Acne Vulgaris

(Otherwise known as zits, pimples and

blackheads)

Cynthia Salinas, M.D.

PGY-3 Patient Conference
February 2, 2005

Conference Goals

Review pathogenesis as a way to help

us understand why we use certain
meds
Differentiate common types of acne
Generate a quick differential diagnosis
Apply a stepwise approach to
treatment prior to referral to
dermatology

Epidemiology
Onset?
Males 10-17 yrs Females 14-19 yrs
May persist through 4 th decade or
older
Prevalence?
Asians 10%
African-American 25%
Caucasians 29%

Causes?

Majority of patients have a family

history of acne
Emotional stress
Androgens
Dioxins, lithium
Occlusion and pressure acne
mechanica
NOT DUE TO CHOCOLATE OR FATTY
FOODS!

Pathogenesis

Plugging of the hair follicle

w/ abnormally keratinized
cells

Androgen-induced
sebaceous gland
hyperactivity

Proliferation of bacteria
- Propionibacterium acnes

Inflammation

Doctor my skin is breaking

out!

34yo Latina comes to your office

stating that she has had bad skin
forever and her face is the worse its
ever been. Saint Ivys scrub is not
helping. Shes trying to eat healthy but
despite her best efforts keeps gaining
weight. She wonders if she is doing the
wrong things and asks for your help.

HPI

When was the onset?

Where?

Adolescence
Face, neck, trunk &
buttocks
Pustules

Does it itch or hurt?

painful
How have the individual lesions changed?
Triggers?
Worse in fall/winter
Hirsutism? Oligomenorrhea?

Differential Diagnosis

Face

Trunk

Staph aureus folliculitis

Rosacea
Perioral dermatitis
Pityrosporum folliculitis
Hot Tub folliculitis

Acne Aestivalis

Appears after sun exposure

Types of Acne
Comedonal
Papulopustular
Nodulocystic

Why is this important?

Directs treatment options

Comedonal Acne

Closed comedones (whiteheads)

Open comedones (blackheads)

Sebum accumulation results in a

white papule visible at the skin
surface

Plug protrudes from canal and turns

dark

Non-inflammatory
Usually responds to topical
keratolytic

Papulopustular Acne

Papules/Pustules

Follicular wall ruptures

Releases sebum and
bacteria into dermis

Topical agents alone

usually insufficient
Consider topical
retinoids plus
systemic antibiotics

Nodulocystic Acne

Soft nodules that are

secondary comedones
from repeated ruptures
reencapsulations and
abscess formations
Painful and disfiguring
Psychological impact
Treatment consists of
topical agents, oral
antibiotics or isotretinoin

Management
Acne often spontaneously clears
Flares may occur in the winter &
w/menses
Scarring can be avoided by proper
treatment early in the course of
disease
Assess the psychological impact of
cosmetic disfigurement

Four Major Goals of Treatment

Correct the abnormal follicular keratinization

Decrease sebaceous gland activity
Decrease follicular bacteria
Inhibit the production of extracellular
inflammation

Take home points:

Retinoids, abx, hormonal treatments target
different areas responsible for acne

Retinoids

Cost
Tretinoin (Retin-A)
$42 (20g)
Adapalene (Differin) $42 (15g)
Tazarotene (Tazarotene) $74 (30g)
Acts as a keratolytic and antiinflammatory
Inactivated by UV light
SE: Dryness, scaling, erythema, burning,
irritation, and photosensitivity

Topical Antibiotics
Cost

Clindamycin Gel (Cleocin)

g)
Erythromycin Gel (Akne-Mycin)
g)

Kills propionibacterium acnes

SE: Irritating; stains clothes

$32 (30
$18 (30

Other

Cost

Benzoyl peroxide gel

$24 (90g)

Reduces antibiotic resistance

SE: erythema, dryness

Ortho-Tricyclin $38 (pack)

Ortho-Cyclen
Desogen

Anti-androgenic
2-4 months before improvement is seen

Comedonal Acne
Tretinoin 0.025% cream or 0.01% gel
0.05% cream or 0.025% gel
0.1% cream

PLUS
qam

benzoyl peroxide 5% gel

-Gels have a drying effect

-Creams/lotions tend to be

qhs

Papulopustular Acne
Tretinoin

0.025% cream or 0.01% gel qhs

0.05% cream or 0.025% gel
0.1% cream

PLUS

clindamycin 1% gel or
erythromycin 2% gel

PLUS

benzoyl peroxide 5% gel

Oral antibiotics
Cost

Tetracycline
$8 (30caps)
Least efficacious but cheap
Decreases efficacy of OCPs; need backup
Must take 1hr before meals; wait 2hrs after taking

Doxycycline
SE: Dyspepsia, nausea, emesis
diarrhea, photosensitivity, esophagitis

Minocycline
$117 (30caps)
Most effective but also most expensive
Can take with food unlike other tetracylines
Infrequently causes photosenstivity
SE: vertigo, mouth & shin hyperpigmentation

$75 (30caps)

Papulopustular Acne

Tetracycline 500mg po tid-qid x 3 months

Doxycycline 100mg po bid x 3 months

Minocycline 100mg daily then to

100mg bid
months

x3

Consider

Hormone Therapy

Ortho-Tricyclen, Desogen, Ortho-Cyclen

Spironolactone 100mg daily

Nodulocystic Acne

Only indication to use Acutane

Acts against the four pathogenic factors
that contribute to acne
It is the only med w/ the potential to
suppress acne over the long term
To prescribe this med the physician must
be a registered member of System to
Manage Accutane-Related Teratogenicity
(SMART) program to educate patients
about the possible severe adverse effects
and teratogenicity of isotretinoin

Education

Improvement occurs over 2-5 months

Face, upper arms and legs tend to respond
more quickly than those on the trunk
Retinoids should be applied at bedtime
Clinda/Erythro/BP are applied in the morning
Combination therapy is BEST!

Avoid using topical antibiotic alone

Should combine with antibacterial agent such as
benzoyl peroxide or oral antibiotic

No improvement? Change topical or add

oral antibiotic

Soaps, detergents, and astringents

remove sebum from the skin surface
but do not alter sebum production
Avoid repetitive mechanical trauma
Avoid occlusive clothing and refrain
from rubbing their faces or picking
their skin
Water-based cosmetics and hair
products are less comedogenic than
oil-based products

Completing Therapy

Once acne cleared you can attempt

to wean meds. Typically wean down
from bid to daily dosing for 2-3
months then off completely. Some
will have complete remission while
others made need repeat treatment.

Follow-up on Patient

Sent labs for PCOS all negative

Concern for early metabolic
syndrome
Started on topical tretinoin cream
and benzoyl peroxide and
spironolactone
Advised to apply tretinoin on
acanthosis nigracans
Referred for PMD

Conclusions

Keratinization androgens bacteria

inflammation
Comedonal, Papulopustular,
Nodulocystic
1st Line: Topical Retinoids!
Minimum use of 3 months prior to
labeling treatment as a failure
Intervene early to prevent scarring

Sources

AAFP
Uptodate
Fitzpatrick, et al Color Atlas &
Synopsis of Clinical Dermatology
Brian Swans Foom Handout