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Acne Evaluation and management PowerPoint Presentation

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Description : Check out this medical presentation on Acne Scar Removal, which is titled "Acne: Evaluation and management", to know about acne and its management.

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Published on : Jul 05, 2021 | Views : 2288 | Downloads : 8

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ACNE: EVALUATION AND MANAGEMENT Betsy Pfeffer MD Assistant Clinical Professor Pediatrics Morgan Stanley Children’s Hospital of New York Presbyterian
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ACNE:WHY DO WE CARE Affects >80% of adolescents >40% of adults over than 25 Genetics plays a role Associated with Disfigurement Pain Loss of confidence Depression Effects on quality of life are comparable to those suffering from chronic diseases like asthma, seizures and diabetes
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PATHOPHYSIOLOGY Typically begins at puberty. Disorder of the pilosebaceous unit (face, neck, chest, shoulders, back). Increased androgen production leads to increased sebum. Abnormal keratinization and desquamation obstructs the pilosebaceous duct and Propionibacterium acnes proliferates in excess sebum and breaks down sebum into free fatty acids. Proinflammatory mediators are activated and result in inflammatory acne.
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EXTRINSIC INFLUENCES Friction and manipulation Occlusive products Close fitting sports equipment Medications: Steroids Antiepileptics Progestin only contraceptives
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DIET, STRESS and ACNE Controversial link between diet and acne although many patients believe that their acne is influenced by certain foods Western diet may be associated with acne Skim milk is associated with acne in teenage girls Stress: acne among university students was associated with exam stress
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CLINICAL FEATURES Mild acne Comedomes: Closed (whiteheads) are closed flesh colored papules 1-3mm in size Open (blackheads) are open and the contents of the comedome oxidizes upon expose to the light (tyrosine is oxidized to melanin) Moderate acne Comedomes/Papules/Pustules Severe acne Papules/Pustules/Nodulocystic lesions
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CLOSED COMODOME
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OPEN COMODOME
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PAPULAR ACNE
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PUSTULAR ACNE
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NODULOCYSTIC ACNE
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CLINICAL FEATURES Postinflammatory changes can occur with healing and resolve over time Risk of scarring Mild acne low risk Moderate acne medium risk Severe acne high risk c/o punctate depressions (ice-pick scars), depressed scars (thumbprint scars), hypertrophic papular scars, keloids
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ICE PICK SCAR
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THUMBPRINT SCARS
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ATROPHIC SCARS
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HYPERTROPHIC SCARS
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KELOIDS
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SEVERE ACNE Acne fulminans Severe acne in young males in association with fever, arthritis Acne conglobata Comedomes, pustules, foul smelling cysts, sinus tracts, atrophic and keloid scarring Treat with high dose steroids
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ACNE FULMINANS
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ACNE CONGLOBATA
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DIFFERENTIAL DIAGNOSIS Keratosis pilaris Perioral dermatitis Angiofibromas Pseudofolliculitis barbae Acne keloidalis nuchae Folliculitis Hidradentis suppurativa
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KERATOSIS PILARIS Small perifollicular papules on the face and the extensor surfaces of the arms and legs May be seasonal May improve w/ keratolytic moisturizers containing ammonium lactate or urea
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KERATOSIS PILARIS
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PERIORAL DERMATITIS Idiopathic May occur after use of topical steroids Treatment- Discontinue steroid use, topical benzoyl peroxide, topical antibiotics
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PERIORAL DERMATITIS
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ANGIOFIBROMAS Tuberous sclerosis Rubbery papules/plaques Flesh colored to brownish Seen on nasolabial folds Begin in childhood Treat with pulsed dye laser therapy or carbon dioxide laser resurfacing
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ANGIOFIBROMAS
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SHAVING Pseudofolliculitis barbae Beard hair, when shaved closely, causes inflammation, papules and nodules Acne keloidalis nuchae Papules and nodules on the nape of the neck Avoid close shaves, use depilatories, topical retinoids, benzoyl peroxide
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PSEUDOFOLLICULITIS BARBAE
