Acne

Question 1

What is the proper name for acne, what are some common names?

Answer 1

acne vulgaris, common names are pimples, spots, zits

Question 2

Where does acne grow?

Answer 2

Acne most often affects the face, but it may spread to

involve the neck, chest and back, and sometimes even more extensively over the body.

Question 3

What is the incidence (% of people with acne)? Is it chronic?

Answer 3

80% of people between 11-30 years old,
20-30% of 20-40 years old
Earlier onset and more persistent in females, severe in males 15%
50% of cases (especially females) persist into adult years.
It is usually considered self-limiting since it subsides in the mid-late 20s but may evolve into a chronic condition

Question 4

Describe treatment effectiveness and adherence?

Answer 4

Treat it like other chronic conditions, proper treatment can control disease and morbidity. Treatment is effective but adherence poor (30-65% of patients do not adhere to treatment, and 50% do not achieve full benefit due to poor adherence)

Question 5

How to improve adherence?

Answer 5

Choose treatment based on symptoms, skin type and skin sensitivity, risk of adverse effects and patient’s preference
Improved treatment satisfaction is likely to adherence

Question 6

What is the general pathophysiology?

Answer 6

• Increased sebum production (androgens may play a
  role) and Increased follicular keratinization
• Proliferation of bacteria which results in lipolysis of
  sebum triglycerides to free fatty acids (bacteria
  feast on the triglycerides)
• Inflammation

Question 7

How is a comedo formed?

Answer 7

• increased androgen production -> increased sebaceous gland size and activity -> increased sebum production
• increased keratinization of the epithelial cells cause obstruction of the follicle forming a dense plug
• Sebum becomes trapped and accumulates forming a comedo
• Comedo contains oily sebum, keratinized cells, bacteria
• Sebum continues to be produced -> comedo continues to grow

Question 8

How do Cutibacterium acne (C. acnes) grow?

Answer 8

feeds off sebum
- C. acnes hydrolyzes the sebum triglycerides into free fatty acids
- Fatty acids increase keratinization feeding into the cycle of more
microcomedones
-> Increase of C. acnes leading to T cell response and inflammation
polymorphonucleocytes move to follicle and bacteria release chemokines - formation of pus

Question 9

What are the terms to describe acne and its different presentations?

Answer 9

Papule, pustule, nodule, cyst

Question 10

Describe papule

Answer 10

Solid, elevated lesion <5mm

Question 11

Describe pustule

Answer 11

Vesical filled with purulent liquid <5mm

Question 12

Describe nodule

Answer 12

Deep lesion. Warm, tender, firm >5mm diameter. May result in scarring

Question 13

Describe cyst

Answer 13

A nodule containing liquid, may result in scarring

Question 14

What does increase in C. acnes lead to?

Answer 14

T-cell response leads to inflammation. Polymorphonucleocytes move to the follicle, bacteria releasing chemokines -> pus formation

Question 15

Non-inflammatory comedones, white heads vs black heads?

Answer 15

White head
• Closed comedone
• First clinically visible
lesion of acne
• Completely obstructed

Black head
• Open comedone
• Dark color due to
contents of the
comedone being
oxidized (lipid and
melanin)

Question 16

What are contributing factors of acne (6 main ones and 1 controversial theoretical one).

Answer 16

1. Genetic predisposition
2. Emotional stress
3. Hormones - Pregnancy, oral contraceptive pills
4. Occlusion (greasy products on the skin, clothing, sweating) - Coal tar, oily products, Physical occlusion from hats, helmets, headbands
5. Picking at lesions
6. Bacteriostatic soaps (e.g. hexachlorophene) are acnegenic
   ? Dietary factors (controversial theory)
    Correlation with Western diet
    ? Milk
    High glycemic index foods (e.g. white rice, white bread)

Question 17

What are some drugs that induce acne? (12)

Answer 17

 Anabolic steroids
 Corticosteroids
 Testosterone
 Progesterone
 Phenytoin
 Lithium
 Phenobarbital
 Azathioprine
 Cyclosporine
 Isoniazid
 Disulfiram
 Quinidine

Question 18

How to go about assessment? ie what things to look for? (8)

Answer 18

Symptons, characteristics, history, onset, location, aggravating factors, remitting factors, explanatory model.

Question 19

What to ask about symptons?

Answer 19

Itch? Pain? Any systemic symptoms? Psychological symptoms?

Excessive hair growth (PCOS)? Weight gain?

Question 20

What to ask about characteristics?

Answer 20

Number and type of lesions present? Distribution of lesions?

Scarring? Hypo- or hyperpigmentation? Inflammation? Signs and symptoms of infection?

Question 21

What to ask about history?

Answer 21

How long? Does it come and go? Have you experienced this before? What have you tried?

Question 22

What to ask about onset?

