Kimberly A. Horii, MDProfessor of Pediatrics

Children’s Mercy Hospitals & ClinicsDivision of DermatologyKansas City, Missouri

Pimples Galore: Management of Teenage Acne

Pimples Galore: Management of Teenage Acne

I have no financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity

I do not intend to discuss off label use of a commercial product/device in my presentation

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Practice Change

As a result of attending this lecture, I encourage you to make the following changes in your practice:

Comfortably assess a patient presenting with acne vulgaris.

Devise an initial treatment plan for patients with acne vulgaris.

Recognize possible side effects/risks of medications used to treat acne vulgaris. 3

Acne Vulgaris

An estimated 45 million people in the United States have acne vulgaris

85% of adolescents and young adults are affected By age 18 as many as 25% of adolescents will

have scarring attributable to acne

Acne Vulgaris

Associated with significant physical & psychological morbidity– Permanent scarring– Painful lesions– Low self esteem– Emotional distress– Depression or anxiety– Social isolation

Acne Myths?

Is acne caused by – Dirt or poor hygiene?– Diet? Worse with high glycemic index diets? Link to dairy intake?

– 1% milk or skin milk

Is acne exacerbated by stress?6

Clinical Manifestations of Acne Non inflammatory lesions

– closed comedones– open comedones

Inflammatory lesions– papules– pustules– nodules– cysts

Scars– pits– depressions– hypertrophic scars and keloids 7

Open Comedone “Black Head” Papule with dark center

Obstructed follicle with a dilated orifice

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Closed Comedone “White Head”

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White or skin colored papule

Obstructed follicle filled with cellular debris

Papules and Pustules Erythematous papules or yellow pustules

Obstructed hair follicle with surrounding inflammation

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Cysts

Deep dermal nodule May have surrounding

inflammation Painful Risk of scarring

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Scars Pitted scars

Atrophic scars

Hypertrophic scars

Keloids

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Acne in Different Age Groups

Neonatal acne

Infantile acne

Adolescent acne

Adult onset acne

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Atypical Presentations of Acne Acne initially appearing in early childhood (between the ages

of 1-7 years) may be a marker of underlying hormonal abnormalities– Precocious puberty

Assess for other clinical signs of hyperandrogenemia– Pubertal development

– Hirsutism, clitoromegaly

– Consider evaluation for precocious puberty or premature adrenarcheor referral to endocrine 14

Adolescent Acne Onset as early as age 8-9 (increase in DHEAS and sebum

production)– Preadolescent acne 8-12 years (or menarche)

– Adolescent acne >12 years (or menarche)

Usually begins with non-inflammatory comedones on the central face

Increase in number of inflammatory lesions with advancing pubertal stage

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Acne Patient Evaluation Thorough history

– Duration/age of onset of acne– Medications used to treat acne– Other medications currently using

May lead to acneiform eruptions

– Type of cosmetics/hair oils Pomade acne

Acne cosmetica

– Occupation/recreational activities– Other medical problems 16

Patient Evaluation Review of systems

– Regular menstrual cycles? PCOS (alopecia, hirsutism, acne)

– Premenstrual flares?

Physical Exam– Face– Neck– Chest– Back 17

Acne Severity

Various forms of assessing acne severity– Based on number and type of non-inflammatory and

inflammatory lesions– Often categorized into

Mild

Moderate

Severe18

Evidence-based Recommendations for Management of Acne vulgaris

Eichenfield LF et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics 2013;131 Suppl 3:S163-186.

Zaenglein AL et al Guidelines of care for the management of acne vulgaris. J Am AcadDermatol 2016;74:945-973.

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Treatment of Acne Vulgaris

Educate patients Compliance is key! Treatment takes time (at least 6-8 weeks before

significant improvement is noted) Objective is to prevent the formation of future

lesions and scarring20

Treatment Options Topical Therapy

– Topical Benzoyl peroxide– Topical combination Benzoyl peroxide & antibiotic – Topical retinoids

Systemic Therapy– Oral antibiotics– Hormonal therapy– Oral retinoids

Light or Laser Therapy? 21

Benzoyl Peroxide Indicated for mild to moderate inflammatory acne Nonspecific mode of antibacterial action through oxidizing

activity Use once daily Available with or without a prescription in 2.5-10% cream,

gel, lotion, or wash Side effects

– Erythema, dryness, peeling, bleaching of clothing– Rare contact dermatitis 22

Combination Topical Therapy Combinations of benzoyl peroxide and a topical antibiotic

improve inflammatory acne and decrease the development of P. acnes resistance– Erythromycin & benzoyl peroxide QD-BID (Benzamycin®)

– Clindamycin & benzoyl peroxide QD-BID (Benzaclin®, DUAC®, Acanya® and Onexton®)

