Acne Management

• Acne

  A common skin disease, especially in adolescents and young adults
• Acne

  • Chronic and recurrent inflammatory dermatosis notable for open or closed comedones (blackheads and whiteheads) and inflammatory lesions, including papules, pustules, or nodules (also known as cysts)
  • Occurs most commonly on the face but may also involve the neck, trunk and proximal upper extremities
  • No mortality associated but often significant physical and psychological morbidity, such as permanent scarring, poor self image, depression, and anxiety

  
• Acne affects approximately 85% of those aged 12 -24 years old, but can occur in most age groups and can persists into adulthood
• The prevalence of acne in boys increases from 40% at age 12 years to 95% at age 16 years while in girls, the prevalence increases similarly from 61% to 83%
• During adolescence, there is a male predominance, particularly with more severe forms of acne
• In contrast, during adulthood, the condition is more common in women than in men
• The Classic Pathogenesis of Acne

  1. Hyperproliferation and abnormal differentiation of the follicular epithelium. Excess sebum production

  2. Inflammation and proliferation and biofilm formation of Propionibacterium acnes

  
• Insulin-like Growth Factor (IGF)-1

  Recent evidence suggests a pivotal role for IGF-1 in the development of acne and upregulation of inflammation in primary human sebocytes
• IGF-1 has been shown to induce androgen synthesis and increase the cutaneous availability of dihydrotestosterone, disinhibit the forkhead box O1 (FoxO1) transcription factor, and activate peroxisome proliferator-activated receptor–gamma, liver X receptor–alpha, and sterol regulatory element binding protein-1c (SREBP-1c), which increases sebum triglycerides and fatty acid desaturation, leading to a proinflammatory and comedogenic monosaturated fatty acid profile
• Comprehensive Acne Severity Scale (CASS)

  Advocated by the Dermatological Society of Singapore and Malaysian MoH CPG on Management of Acne for evaluating acne severity
• Management of Acne

  • Treatment is based on the grade and severity of acne
  • Goals include resolution of lesions, reduction of psychological morbidity and prevention of scars
  • Early intervention is important to prevent complications
  • Treatment can be divided into pharmacological (topical and systemic) and physical therapies
• Topical Benzoyl Peroxide

  Monotherapy or in combination with other topical therapy should be given in mild to moderate acne vulgaris
• Topical Retinoids

  Includes topical Tretinoin/Retinoic Acid, Adapalene, Tazarotene, and Isotretinoin
• Topical Trifarotene

  A new gamma-selective retinoid cream that is suitable for acne vulgaris on the face and trunk, with comedolytic, anti-inflammatory and anti-pigmenting properties
• Topical Antibiotics

  The use of topical antibiotics as monotherapy should be avoided to prevent bacterial resistance
• Topical Clindamycin and Erythromycin

  Topical antibiotics
• Topical Minocycline foam 4%

  A new topical antibiotic recently approved for moderate to severe acne vulgaris
• Topical Azelaic Acid

  Has both antimicrobial and anticomedonal properties, and is also effective for post-inflammatory hyperpigmentation (PIH)
• Topical Salicylic Acid, Dapsone, Sulphur

  Other topical therapies for acne
• Topical Clascoterone

  A novel, steroidal anti-androgen chemical that competes with dihydrotestosterone (DHT) receptor in the skin, leading to reduction of sebum production and pro-inflammatory cytokines
• Systemic Antibiotics

  Tetracycline class (Tetracycline, Doxycycline, Minocycline, Lymecycline, Sarecycline) and Macrolide class (Erythromycin, Azithromycin) are effective due to their anti-inflammatory effects and antibacterial action against C. acnes. Contraindicated in pregnant women, children < 8 years old and those with allergy.
• Trimethoprim-sulfamethoxazole (Co-trimoxazole)

  Should only be used when other antibiotics have failed or are contraindicated because of its potential serious adverse events
• Oral antibiotic therapy should not exceed 3 - 4 months and that minimum duration of 6 - 8 weeks is required to see clinical improvement in acne vulgaris
• Oral Isotretinoin