Answer 22

When did it start? What were you doing? Anything change in your life at that point?

Question 23

What to ask about location?

Answer 23

Where is it?

Question 24

What to ask about aggravating factors?

Answer 24

What make it worse? Probe with specific examples. Diet probing, occlusion due to helmets, masks, etc

Question 25

What to ask about remitting factors?

Answer 25

What makes it better? Probe with specific examples.

Question 26

What to ask about explanatory model?

Answer 26

How does this symptom or condition affect you?

Question 27

How does acne affect people?

Answer 27

``` 1. Physical symptoms  Soreness  Itching  Painful 2. Psychosocial symptoms (studies show 50% of patients have symptoms of mild to moderate depression and anxiety)  Low confidence  Low self-esteem  Withdrawing from society  Depressive symptoms ```

Question 28

What global scales are used to access the impact of acne?

Answer 28

DLQI - dermatology life quality index, introduced in PMCO 4 | Acne Quality of Life Scales

Question 29

What are some red flags with acne? (7)

Answer 29

- Acne is drug-induced or due to a known endocrinopathy (e.g., polycystic ovarian syndrome as it may be suspected with hirsutism, weight gain) - Systemic symptoms are present (fever, malaise) - Psychological assessment is required - Acne at a very young age (may need endocrinology consult) - Moderate to severe acne requiring prescription therapy (asses your competency to manage acne) - Acne that is nonresponsive to initial therapy - Presence of scarring, especially if moderate to severe

Question 30

What are 2 differential diagnosis to acne?

Answer 30

1. Perioral dermatitis - excessive steroid use - erythema, scaling, papulopustular lesions around nasiolabial folds, mouth and chin - topical steroids on face - refer 2. Rosacea  Chronic, relapsing condition involving blood vessels  Flushing (redness or erythema), followed by development of inflammatory lesions  Refer to dermatologist

Question 31

Describe perioral dermatitis

Answer 31

```  Due to excessive use of steroids on the face  Erythema, scaling and papulopustular lesions clustered around the nasolabial folds, mouth and chin.  D/c use of topical steroids on face and refer to dermatologist for management ```

Question 32

Describe rosacea

Answer 32

```  Chronic, relapsing condition involving blood vessels  Flushing (redness or erythema), followed by development of inflammatory lesions  Refer to dermatologist ```

Question 33

What are 2 variants of acne?

Answer 33

Neonatal acne | Acne conglobata

Question 34

Describe neonatal acne

Answer 34

```  One in 5 infants ≤3 months of age may develop papules, pustules, closed or open comedones on face  Due to placental transfer of maternal androgens (neonatal acne)  Usually resolves on its own but topical agents under the advice of a paediatrician may be used. ```

Question 35

Describe acne conglobata

Answer 35

```  When acne cysts and nodules fuse together deep in the skin.  A form of nodulocystic acne (rare but serious inflammatory skin condition)  Face, back, and chest  Refer! Requires aggressive management with systemic therapy and cosmetic approaches (lasers). ```

Question 36

What are the 4 goals of therapy for acne?

Answer 36

1. Clear existing lesions 2. Prevent new lesions 3. Treat early to minimize scarring, hypo/hyperpigmentation 4. Minimize psychological impact

Question 37

Treatment -> Non-pharm

Answer 37

1. Address contributing factors and introduce lifestyle/self-care measures 2. Do not pick and touch lesions 3. Cleansing  No more than twice daily  Suggest cleansers that are mild and unscented  Do not scrub skin 4. Cosmetics  Use oil-free make-up, try to avoid multiple layers  Wash off at night!  Hairspray can clog pores, discontinue if possible or wear a headband over exposed skin. 5. Educate on stress management 6. Encourage a well balanced diet 7. Cationic (C) bond strips  Activated by water, dirt/oil is anionic, strip adheres to this molecules and removes it when strip peeled off  Temporary improvement in appearance of skin but limited permanent change 8. Comedone Extraction  Efficacy may be enhanced if pretreated with a peeler (i.e. glycolic acid, salicylic acid)

Question 38

Treatment - Pharm

Answer 38

- Thousands of non-prescription acne products available - Different brands, products within the same brand contain varying concentrations of the same medicinal ingredients  Benzoyl peroxide  Salicylic acid  Glycolic acid - Instead of memorizing product names, always look at the active ingredient list on the product label.

Question 39

Topical Benzoyl Peroxide details ``` when to use strength MOA Vehicles Administration Response time AE ```

Answer 39

When to use: First line for mild-moderate acne as monotherapy, combination Strength: - 2.5-5% most common - BPO > 5% no more effective and more irritating - Unscheduled: strength <5% - Schedule I: >5%, combination product with a topical antibiotic or retinoid Mechanism of action: Antibacterial: oxidation of bacterial proteins. Eliminates C. acnes on the surface of the skin and sebaceous follicle. Effective in the prevention of bacterial resistance. - Mildly comedolytic Vehicles: Gel, cream, solution, lotion, wash, soap • Avoid recommending washes, soaps -> little contact time with the face = least effective Administration: Apply topically to entire affected area To minimize irritation, start with applying for 15 mins 1st night, 30 mins 2nd night, increase to over night eventually Response time: • Rapid bactericidal effects may start seeing a decrease in inflamed lesions ~5 days. See optimal improvement 8-12 weeks Adverse effects • Dryness, peeling, erythema, burning, bleaches clothing, smell that lingers (body odor) Other counseling • Decrease irritation at initiation by decreasing frequency (eg. apply every 2-3 days, various regimens) • Sunscreen during the day, BP at night • Can bleach hair/ clothing • PRACTICAL TIP: use at night to avoid staining of clothes Examples: Non-prescription • Neutrogena On-the-Spot (2.5% benzoyl peroxide) Prescription • BenzaClin gel (benzoyl peroxide 5% clindamycin 1%) - Rx

Question 40