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ACNE KELOIDALIS NUCHAE
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FOLLICULITIS Papules/pustules on the face, back buttocks Typically staph aureus Benzoyl peroxide or topical antibiotics may help prevent outbreaks
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FOLLICULITIS
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HIDRADENITIS SUPPURATIVA Disease of the follicle Deep tender nodules in the groin, axilla, buttocks Difficult to treat May respond to Accutane
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HIDRADENITIS SUPPURATIVA
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TREATMENT Basic skin care No washing, scrubbing or picking Cleanse with a gentle soap, may contain salicylic acid, glycolic acid or benzoyl peroxide If moisturize use noncomedogenic agent Based on skin type, choose appropriate vehicle for topical treatments Oily (solutions, gels, pledgets) Combination (lotions) Dry (cream, ointment)
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TOPICAL RETINOIDS Tretinoin (Retin A), Adapalene (Differin), Tazarotene (Tazorac) Excellent choice for comedomal acne Improves follicular desquamation and dyschromia Anti-inflammatory action (Differin best) Use at night over entire face, exposure to the sun increases irritation Results in six to eight weeks. May increase concentration over time Degraded by prolonged exposure to the sun and when used with benzoyl peroxide (Differin most photostable)
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TOPICAL RETINOIDS Adverse affects Irritant potential (Tazorac most irritating, Differin least) Sun sensitivity Pustular eruption after 3-4 weeks Potential hyper/hypopigmentation in black and Asian patients Contraindicated in pregnancy
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TOPICAL ANTIBIOTICS Erythromycin, Clindamycin, Decrease P.acnes and percentage of free fatty acids Slow to act Resistance often develops over time Best used in combination with topical retinoids/benzoyl peroxide Rare cases of pseudomembranous colitis w/ topical clindamycin
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BENZOYL PEROXIDE Bactericidal effect on P.acnes No evidence of resistance BP combined with a topical antibiotic may help decrease the presence of antibiotic resistant P. acnes Mild comedolytic action, decreases free fatty acids Adverse effects Irritation Bleaches clothing and hair Allergic contact dermatitis
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AZELAIC ACID Dicarboxylic acid that is bacteriostatic against P.acnes and normalizes keratinization Most effective when used with other agents Side affects uncommon Use in caution in teens w/ dark complexions due to potential risk of hypopigmentation
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SYSTEMIC ANTIBIOTICS Primarily used for moderate to severe inflammatory acne Decreases P.acnes Reduces amount of free fatty acids Preferred agents: Tetracyclin, Doxycyclin, Minocyclin High rates of resistance to Erythromycin
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HORMONAL CONTROL Oral contraceptive pills in females Increases production of sex hormone binding globulin leading to a decrease of circulating androgens Decreases ovarian androgen production Ortho tri-cyclen, Estrostep FDA approved for the treatment of acne Oral antiandrogens (spironolactone) can be useful Oral corticosteroids, short course for patients with severe inflammatory disease
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ISOTRETINOIN Systemic retinoid used for nodulo-cystic acne Most effective treatment with remission in 60% after single course (15-24 weeks) Reduces sebum production Normalizes follicular keratinization Decreases inflammation Baseline CBC, LFT’s, cholesterol, triglycerides, urinalysis, pregnancy test. Repeat monthly Post pubertal females must be on contraception and have two sequential negative pregnancy tests before starting
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ISOTRETINOIN Adverse effects Teratogenic (facial dysmorphism, abnormalities of brain, eye, ear, CV system, thymus) and retinoid embryopathy can occur with single exposure during gestation Drying/chapping of skin and mucous membranes Myalgias/arthralgias Photosensitivity GI effect: transaminitis, lipid abnormalities, pancreatitis Hematological: leucopenia, elevated platelets and ESR Neurological: pseudo tumor cerebri Renal: proteinuria, hematuria Mood disorders, depression, suicidal ideations and suicides
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MISCELLANEOUS THERAPY Comedome removal May be helpful if comedomes are resistant to other treatments Chemical peels Little evidence supporting efficacy Intralesional steroids Used for large inflammatory nodules/cysts Can be associated with local atrophy Topical tree oil One clinical trial documented effectiveness
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OVERVIEW OF THERAPY Mild acne: Topical therapy with retinoid for comedomes, add BP or topical antibiotic if mild inflammation present Moderate acne: Topical therapy plus oral antibiotics for inflammatory lesions, add BP to reduce antibiotic resistance. Consider OCP’s Severe acne: Accutane if topical therapy and oral antibiotics fail