EFFECTIVE PRIMARY CARE MANAGEMENT OF ACNE VULGARIS

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1 EFFECTIVE PRIMARY CARE MANAGEMENT OF ACNE VULGARIS

2 WHY ACNE? EXCESS OIL PRODUCTION BY OVERACTIVE SEBACEOUS GLANDS. IMPROPER CELL TURNOVER/EXFOLIATION CLOGS PORES. DISRUPTED OXYGEN SUPPLY ALLOWS P. ACNE BACTERIA TO GROW AND MULTIPLY => INFLAMMATION OTHER FACTORS THAT CAN CONTRIBUTE OR EXACERBATE THE CONDITION INCLUDE: HORMONES (PREMENSTRUAL, PREGNANCY, PCOS) ENVIRONMENTAL FACTORS (SMOKING!)/UV ADDITIONAL BACTERIA IN CONTACT WITH SKIN S SURFACE IMPROPER CLEANSING/MOISTURIZING

3 WHO IS PRESENTING WITH ACNE? 3.5 MILLION GP VISITS A YEAR IN UK LIFETIME PREVALENCE 85%, AND 20% OF THOSE ARE MODERATE OR SEVERE WOMEN SEEK TREATMENT EARLIER AND FOR LONGER Male Female Teenagers 90% 90% Over 25 40% 54% Over 40 1% 5%

4 THEORIES OF MANAGEMENT ANTI-BACTERIAL INGREDIENTS CONTROL THE SPREAD OF P.ACNES CONTROL OIL PRODUCTION TO PREVENT CLOGGED PORES. ANTI-INFLAMMATORIES TO REDUCE IRRITATION ASSOCIATED WITH BREAKOUT. RETINOIDS TO HELP PROMOTE CELL TURNOVER.

5 ACNE IS HIGHLY SUBJECTIVE STUFF GET THE HISTORY AGE OF ONSET FAMILY HISTORY CURRENT SKINCARE AND CONTRACEPTION REGIME PREVIOUS TREATMENTS, DURATION AND COMPLIANCE AREAS OF INVOLVEMENT FACE/BACK/SHOULDERS? OTHER DRUGS ESP OCP AND STEROID MISUSE

6 GRADE YOUR ACNE MILD PAPULES PUSTULES COMEDONES MODERATE ABOVE + SCARRING PSYCHOLOGICAL ISSUES SEVERE ABOVE WITH NODULAR-CYSTIC LESIONS PSYCHOLOGICAL ISSUES

7 Propionibacterium acnes

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9 MILD ACNE ANTI INFLAMMATORY & ANTI MICROBIAL TREATMENTS PROFOUNDLY IRRITANT NEED TO BUILD A TOLERANCE BLEACHES CLOTHING/PILLOWS ACNECIDE - BENZOYL PEROXIDE 5% GEL BREVOXYL BENZOYL PEROXIDE 4% CREAM QUINODERM BENZOYL PEROXIDE 5 & 10% CREAM PANOXYL BENZOYL PEROXIDE 2.5, 5 & 10% CREAM / GEL / WASH

10 MILD ACNE COMEDOLYTIC TREATMENTS CAN CAUSE SKIN IRRITATION GOOD FOR MAINTENANCE PREVENTS BLACKHEADS COMBINE WITH BENZOYL PEROXIDE IF INFLAMMATION MARKED DIFFERIN ADAPALENE 0.1% GEL OR CREAM ISOTREX ISOTRETINOIN 0.05% GEL NICAM NICOTINAMIDE GEL SKINOREN AZELAIC ACID 20% CREAM

11 MILD ACNE ANTI BACTERIAL TREATMENTS BACTERIAL RESISTANCE DEVELOPS QUICKLY TRY NOT TO USE ALONE AT BEST, 12 WEEKS DO NOT USE COMBINED WITH DIFFERENT SYSTEMIC ANTIBIOTICS ZINERYT ERYTHROMYCIN TOPICAL SOLUTION (& ZINC) DALACIN T CLINDAMYCIN TOPICAL SOLUTION / LOTION STIEMYCIN ERYTHROMYCIN SOLUTION ZINDACLIN CLINDAMYCIN GEL (& ZINC)