  • Conventionally, a course is prescribed until a total cumulative dose of 120 - 150 mg/kg is achieved, but may be discontinued earlier (4 - 8 weeks after clearance of skin lesion) based on clinical judgement
  • Teratogenic and strict contraceptive practice is required for females who may become pregnant
  • Prescribed for nodulocystic or severe acne vulgaris and treatment-resistant moderate acne vulgaris
• Oral Hormonal Therapy

  Can be considered in women with hyperandrogenism, e.g. PCOS. Options include combined oral contraceptives, Spironolactone, and Metformin
• Intralesional Corticosteroid injection

  For nodular acne, using IL triamcinolone 5 or 3.3mg/ml. Local AEs include skin atrophy, pigmentary changes, telangiectasia, haematoma and infection
• Comedone Extraction, Chemical Peels

  Physical therapies that may be used as adjunct therapy
• Energy Based Devices

  Includes light-based therapy, photodynamic therapy, intense pulsed light, radiofrequency treatment, and laser therapy. May be used as an adjunct treatment in acne vulgaris.
• Comedone Extraction

  • May cause skin atrophy, pigmentary changes, telangiectasia, haematoma and infection

  
• Chemical Peels

  • May be used as adjunct therapy
  • Salicylic acid, Glycolic acid, Jessner's solution, Tricholoacetic acid, Azelaic acid
  • Combination peels
• Physical Therapy – Energy Based Devices

  • Light-based therapy
  • Visible light sources
  • Blue light therapy (407-420nm), red light therapy (630-640nm)
  • Photodynamic therapy
  • Intense pulsed light
  • Radiofrequency treatment
  • Laser therapy
  • Erbium glass laser
  • Neodymium-doped yttrium aluminium garnet laser (Nd:YAG)
  • Pulsed dye laser
  • Non-ablative fractional laser
• Laser may be used as an adjunct treatment in acne vulgaris
• Treatment in Special Group - Pregnancy and Lactation

  • Hormonal therapy, tetracyclines, co-trimoxazole, and both oral and topical retinoids should be avoided
• Treatment in Special Group - Adolescent

  • Topical benzoyl peroxide and topical retinoids (tretinoin and adapalene) may be used safely
  • Oral tetracycline derivatives (e.g. tetracycline, doxycycline and minocycline) should not be used in patients aged <8 years
  • Oral isotretinoin can be used safely in patients aged ≥12 years with severe acne vulgaris
• 7 REASONS TO TREAT ACNE EARLY

  • Get faster results from treatment
  • Reduce scars
  • Stop lingering spots from developing when acne clears
  • Prevent mild acne from becoming severe
  • Decrease the likelihood you'll need stronger acne medicine
  • Avoid years of acne
  • Sidestep emotional distress
• Acne Scar

  • Acne lesions can result in permanent scarring that can remain for life with a marked impact on quality of life
  • Genetic factors, disease severity and delay in treatment are the main factors influencing scar formation
  • Scarring is the main complication of acne and arises from the disorganised production and deposition of collagen around inflamed follicles, resulting in visibly depressed scars
  • Such scarring is very common and can lead to impairment in quality of life, as well as being a risk factor for depression and even suicide
  • Furthermore, it has been linked to poor self-esteem, anxiety and lowered academic performance

  
• Acne Scar Types

  • Hypertrophic
  • Atrophic (icepick, rolling scars, boxcar)
  • Keloidal

  
• The prevalence and severity of acne scarring in the population is largely unknown
• Acne Management Tips


  • Comedonal/ Mild Acne: Topical retinoids +/- Topical BPO 5% or Topical combination therapy
  • Moderate Acne: Oral doxycycline or oral erythromycin + Topical retinoids + Topical BPO 5% or Topical combination therapy
  • Severe Acne: Oral Isotretinoin + Topical BPO 5% /Topical Combination or Oral doxycycline/ oral erythromycin + Topical retinoids + Topical BPO 5% or Topical combination therapy