Topical antibiotics should not be used as monotherapy

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Topical Retinoids Indicated for non inflammatory/comedonal acne Therapeutic effects of topical retinoids

– Normalizes desquamation of the follicular epithelium

– Prevents formation of new comedones and resolves old comedones(comedolytic-unplugs the pores)

Daily application Side effects

– Irritation, erythema, dryness, sun sensitivity24

Topical Retinoids Tretinoin (Retin-A®) 0.025%, 0.05%, and 0.1% cream &

0.01% and 0.025% gel

Retin-A micro® (Incorporation of Tretinoin into microsponges) 0.04% or 0.1% gel

Adapalene (Differin®) 0.1% or 0.3% gel, 0.1% cream, and 0.1% lotion

Tazarotene (Tazorac®) 0.05% and 0.1% cream or gel– Pregnancy Category X 25

Topical Retinoid Combination Products

2.5% benzoyl peroxide & 0.1% adapalene gel (Epiduo®)-once daily application

Clindamycin phosphate 1.2% gel & tretinoin0.025% gel (Ziana®)-once daily application

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Oral Antibiotics Indicated for moderate to severe inflammatory acne not

responsive to topical therapy Bactericidal and antiinflammatory Decrease P. acnes colonization Inhibit neutrophil chemotaxis Reduces free fatty acids in sebum Should not be used as monotherapy ? Length of treatment 27

Oral Antibiotics Tetracycline (250-500 mg QD-BID)

– Not commonly prescribed

Doxycycline (50-100 mg QD-BID)– Photosensitivity

– GI upset/esophagitis

Minocycline (50-100 mg QD-BID)– Multiple possible side effects

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Minocycline Possible side effects

– Hyperpigmentation

– Vertigo like symptoms

– Arthralgia and arthritis

Severe adverse reactions– Drug induced lupus (late reaction pattern)

– Serum sickness like reaction

– Benign intracranial hypertension (pseudotumor cerebri)

– Autoimmune hepatitis

– Hypersensitivity syndrome reaction (fever, rash, LAD, malaise, facial swelling) 29

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Hormonal Therapy Adjunctive treatment option for females with recalcitrant

acne Lowers circulating and local androgen levels

– Reduces sebum production

Reduction of androgen expression– Oral contraceptives

Androgen receptor blockers– Spironolactone (pregnancy category C)

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Candidates for Hormonal Therapy

History of failed standard acne therapies

History of menstrual irregularities

Premenstrual flares of acne

Hirsutism

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Oral Contraceptives Can improve acne in adolescent females and women

Ideally a combination oral contraceptive consisting of ethinylestradiol with a progestin having low intrinsic androgenicity

FDA approved for contraception and acne vulgaris– Norgestimate (Ortho-Tri-cyclen®)– Norethindrone (Estrostep®)– Drospirenone (Yaz®)

?increased risk of clots 33

Contraceptives Which May Worsen Acne

Long acting progestin-only contraceptives– Depot injections

Medroxyprogesterone

– Subdermal implants Etonogestrel

– Hormone intrauterine devices Levonorgestrel

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Systemic Retinoids Indicated for patients with severe or refractory inflammatory

or nodulocystic acne Isotretinoin (13-cis retinoic acid) previously known as

Accutane®– Now only available in generic brands

Analogue of Vitamin A Human teratogen, many adverse side effects Pregnancy Category X

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Isotretinoin Side Effects• TERATOGEN• Hypertriglyceridemia• Hepatotoxicity• Muscle pain• Bone and joint pain

– Hyperostosis

– Calcification of tendons/ligaments

• Headache– Benign intracranial hypertension

(pseudotumor cerebri)

• Diminished night vision

Mucocutaneous effects Dry skin, lips, eyes

Epistaxis

Photosensitivity

Hair thinning/loss

Erythema

Possible mood changes/depression

Possible inflammatory bowel disease

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Isotretinoin and Depression

Unclear if there is a specific causal link between depression and Isotretinoin use

Reconsider treatment options if patient or family has a history of depression or a psychiatric disorder

Patients should be advised to immediately report mood swings or symptoms suggestive of mood changes

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Risk Management Program

FDA has required all prescribers, patients (male & female), and pharmacies be registered with a national database and comply with all requirements

– iPLEDGE

Appropriately timed and documented negative pregnancy tests and pregnancy prevention counseling are required before Isotretinoin can be dispensed for females

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Alternative Treatment Options? Topical antioxidants

– Vitamin C– Nicotinamide

Botanicals– Green Tea– Tea Tree Oil (Melaluca)

High irritation potential

Dietary modification– Lower carbohydrate/glycemic index diet– Limit dairy intake 39

Acne Management

How do you decide which medications to prescribe? Depends on several factors

– Severity and type of acne lesions

– Patient’s past medication experiences and personal preferences

– Availability and cost of medications

Combination therapy is recommended

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Acne Combination TherapyAcne Severity Recommended Treatment

