Acne Vulgaris

Seborrheic Dermatitis Differin

Inflammatory disorder of pilosebaceous follicles with a 90% prevalence in adolescence and young adulthood.

Etiology: Abnormal follicular keratinization, increased sebum 2° to androgens, Propionibacterium acnes (bacteria), inflammation.

Genetic factors; occlusive cosmetic agents; medications: steroids, ACTH, androgens, danazol, iodides, lithium, antiepileptics, oral contraceptives; diseases: congenital adrenal hyperplasia (CAH), polycystic ovarian syndrome (PCOS); worse with emotional stress.

History: Often asymptomatic lesions (especially comedones), although can be tender (nodules).

Physical:Two types of lesions, predominantly affect face, neck, chest and back.

a. Noninflammatory—open ("black heads") and closed ("white heads") comedones.

b. Inflammatory—papules, pustules, cysts, nodules; deep lesions leave scars, inflammatory papules, pustules & nodules on back and check with early scarring.

DDx: Folliculitis, perioral dermatitis, rosacea

Investigations: If irregular periods, hirsutism, virilization, or not responding to conventional therapy, work-up to rule out virilizing tumor or PCOS.

Treatment Options Based on Acne Type

Treatment

Comedonal

Inflammatory

Nodulocystic

Topical Therapy

Salicylic acid

X

Retinoids

X

X

Azelaic acid

X

X

Benzoyl peroxide

X

X

Antibiotics

X

X

Systemic Therapy

Oral contraceptives

X

X

X

Antibiotics

X

X

Isotretinoin

X

X

X

Selected Topical Medications for the Treatment of Acne

Medication

Dosage

Side Effects

Retinoids*

Adapalene (Differin)

Qhs-bid

Same as tretinoin but less severe

Tazarotene (Tazorac)

Qhs

Same as tretinoin but more severe

Tretinoin (Retin-A)

Qhs

Dryness, scaling, erythema, burning, irritation, and photosensitivity

Tretinoin microsphere (Retin-A Micro)

Qhs

Same as tretinoin but less severe

Antibiotics

Clindamycin

Qd-bid

Local irritation, dryness

Erythromycin

Qd-bid

Local irritation, dryness

Other

Azelaic acid (Azelex)

Qd-bid

Dryness, scaling, erythema, burning, irritation, pruritus; rarely, hypopigmentation

Benzoyl peroxide (2.5%-10%)

Qd-bid

Erythema, peeling, contact dermatitis, dryness, bleaches bedding/clothing

Salicylic acid (Stri-Dex, Clearasil)

Qd-bid

Dryness, irritation

Sulfacetamide (Klaron)

Bid

Itching, redness, irritation; con-traindicated if sulfa allergy

Sulfacetamide/ sulfur (Sulfacet-R)

Bid

Same as sulfacetamide

Combination products (Duac, Benzamycin)

Qd-bid

Erythema, peeling, contact dermatitis, dryness, bleaches bedding/clothing

*Due to irritation, retinoids can be used every second day or as tolerated.

Selected Systemic Medications Acne Treatment

Medication

Dosage

Side Effects

Erythromycin

250 mg bid-qid; with meals

N/V/D, abdominal pain and cramps, rash, stomatitis, elevated liver transaminase levels, jaundice

Doxycycline

50-100 mg qd-bid (or 20 mg bid subantimicro-bial dose); with meals

N/V/D, photosensitivity, stomatitis, discolored teeth (if <8 yr), esophagitis, lightheadedness, dizziness, vertigo, headache, pseudotumor cerebri

Tetracycline

500 mg bid; take on empty stomach

Same as doxycycline

Minocycline

50-100 mg qd-bid; with meals

Same as doxycycline (except less photosensitivity), plus rare lupus-like syndrome, or rare hypersensitivity reaction, and skin and mucous membrane hyperpigmentation

Isotretinoin

Start at 0.5-1 mg/kg/day. After 1 mo, full dose of 1 mg/kg/day to cumulative dose of 120-150 mg/kg (usually 15-20 wk) Lab tests:

CBC, TG, ALT, B-hCG — baseline & monthly

Common: cheilitis, dry skin and mucous membranes, pruritus, epistaxis, conjunctivitis, photosensitivity, arthralgia, hypertriglyceridemia, elevated liver transaminase levels, decreased night vision Rare: pseudotumor cerebri, hepatotoxicity, major birth defects (Counsel regarding birth control/abstinence), cataracts, neutropenia, thrombocytopenia, reported cases of depression

N/V/D=5-nausea/vomiting/diarrhea.

■ Other options: comedone extraction, intralesional cortisone injection (for papulonodules, cysts), oral contraceptives (esp. anti-androgenic such as cyproterone acetate, Yasmin®), photodynamic therapy, spironolactone (reduces androgen production; 50-200 mg/day); dermabrasion, chemical peels

■ Treatment improves cosmesis and psychosocial well-being, and helps prevent further scarring and hyperpigmentation.

■ Patients should be forewarned of acne exacerbations in the first month of systemic therapy as deep-seated acne comes to the surface. Also, systemic therapy can require 6 wk before benefits are noted.

■ Isotretinoin should be taken with a fatty snack or meal that has some fat in it

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