ACNE VULGARIS

DR.Anahita Diniyaryan
Pharm.D

 2001 2



.

EPIDEMIOLOGY
Post-adolescent acne predominantly affects
women, in contrast to adolescent acne, which has
a male predominance. In one survey of over 1000
adults, self-reported acne in men and women
was documented as follows
20 to 29 years: 43 and 51 percent, respectively
30 to 39 years: 20 and 35 percent, respectively
40 to 49 years: 12 and 26 percent, respectively
ages 50 and older: 7 and 15 percent, respectively

Inflammation results from the

proliferation of P. acnes
Enzymes produced by P. acnes may promote the
degradation of the follicular wall and follicular
rupture.
P. acnes surface proteins may play a role in
antigenicity, triggering humoral and cell-mediated
immune responses.
Heat shock proteins, which promote inflammation
via the innate immune system, are produced by P.
acnes.
Porphyrins produced by P. acnes may contribute to
adjacent tissue damage and inflammation

TREATMENT PRINCIPLES
Determining the most effective course of

treatment for acne involves a

comprehensive assessment of the
patient. Treatment of acne is aimed at
counteracting follicular
hyperproliferation, increased sebum
production, Propionibacterium acnes
proliferation, and inflammation

( 0.5 )%2
%5

( 2.5 )%5
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Vit PP

Fluidactiv

THYMOL

inflamine
THYMOL

Nordihydroguaiaretic acid
(NDGA)

URIAGE
HYSEAC

AHA and BHA complex

Licorice extract
Piroctone Olamine
Mattifying agent

Acknyl
thymol

NOREVA
Zeniac Roll Active

Mandelic acid 5%
Soluble sulfur 0.5%
Salicylic Acid 2%

BIODERMA

SEBIUM GLOBAL

ENOXOLONE

) )
AHA ester 6%
Citric acid 5%
Salicylic acid 2%
) )

ZINC GLUCONATE
( P.acne
)

NOREVA
ACTIPUR

Keratozine A 5%
Phytosphingosine
PP Vitamin
Micro-sponges

PRETREATMENT ASSESSMENT
Clinical type and severity of acne (eg, comedonal, papulopustular, mixed, nodular)
Determines the types of treatments needed
Skin type (eg, dry, oily)
Influences choice of topical drug vehicle
Presence of acne scarring
Indicates need to consider more aggressive acne therapy and treatments for scarring
Presence of postinflammatory hyperpigmentation
Indicates need to consider therapies for hyperpigmentation as well as the need to resolve and
prevent inflammatory acne lesions
Menstrual cycle history and history of signs of hyperandrogenism in women
Identifies need to consider laboratory workup and hormonal therapies women with acne
vulgaris")
Treatment history
Identifies successful and unsuccessful previous treatments
History of acne-promoting cosmetic products and medications
Identifies potential for improvement with discontinuation of topical cosmetic products
Psychological impact of acne on the patient
Identifies need for a more aggressive treatment approach or psychological services

ATTENTION


Only prescribe antibiotics when necessary. The duration of treatment should be limited; an
oral antibiotic should be discontinued when there is no additional clinical improvement or
clinical improvement is absent.One panel of experts suggested limiting treatment courses
to a maximum of 12 to 18 weeks when feasible
In order to avoid changing oral antibiotics prematurely, six to eight weeks of therapy should
be allowed prior to evaluating treatment efficacy .After six to eight weeks, a change in the
type of antibiotic can be considered if there is no response. In cases in which a partial
response is seen, therapy should be continued and response reassessed after another six to
eight weeks.
If oral antibiotics are stopped and need to be restarted, prescribe the same antibiotic the
second time as long as it remains effective
Do not simultaneously treat with a topical antibiotic and an oral antibiotic, particularly if the
agents are chemically different.
Avoid use of antibiotics (topical or oral) as monotherapy or as maintenance therapy
Prescribe benzoyl peroxide at the start of antibiotic therapy. Concomitant use of benzoyl
peroxide can decrease the incidence of antibiotic resistance. It may also be helpful to use
benzoyl peroxide for a minimum of five to seven days between antibiotic courses.
Prescribe a topical retinoid. A topical retinoid should be used at the start of treatment with an
oral antibiotic.Combination therapy with a retinoid and oral antibiotic improved treatment
efficacy in several studies, including two randomized trials.
Topical retinoids are effective as long-term maintenance therapy and can decrease dependence
on the extended use of antibiotics

ADJUNCTIVE THERAPIES

Microdermabrasion
Office-based superficial chemical peels
Comedo extraction
Intralesional glucocorticoids(1.25-2.5 mg/ml)
Heat
Diet :Data on favorable effects of dietary factors such as zinc,
omega-3 fatty acids, antioxidants, vitamin A, and dietary fiber on
acne vulgaris are limited .Further studies are necessary to
determine the roles of these supplements in acne vulgaris.

IGP (INSULIN LIKE GROWTH FACTOR) OR GLYCEMYC LOAD

STRESS

smoking

Oral isotretinoin
Scarring acne
Acne causing significant psychological distress
Acne fulminans
Antibiotic-induced gram-negative folliculitis in
patients with acne vulgaris

Administration

subsequently increased to 1 mg/kg/day. Dosing can be once or twice daily. The

total treatment goal is 120 to 150 mg/day, and is typically reached over four to
six months (usual duration of treatment 20 weeks)The drug is discontinued
without tapering. There is some evidence that lower doses may also be effective.
Absorption of isotretinoin is improved when taken with food (especially high-fat
meals); thus, administration during meals is recommended
Other acne medications are typically discontinued during isotretinoin therapy.
Isotretinoin causes temporary xerosis, cutaneous atrophy, and skin fragility .and
topical acne medications may be poorly tolerated. Isotretinoin should not be
given with tetracycline antibiotics due to the risk of idiopathic intracranial
hypertension (pseudotumor cerebri) associated with both of these drugs.
Acne may initially worsen with isotretinoin therapy; initiating therapy at 0.5
mg/kg/day during the first month may decrease this risk. The early flare typically
resolves with further treatment .More severe flares may occur in patients
presenting with severe inflammatory acne (eg, acne conglobata, acne fulminans).
In some of these cases, the inflammatory nodules may ulcerate or form
exuberant granulation tissue. If this happens, isotretinoin is temporarily stopped.
Systemic glucocorticoids (0.5 to 1 mg/kg/day) are sometimes given before
isotretinoin therapy or concurrently for the first two to four weeks of treatment
in an attempt to prevent severe flares. Rarely, isotretinoin may induce acne
fulminans.

Isotretinoin and pregnancy

Isotretinoin is teratogenic. Women of
childbearing potential must use two forms of
contraception during treatment and for one
month thereafter.

Infantile acne
Infantile acne is a distinct entity from neonatal
cephalic pustulosis. It presents at three to four
months of age. It results from hyperplasia of
sebaceous glands secondary to androgenic
stimulation, and is more common in boys .The
clinical presentation is more severe than that of
cephalic pustulosis and consists of typical
acneiform lesions including comedones,
inflammatory papules, pustules, and sometimes
nodules on the face .It usually clears
spontaneously by late in the first year of life, but
may persist until three years of age.

Infantile acne
Treatment may be required, because infantile
acne can persist and occasionally cause scarring,
unlike neonatal cephalic pustulosis. When
inflammation is mild or moderate, mild
keratolytic agents, such as benzoyl peroxide
(2.5%), topical antibiotics (eg, erythromycin or
clindamycin), or topical retinoids may be used
.In more severe cases, systemic therapy with
oral erythromycin or oral isotretinoin may be
indicated.