Mild

Moderate

Severe

Topical Benzoyl PeroxideTopical Antibiotic/Benzoyl Peroxide ComboTopical Retinoid

Topical Benzoyl PeroxideTopical Antibiotic/Benzoyl Peroxide ComboTopical RetinoidOral AntibioticHormonal TherapyConsider Referral to Dermatology

Topical Benzoyl PeroxideTopical Antibiotic/Benzoyl Peroxide ComboTopical RetinoidOral AntibioticHormonal TherapyReferral to Dermatology for Oral Retinoid

Acne Conclusions

Acne is a common skin condition May cause significant psychosocial effects Multiple treatment options Consider referral of atypical/recalcitrant cases

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Practice ChangeAs a result of attending this lecture, I encourage you

to make the following changes in your practice: Comfortably assess a patient presenting with acne

vulgaris Devise an initial treatment plan for patients with

acne vulgaris Recognize possible side effects/risks of medications

used to treat acne vulgaris 43

Acne ReferencesJames WD. N Engl J Med 2005;352:1463-1472.

Yentzer BA et al. Cutis 2010;86:94-99.

Fried RG et al. Semin Cutan Med Surg 2010 29:9-12.

Halvorsen JA et al. J Invest Dermatol 2010;131:363-370.

Saitta P et al. Cutis 2011;88:92-97.

Schroeder RE et al. Cosmet Dermatol 2012;25:66-70.

Adebamowo CA et al. J Am Acad Dermatol 2008;58:787-793.

LaRosa CI et al. J Am Acad Dermatol 2016;75:318-322.

Bowe WP et al. J am Acad Dermatol 2010;63:124-141.

Choi JM et al. Cosmetic Dermatol 2005;18(8):571-577. 44

Acne ReferencesChui A et al. Arch Dermatol 2003;139(7):897-900.

Veith WB et al. Cutis 2011;88:84-91.

Eichenfield LF et al. Pediatrics 2013;131:s163-S186.

Zaenglein AI et al. J Am Acad Dermatol 2016;74:945-973.

Cantatore-Francis JL et al. Dermatol Ther 2006;19:202-209.

Harper JC. J Drugs Dermatol 2008;7(6):527-520.

Goldberg JL et al. Pediatr Dermatol 2011;28(6):645-648.

Mornin SB et al. J Drugs Dermatol 2010;9(6):627-636.

Eichenfield LF et al. Semin Cutan Med Surg 2010;29:13-16.

Thiboutot D et al. J Am Acad Dermatol 2009;60:S1-50. 45

Acne ReferencesGhali F et al. Cutis 2009;83 (suppl 2):4-15.

Rosen T. J Drug Dermatol 2011;10(7):724-733

Patel M et al. J Drug Dermatol 2010;9(6):655-664.

Thiboutot D et al. J Am Acad Dermatol 2009;60:S1-50.

Webster GF. J Drugs Dermatol 2011;10(6):636-644.

Lortscher D et al. J Drugs Dermatol 2016;15(6):670-674.

Lam C et al. Clin Dermatol 2014;32:502-515.

Fanelli M et al. Arch Dermatol 2011;147(8):917-921.

Brown RJ et al. Arch Dermatol 2009;145(1):63-66.

Junkins-Hopkins et al. J Am Acad Dermatol 2010;62:486-488. 46

Acne ReferencesO’connell K et al. Cutis 2008;81(suppl 1):8-12.

Rich P. Cutis 2008;81(suppl 1):13-18.

Cao H et al. Cochrane Database of Systematic Reviews 2015, Issue 1. Art No.: CD009436.

American Academy of Dermatology Consensus Conference on the Safe and Optimal Use of Isotretinoin. J Am Acad Dermatol 2004;50:900-906.

Del Rosso JQ. J Clin Aesthetic Dermatol 2012;6(11):17-24.

Bremner JE et al. Am J Psychiatry 2005;162:983-991.

Chia CY et al. Arch Dermatol 2005;141(5):557-560.

Sundstrom A et al. BMJ 2010 Nov 11;341:c5812.doi:10.1136/bjm.c5812.

Wysowski D et al. Arch Dermatol 2005;141:640-641.

Alikhan A et al. J Am Acad Dermatol 2011;65(3):650-654. 47

Acne ReferencesCrockett SD et al. Am J Gastroenterol 2009;104:2387-2393.

Crockett SD et al. Am J Gastroenterol 2010;105:1986-1993.

Etminan M et al. JAMA Dermatol 2013;149(2):216-220.

Haedersal M et al. JEADV 2008;22:267-278.

Kim GK et al. J Drugs Dermatol 2010;9(6):614-621.

Sakamoto FH et al. J Am Acad Dermatol 2010;63:183-193.

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