Monday, February 6th, 2012

Acne!José L. González, MD

Risk Factors

first degree relative no data suggesting dietary influences endocrine

steroids anabolic cortico-

androgen excess PCOS

Classification

inflammatory open comedo (whitehead) closed comedo (blackhead)

non-inflammatory papule < 5mm tender, erythematous bump pustule < 5mm bump containing visible

material nodule / cyst > 5mm

Types of Acne & Acne Impersonators

acne conglobata / acne fulminans drug-induced acne rosacea – telengectasias, central face acne excoriée des jeunes filles bacterial folliculitis – s. aureus granulomatous & neoplastic d.o.

sarcoidosis, tuberous sclerosis, multiple trichoepitheliomas

female pts & signs of androgen excess

testosterone (free & total) dehydroepiandrosterene sulfate LH, FSH

PCOS? fasting glucose & insulin levels

pathogenesis

1. hyperkeratinization 2. increased sebum production 3. propionobacterium acnes 4. inflammation

treatment

non-inflammatory (comedolysis + keratolysis) – topical tx

retinoids benzoyl peroxide salicylic acid azelaic acid

inflammatory – combination tx topical + oral abx benzoyl peroxide + tetracycline

common oral abx & SEs

Tetracyclines – phototoxicity, nausea doxycylcine – tooth staining & vertigo minocylcine – SLE-like reaction

Macrolides erythro & azithromycin – GI upset / diarrhea

Bactrim – Stevens Johnson

Other Oral Therapies

Hormonal OCPs – 50 – 60% improvement

norethindrone acetate-ethinyl estradiol norgestimate-ethinyl estradiol

SEs: migraines, nausea, VTE

Steroids high dose → taper; short term low dose; long term

Isotretinoin aka Retinoic Acid

long term remission use in severe nodular acne, resistant to abx SEs

birth defects, iPLEDGE skin: dry eyes, mm, epistaxis, hair shedding MSK: hyperostosis, premature epiphyseal

closure neuropsych: it'll make you crazy! (but beautiful) liver: check triglycerides & LFTs

Other Options

Newer treatments blue light, phototherapy, laser therapy,

radiofrequency non-ablative high cost relapse in 3-6 months

Referral to Dermatologist very severe acne use of isotretinoin