1 OTH18-07-0203 DOP: August 2018 This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only. [Speaker Title] [Speaker Name] Acne Vulgaris • Explain the pathophysiology of acne • Demonstrate the assessment of acne • Select individualised management and treatment based on the latest clinical data and guidelines • Evaluate the psychological impact • Recognize when to refer to a specialist Learning Objectives Pre-Quiz 1 1. Where on the body is acne commonly found? 2. What is another name for an open comedone? 3. Name 2 types of acne lesions 4. What systemic treatment is recognised for severe or nodulocystic acne? OTH18-07-0203a DOP: Sept 2018 This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.
Transcript
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OTH18-07-0203 DOP: August 2018
This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.
[Speaker Title]
[Speaker Name]
Acne Vulgaris
• Explain the pathophysiology of acne
• Demonstrate the assessment of acne
• Select individualised management and treatment based onthe latest clinical data and guidelines
• Evaluate the psychological impact
• Recognize when to refer to a specialist
Learning Objectives
Pre-Quiz 1
1. Where on the body is acne commonly found?
2. What is another name for an open comedone?
3. Name 2 types ofacne lesions
4. What systemic treatment is recognised for severe or nodulocystic acne?
OTH18-07-0203a DOP: Sept 2018
This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.
2
Pre-Quiz 2
1. Name the 4 pathogenic factors of acne
2. Cite 4 patients types with acne who should be referred
3. List 4 potential psychological aspects of acne
4. Which treatment is strongly recommended for comedonal acne by the Primary Care Dermatology Society (PCDS)?
Background
• Acne is a common and chronic disorder of the pilosebaceous unit1
• Acne manifests in areas with larger, more numerous sebaceous glands,such as the face, neck, back, chest, shoulders and upper arms1
• Acne lesions can be separated into1,:
• Inflammatory (papules, pustules or nodules/cysts)
• Non-inflammatory (closed or open comedones, microcomedones)
• Most people with acne have a mixture of inflammatory and non-inflammatory lesions2
1. Williams HC, et al.. Lancet. 2012;379(9813):361-372. 2. Nast A, et al. http://www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne.
Epidemiology
Acne is one of the most common skin conditions in the United Kingdom1
Acne instigates 3.5 million visits to primary care practitioners every year1
1. Dawson AL, et al. BMJ. 2013 May 8;346:f2634. 2. British Skin Foundation (BSF). http://www.britishskinfoundation.org.uk/LinkClick.aspx?fileticket=DAHfKofYgBg%3d&tabid=172. Accessed June 2018
Acne affects 8/10 people aged 11-30 years in the
UK2
OTH18-07-0203a DOP: Sept 2018
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Prevalence
• Almost 90% of teenagers have acne and half will continue to experience acne into adulthood1
• Acne is more common in males during adolescence but in adulthood, incidence is higher in women2
– Acne in males generally resolves during their 20’s4
1. Dawson AL, et al. BMJ. 2013 May 8;346:f2634. 2. NICE CKS https://cks.nice.org.uk/acne-vulgaris. 3. Collier et al. JAAD 2008;58(1):56-9. 4. Goulden V, et al. 1999;41(4):577-580.
68.5%
42.5%
20.1%
12.0%
7.3%
66.8%
50.9%
35.2%
26.3%
15.3%
0.0% 20.0% 40.0% 60.0% 80.0%
Teenager
20‐29*
30‐39*
40‐49*
>50* Female Male
Ag
e (
y)
* P < 0.05
*
Prevalence of female and male acne in different age groups3
Adapted from Collier et al 2008
The Acne Disease Pathway1,2
Androgen hormone
influences and stimulates sebaceous
gland
Excessive sebum production
Hyperkeratinization
Sebaceous glands enlarge
Over production of epithelial cells
lining follicles
Microcomedone formation
A thick hyperkeratotic
plug
White heads and black heads form
Inflammation and immune response
Propionibacterium acnes colonization
in anaerobic environment
Formation of pustules and cysts
Scars
Pathogenic factors of acne
1. Excessive sebum production
2. Hyperkeratinization (abnormal cell turnover)
3. Inflammation and immuneresponse
4. P. acnes colonization
Goal of treatment: To target as many
pathogenic factors of acne as possible
Pathogenic factors of acne
1. Excessive sebum production
2. Hyperkeratinization (abnormal cell turnover)
3. Inflammation and immuneresponse
4. P. acnes colonization
Goal of treatment: To target as many
pathogenic factors of acne as possible
1
2
3
4
1. Nast A, et al. http://www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne. 2. NICE CKS https://cks.nice.org.uk/acne-vulgaris.
