Acne Vulgaris and it's Treatment

1. Acne Vulgaris

3. 8% of 25 - 34 yr olds

5. Self-limited disorder that is seen primarily in adolescentswww.bilkent.edu Variety of lesions: Comedones- (closed and open): Whiteheads and blackheads) Papules- Small or larger red or skin-colored acne bumps Pustules- Bumps filled with white or yellow pus Nodulocystic- Very large pus-filled, often painful acne lesions

6. Course of acne maybe self-limiting Sequelae will be life-long, with pitted or hypertrophic scar formation

7. Epidemiology www.gatoveramce.com Mild degrees of acne frequently seen at birth, resulting from follicular stimulation by adrenal androgens neonatal period In the very young patients the predominant lesions are comedones. imresidents.mhri.org imresidents.mhri.org Closed comedo (whiteheads & blackheads)

8. Epidemiology cont… Particularly in women, acne may persist through out the third decade or even later. www.bilkent.edu Nodulocystic acne has been more common in white males than in black males.

9. Etiology and Pathogenesis Pathogenesis of acne Four basic steps have been identified Follicular epidermal hyperproliferation (microcomedones) Excess sebum production Inflammation The presence and activity of Propionobacterium acnes

11. Cohesive corneocytes

13. Marked perifollicular inflammation

15. Proliferation of Propionobacterium acnes

18. Factors affecting keratinocytehyperproliferation Dihydrotestosterone (DHT) is a potent androgen that may play a role in acne 17B-hydroxysteroid dehydrogenase and 5a-reductase are enzymes responsible for converting DHEAS to DHT Compared to epidermal keratinocytes, follicular keratinocytes show increased 17B-hydroxysteroid dehydrogenaseand 5a-reductase activities. DHT may stimulate follicular keratinocyte proliferation and regulated by linoleic acid. Fitzpatrick’s Dermatology in General Medicine Seventh Edition(Volume 1; Chapter 78; pp 690-703)

21. Promote bacterial clumping and colonization of P. acnes  incites inflammationwww.nature.com www.nature.com

22. III. Inflammation brownskin.net Micromedo continues to expand with densely packed keratin, sebum, and bacteria. brownskin.net This distension causes follicular wall rupture. brownskin.net Extrusion of keratin, sebum and bacteria into the dermis results in a brisk of inflammatory response.

23. Clinical Findings www.gatoveramce.com History Neonatal acneappears at approximately 2 weeks of age and infantile acne develops at 3 to 6 months of age. www.wedmd.com ten.wikipedia.org Hyperandrogenismshould be considered in the female patient whose acne is severe, sudden onset, or associated with hirsutism or irregular menstrual periods ten.wikipedia.org ten.wikipedia.org

24. History cont… Drug-induced acne may be caused by: Anabolic steroids Corticosteroids Corticotropin Phenytoin Lithium Isoniazid Vitamin B complexes Prolonged use might cause an irritation of the follicular epithelium and subsequently produces an inflammatory reaction Chemotherapy medication Cancer drugs Doxorubicin (Andriamycin) Erlotinib (Tarceva) Paclitaxel (Taxol) Cetuximab (Erbitux) EGFR-blocking agents playing a central role in the normal differentiation and development of hair follicle

25. ten.wikipedia.org Sites of Predilection Primary sites of acne are the face, back, chest, and shoulders www. healthline.com/image ten.wikipedia.org www. healthline.com/image www. healthline.com/image

26. Non-Inflammatory Types: lesions are comedones, which may be either open (blackheads) or closed (whiteheads) imresidents.mhri.org imresidents.mhri.org imresidents.mhri.org

27. Inflammatory Types ten.wikipedia.org Papules- Small or larger red or skin-colored acne bumps Pustules- Bumps filled with white or yellow pus Nodulocystic- Very large pus-filled, often painful acne lesions

28. Acne Variants www.gatoveramce.com Neonatal acne Lesions appear within 2 weeks and resolve in 3 months Infantile acne 3 to 6 months of age marked by the presence of comedones www.getacnehomeremedies.info

29. Acne Variants cont….. Acne Conglobata Common in teenage males Acne Fulminans Known as (acute febrile ulcerative acne) Treated with systemic glucocorticoids and isotretinoin ten.wikipedia.org ten.wikipedia.org

30. Acne Variants cont.. SAPHO syndrome Synovitis Acne PustulosisHyperrostosisOsteitis (SAPHO) Inflammatory bone disorder ten.wikipedia.org PAPA syndrome PyogenicArthritis, Pyodermagangrenosum and Acne Rare genetic disorder ten.wikipedia.org ten.wikipedia.org

31. Acne Variants cont…. Acne Excoriee des JeunesFilles( Excoriated acne) Mild acne accompanied by extensive excoriations www. chelseaderm. com/physician_service/acne Acne Mechanica Acneiform eruption, observed after repetitive physical trauma to the skin (rubbing, occurring from clothing (belts and straps) or sports equipments (football helmets and shoulder pads) www. chelseaderm. com/physician_service/acne