12 MILD MODERATE ACNE (COMBINATION TREATMENTS) CAN IRRITATE TITRATE USE IMPROVED EFFICIENCY OF ANTIBIOTIC, WITH DECREASED RISK OF RESISTANCE EXAMPLES: DUAC - CLINDAMYCIN 1% AND BENZOYL PEROXIDE 3 & 5% GEL EPIDUO - ADAPALENE 0.1% AND BENZOYL PEROXIDE 2.5% GEL ISOTREXIN - ERYTHROMYCIN 2% AND ISOTRETINOIN 0.05% GEL TRECLIN - CLINDAMYCIN 1% AND TRETINOIN 0.025% GEL

13 Grades of facial acne

14 MODERATE ACNE SYSTEMIC ANTIBIOTICS GOOD FOR LARGE/HARD TO APPLY TO AREAS ADD IN TOPICAL RETINOID/BPO TO DECREASE RESISTANCE LYMECYCLINE 408MG OD OXYTETRACYCLINE/ERYTHROMYCIN 500MG BD DOXYCYCLINE MG OD TRIMETHOPRIM 300MG BD (STOP IF DEVELOPS A RASH) OFF LICENSE

15 HOW LONG FOR? SUGGEST 3 MONTHS TO ASSESS BENEFIT BEFORE CHANGING REVIEW EVERY 6-12 MONTHS TO CONTINUE TO PROMOTE SAFE USE, INITIATE TOPICALS WITH EVENING ONLY RULE FOR THE FIRST WEEK

16 WHERE DOES DIANETTE FIT IN? LICENSED FOR TREATMENT OF MODERATE-SEVERE ACNE RELATED TO ANDROGEN SENSITIVITY AND HIRSUITISM NEED TO USE AFTER TOPICAL THERAPY OR ANTIBIOTICS HAVE FAILED VTE RISK OF LNG PILL 5-7 PER 10,000 HEALTHY WOMEN DIANETTE IS APPROX X INCREASED RISK SIMILAR TO DESOGESTREL/GESTODENE/DROSPIRENONE PILLS STILL ONLY HALF THAT OF GETTING PREGNANT?SLIGHTLY INC RISK OF CA BREAST IF > 5YRS DURATION

17 SEVERE ACNE - ISOTRETINOIN DON T REFER TO ICATS STRAIGHT TO BGH PLEASE BUT WE WOULD LIKE BLOODS BEFOREHAND (FBC/U&E/LFT/LIPID PROFILE) BENEFIT VS RISKS (VERY EFFECTIVE!) TERATOGENIC MOOD CHANGES / DEPRESSION / SUICIDE RISK CONTROVERSIAL DRUG INFLAMMATORY BOWEL DISORDERS

18 BENEFITS OF ISOTRETINOIN

19 ACNE SCARRING TREAT EARLY TO TRY AND AVOID REFER TO PLASTICS INTRADERMAL STEROIDS DERMABRASION CHEMICAL PEELS LASER...FUNDING ISSUES

20 KEY MANAGEMENT MESSAGES MULTIPLE DIFFERENT TOPICAL TREATMENTS AVAILABLE DEPENDING ON THE TYPE & SEVERITY OF ACNE LESIONS BE AWARE OF BACTERIAL RESISTANCE BE AWARE OF PSYCHOLOGICAL IMPACT OF ACNE DO NOT SEND SEVERE ACNE PATIENTS TO ICATS TRY TO PREVENT SCARRING ACNE

21 FINAL NOTE DECENT SKINCARE NO WET WIPES OR LIQUID PARAFFIN/MINERAL OIL MAKE SURE IT SAYS NON COMEDOGENIC MY PERSONAL RECOMMENDATIONS? HIGH END CLINIQUE MIDDLE MARKET EFFACLAR DUO + MASS MARKET NEUTROGENA VISIBLY CLEAR

22 WHY THOSE THEN?? CLINIQUE ANTIBLEMISH RANGE SALICYCLIC ACID EFFACLAR = DUO B VITAMINS AND LHA, H FOR ROACCUTANE PATIENTS NEUTROGENA AVAILABLE EVERYWHERE, AFFORDABLE