Changes in the ductal micro environment results in P. acnes
(ductal) colonisation
Changes in the ductal micro environment results in P. acnes
(ductal) colonisation
InflammationInflammation
Figure adapted from PCDS Guidance: Acne Vulgaris
Potential Triggers1-3
1. Thiboutot DM et al. J Am Acad Dermatol. 2018 Feb;78(2S1):S1-S23.e1. 2. Dréno B. J Eur Acad Dermatol Venereol. 2017;31(Suppl 5):8-12. 3. Bhate K et al. Br J Dermatol. 2013;168(3):474-485.
Family History Hereditary factors seem to play a large role in acne development.
Hormonal FactorsMany women note that their acne tends to get better and worse in cycles, related to their menstrual period. Roughly 70% of female patients note acne flare-ups in the days leading up to their period. Hormonal changes during pregnancy may also result in temporary acne flares.
Drugs Certain medications containing corticosteroids, anabolic steroids, lithium, ciclosporin and iodides.
Stress Psychological stress may exacerbate acne, but data is limited.
DietThe role of diet in acne is an evolving concept, as evidence is not strong, some people with acne have reported improvement in their skin following a low-glycaemic index diet.
Cosmetics Caused by oil-based cosmetics
Assessment • Duration1
• Family History1
• Treatment Response1
• Therapy Adherence1
• Exacerbating Factors1
• Differential Diagnosis1
• Systemic Features1
• Underlying Cause1
1. NICE CKS https://cks.nice.org.uk/acne-vulgaris. 2. Nast A, et al. http://www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne. 3. Bhate K, et al. Br J Dermatol. 2013;168(3):474-485.
Key – Patient/Prescriber Relationship2
• Persistent/Late-Onset1
• Lesion Type + Location1
• Lesion Severity1
• Psychosocial Impact1
• Scarring2
• Pigmentation3
• Patient Education1
• When to Refer1
OTH18-07-0203a DOP: Sept 2018
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1. NICE CKS https://cks.nice.org.uk/acne-vulgaris. 2 Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S1-37. 3. Tasoula E, et al. An Bras Dermatol. 2012;87(6):862-869. 4. Nast A, et al.http://www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne. 5. Baldwin HE. Cutis. 2002;70(2):133-139.
*Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing.
• Topical retinoids should be used for all grades of acne1
• Irritation with topical retinoids and BPO can be ameliorated by gradual introduction1
• Concurrent use with light non-comedogenic emollients may be useful1
• Azelaic acid may be beneficial in patients with darker skin1
• BPO can cause bleaching of fabric1
• Oral antibiotics should not be used as sole treatment1
• Combine systemic antibiotics with topical agents to reduce bacterial resistance2
• All treatments should be routinely reviewed at 12 weeks2
• Early intervention can help avoid permanent scarring
• Treatments used correctly can take at least two months to show improvement
• Irritation may occur with treatments so build up treatments gradually
• Use oil-free or non-comedogenic soap substitutes, moisturisers and makeup
• Little evidence that foods cause acne, but a balanced diet will benefit health overall
1. BAD Acne. 2017. http://www.bad.org.uk/shared/get-file.ashx?id=65&itemtype=document.
Global Antibiotic Resistance
1. Tagliabue A. Front Immunol. 2018;9:1068. 2.Antimicrobial Resistance https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
Asia4,730,000
Oceania22,000
Africa4,150,000
Europe390,000
North America317,000
Latin America392,000
Adapted from: Review on Antimicrobial Resistance 20142
Deaths attributable to antimicrobial resistance every year by 20501
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A call to limit antibiotic use in acne1
• There is significant and often prolonged antibiotic use in acne
• P. acnes is only one of the 4 pathogenic factors
• Topical retinoid + antimicrobial is now first line treatment
• Reports that more than 50% of P. acnes strains are resistant
• Do not use antibiotics as monotherapy or combine topical and systemic antibiotics
• Benzoyl peroxide (BPO) and systemic antibiotics should be combined with a topical retinoid