``` Salicylic acid details when to use strength MOA Vehicles Administration Response time AE ```

Answer 40

Schedule U: in topical preparations in concentrations <40% Mechanism of action: Mildly comedolytic Keratolytic, mildly antibacterial, mildly antiinflammatory Available strengths: 0.5-3.5% daily-BID Vehicles: Gels, toners, cleansers, washes, pads Adverse effects: Drying, burning, stinging, erythema, pruritus, peeling ``` Other • Well tolerated • Less potent than equal strength benzoyl peroxide • 8-12 weeks time to effect ```

Question 41

Glycolic acid details ``` schedule strength MOA Vehicles Administration Response time AE ```

Answer 41

Schedule: U Mechanism of action: Mildly comedolytic, causes desquamation Available strength: 2-15% (40% used as a peel) Vehicles: • solution, gel, lotion, cream; • apply once to BID Adverse effect: Burning, stinging, erythema, dryness, pruritus Other: • At higher concentrations used for chemical peels • 6-7 weeks time to effect

Question 42

zinc acetate or zinc gluconate details ``` schedule strength MOA Vehicles Administration Response time AE ```

Answer 42

``` Schedule: U Mechanism of action: Absorb excess sebum Available strengths: n/a Vehicles: cleansers Adverse effects: burning, stinging Other: • Well tolerated • Time to effect? Assess for improvement @ 4-8 weeks ```

Question 43

Resorcinol details

Answer 43

Schedule: U Mechanism of action: Keratolyltic (mild) and bactericidal and fungicidal Available strengths: 1-2% (+ sulfur, salicylic acid) Vehicles: Variety of formulations Adverse effects: • Burning, stinging (Do not apply to large areas of skin or broken skin) • Can pigment skin in darker individuals Other: • Needs protective packaging because reactive to light and O2. • Time to effect? Assess @ 4-8 weeks

Question 44

ProActiv

Answer 44

 Very expensive “acne system” |  Contains mostly benzoyl peroxide 2.5% and sulphur

Question 45

Mask-ne

Answer 45

Due to occlusion of the skin around the perioral region and jawline: - Hormonally dependent area (more so in females) Development of blackheads and white heads along the mask line ``` Management: - Non Pharm:  Wash mask frequently  Choose a cotton mask  Follow general care measures as discussed ``` ``` - Pharm:  OTC Benzoyl Peroxide  OTC Salicylic Acid  Prescription: Topical Retinoid, Topical Dapsone, BP + Topical Antibiotics ```

Question 46

Patient education (6) things to tell them to be aware of

Answer 46

1. Therapy needs to be used for an extended period of time with a switch to maintenance therapy once control established (recall the cascade of acne development). 2. Frame patient’s expectations. Empathy from and encouragement from clinician enhances adherence. 3. Those with darker skin tones are more susceptible to hyperpigmentation. - Need early and aggressive treatment - Therapy duration is longer in these individuals 4. Encourage sunscreen use - Avoid sunscreens with acnegenic benzophenones 5. Assess adherence and implement strategies to enhance adherence 6. Maintain a balanced, low-glycemic-load diet

Question 47

Monitoring for patient

Answer 47

Encourage patient to record their treatment response in a diary - Timeframe 4-8 weeks for monitoring - Lesion count and type (blackheads, white heads, pustules) - Inflammatory lesions (weeks?) - Anxiety/depressive symptoms - The amount and time frame of acne free periods - Scarring or pigmentation

Question 48

Follow up for patient

Answer 48

may take several months (2-4 months or longer) to see results. However, it may be beneficial to check in with the patient within a few days of initiating therapy to see how the patient is tolerating therapy. Future follow-up periods can be extended as applicable and based on parameters that patient monitors.