
treatmentanda\er4- 6weeksoftreatmentLiverfunc.on Performedbefore
treatmentanda\er4- 6weeksoftreatment
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Mucocutaneous Adverse Events as a Percentage
Drychappedlips Dryskin Itching Drynessinmouth Thirst Rashorredness(face) Dryeyes Peelingoffinger.ps Nosebleeding
Ihaveprescribedisotre.noinsince1982.Noserioussideaffectnoted-moreserious
reac.oninmyexperiencewithBactrimandminocycline
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Prednisone
Alimited,butdefiniteplaceinmanagementofacne
IntralesionalCor,losteriod30gaugeneedle
2.5-10mg/mlintocyst
Other Types of Acne
• Gramnega.veacne• Steriodacne• Neonatalacne• Intan.leacne• AcneMechanica• Acnecosme.ca• Excoriatedacne
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Perioral Derma66s
Acne Rosacea
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Inconclusionmostofyoushouldbeabletomanagemostacnepa,ents.Theuseofisotre,noinisnotlimited
toDermatologist
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Thankyou,
Anyques,ons?