32. Acne Variants cont… Acne with Solid Facial Edema Known as (Morbihan disease) Isotretinoin (0.2 to 0.5 mg/kg/day) Oral glucocorticoids (1 to 2 mg/day) Clofazimine for 4 to 5 months www. chelseaderm. com/physician_service/acne Acne with Associated Endocrinologic Abnormalities Irregular menstrual cycle , deepened voice , increased libido, and hirsutism ten.wikipedia.org

33. Laboratory Tests Laboratory workup is not indicated for patients with acne unless hyperandrogenism is suspected. Elevated serum levels of androgens (severe cystic acne) and in acne associated with a variety of endocrine conditions: Congenital adrenal hyperplasia (CAH; 11B- and 21B- hydroxylase deficiencies) Ovarian or adrenal tumors Polycystic ovarian disease

35. Inactivated by concomitant use of benzoyl peroxide

37. Competitive inhibitor of tyrosinase decreasing pigmentation

39. anticomedonal

41. Promotes desquamation

43. anticomedonal

46. Treatment of Acne Vulgaris (Inflammatory) Nodulocystic Isotretinoin Oral corticosteroids

47. Treatment of Acne Vulgaris Hormonally induced-acne Oral contraceptives Mechanism of Action: Inhibits the production of androgens by gonadal tissue via a negative feedback loop on pituitary gonadotropin release Regulating genes that suppress sebaceous gland growth or lipid production Antiandrogens (Spironolactone)

48. Treatment of Acne Vulgaris Hormonally Induced Acne Corticosteroids Flutamide

49. IntralesionalGlucocorticoids Decrease the size of deep nodular lesions Injection of triamcinolone acetonide suspension

50. Treatment Summary ofAcne Vulgaris imresidents.mhri.org

51. Medications use to treat Acne

52. Medications use to treat Acne

53. Medications use to treat Acne

56. Phenytoin

57. Lithium

58. Isoniazid

59. High-dose vitamin B complex

60. Halogenated compounds

61. Epidermal growth factor receptor inhibitors

62. Chemotherapy Induced AcneDoxorubicin (Andriamycin) Erlotinib (Tarceva) Paclitaxel (Taxol) Cetuximab (Erbitux) mons.wikimedia.org

63. Epidermal Growth Factor Receptor Inhibitor-Associated Eruption Treat non-small cell lung cancer, colorectal cancer, and breast cancer Highly expressed in the basal cell layer of the epidermis, follicular keratinocytes, and the sebaceous epithelium ten.wikipedia.org Occupational acne and Chloracne Tar derivatives Insoluble cutting oils Chlorinated hydrocarbons- (chloracne) found in fungicides, insecticides, and wood preservatives ten.wikipedia.org

65. Mainly on trunk and buttocksten.wikipedia.org

66. Rosacea Mild, moderate, and severe Presents with burning and stinging of the facial skin Sebaceous or glandular features characterized by thickened skin and large follicular orifices Ocular rosacea may develop before cutaneous symptoms up to 20% Severe cases  rosaceakeratitis may lead to vision loss Granulomatous rosacea only true rosacea variants Yellow-brown or red papules or nodules that are monomorphic and located on the cheeks and periorificial facial skin Apple-jelly-like change in color similar to sarcoidosis or lupus vulgaris

67. Perioral Dermatitis Discrete and grouped erythematous papules, vesicles, and pustules Unilateral and appear in the perioral, perinasal, and periorbital regions Distinct of 5-mm clear zone at the vermilion edge In addition also appears on the ears, scalp, trunk, labia majora, and extremities

69. Milia

70. Sebaceous hyperplasia

71. Open comedonal acne

72. Dilated pore of Winer

73. Favre- Racouchot syndrome

74. Inflammatory acne

75. Rosacea

76. Perioral Dermatitis

77. Neonatal acne

80. Chloracne

81. Open comedonal acne

82. Acne due to systemic agents

83. Contact acne

84. Chloracne

85. Inflammatory acne

86. Acne due to systemic agents

87. Staphylococcal folliculitis

88. Gram-negative folliculitis

89. Eosinophilicfolliculitis

90. Furuncle/ Carbuncle

91. Neonatal acne

92. Candidal infections

94. Osteoma cutis

95. Tricoepitheliomas

96. Tricodiscomas

97. Fibrofolliculomas

99. Sequelae: 4 general types of acne scars www.nature.com Ice pick- narrow, deep scars, widest at the surface of the skin and taper to a point in the dermis Rolling- shallow, wide scars that have undulating appearance www.nature.com Box scar – wide, sharply demarcated scars www.nature.com Hypertrophic- scars on the trunk www.nature.com

100. References Fitzpatrick’s Dermatology in General Medicine Seventh Edition(Volume 1; Chapter 78; pp 690-703) Sheretz EF. Acneiform eruption due to "megadose" vitamins B6 and B12. Cutis. 1991 Aug; 48(2): 119-20 Adams DH, Nutt T. A case report and discussion of cetuximab-induced folliculitis. Am J ClinDermatol. 2006;7(5):333-6.