1. Thiboutot D, et al. J Drugs Dermatol. 2013;12(12):1331-1332.
Scarring
Atrophic scars: the most common type, are caused by collagen loss and present as skin indentations1
Ice pick scars: are usually narrow (<2 mm), deep, sharply demarcated tracts1
Rolling scars: are usually wider (4 to 5 mm) and more shallow with an undulating appearance1
Boxcar scars: are either shallow (<0.5 mm) or deep (>0.5 mm) round- to oval-shaped skin dimples with sharp margins1
Hypertrophic acne scars and keloids: are firm, raised papule or plaque, characterized by collagen gain subsequent to an acne lesion resolution - hypertrophic scars do not extend beyond the original wound margin and keloids extend beyond the margin1
Hyperpigmentation - not technically a scar, these are red or dark marks that remain after the spot has cleared2
1. Ankit S, et al. Int J Sci Invent Today. 2018;7(3):614-631. 2. Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S1-37.
• Acne is a very common and chronic problem, that affects both adolescents and adults1
• It causes physiological and psychological scarring for many people2
• Patient education on the condition and treatments may improve theirquality of life throughout the disease process3
1. Williams HC, et al.. Lancet. 2012;379(9813):361-372. 2. Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S1-37.3. NICE CKS https://cks.nice.org.uk/acne-vulgaris.
OTH18-07-0203a DOP: Sept 2018
This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.
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Pre-Quiz 1 - Answers
1. Where on the body is acne commonly found?
2. What is anothername for an open comedone?
3. Name 2 types of acne lesions
4. What systemic treatment is recognised for severe or nodulocystic acne?
Acne mostly occurs on the face. However, acne can form anywhere there is a
concentration of oil glands, including on
the neck, back, upper chest, and shoulders.1
Blackhead.1
Papules, pustules, nodules or cysts.1
Oral isotretinoin.2
1. Williams HC, et al.. Lancet. 2012;379(9813):361-372. 2. Bewley T, et al. http://www.pcds.org.uk/ee/images/uploads/general/Acne_Treatment_2015-web.pdf
Pre-Quiz 2 - Answers
1. Name the 4 pathogenic factors of acne
2. Cite 4 patients types with acne who should be referred
3. List 4 potential psychological aspects of acne
4. Which treatment is strongly recommended for comedonal acne by the Primary Care Dermatology Society
(PCDS)?
(1) Sebaceous gland hyperplasia with seborrhoea;
(2) Altered follicular growth and differentiation;
(3) Propionibacterium acnes; (4) Inflammation and immune
response.1
(1) Patients with severe acne – refer early2;(2) Moderate acne only partially responding to treatment and
starting to scar and/or causing significant hyperpigmentation2;
(3) Patients with associated and severe psychologicalsymptoms, regardless of physical signs2;
(4) Patients where there is diagnostic uncertainty3; (5) Patients failing to respond to multiple therapeutic
interventions.3
Stress; anxiety and depression; social implications; occupational implications; self-esteem; body
*Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing.
*Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing.
Moderate to severe acne
• 17 year old male
• Embarrassed by spots on face
• Doesn’t want to change for PE and wears a T-shirt under school shirt
*Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing.
OTH18-07-0203a DOP: Sept 2018
This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.
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Severe Acne
• 20 year old man
• Had acne since the age of14 years
• Has been self-conscious aboutit for 6 months
• Has had one short course of antibiotics – worked initially butwhen discontinued came back
*Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing.
Top Tips in Managing Acne1,2
• Main aim of treating acne is to prevent scarring, so monitor the patient for evidence of scarring
• Discuss key elements with the patient - family history and “no cure” for acne
• Explore how acne affects the patients quality of life
• Examine the areas affected and grade as mild, moderate, severe or use Leeds acne grading system including back and chest if affected
• Explain to the patient the 4 pathogenic factors of acne: (1) Excessive Sebum; (2) Abnormal skin cell turnover; (3) Inflammation; (4) P. Acnes
• Explain how the treatment fits in with the above factors
• Educate on topical treatments and how to build them up slowly
• Use non – comedogenic moisturiser/make-up
• Discuss antibiotics and length of use – no longer than 3 months
