Acne Vulgaris (and Rosacea)

-2-
Learning Goal:
TT: tanı koyabilmeli, tedavi edebilmeli (Should diagnose
and treat)
İ: birinci basamak şartlarında uzun süreli takip (izlem) ve
kontrolünü yapabilmeli (Should do long term follow up
and controls in primary health care facilities)

Assoc. Prof. Berna Aksoy

VM Medicalpark Kocaeli Hospital
B Aksoy – Acne Vulgaris 1
Treatment of acne vulgaris
Topical retinoids
comedolytic > anti-inflammatory
effects

• Tretinoin,

• Adapalene,

• Tazarotene

B Aksoy – Acne Vulgaris 2

 Treatment of acne vulgaris
Topical retinoids
• Response requires 3–4 weeks (sometimes
preceded by pustular flare)
• use a small amount and treat all acne-prone
areas at night (1x1, at night)
• Initial use of lower concentration and/or
alternate-night application can minimize
irritation
• Tretinoin is photolabile and inactivated by BPO
(so generally applied at night, separately from
BPO);
• tazarotene is the most irritating of the topical
retinoids and is pregnancy category X.

B Aksoy – Acne Vulgaris 3

 Treatment of acne vulgaris
Topical antimicrobials (1-2x1, day )
1. Benzoyl peroxide (BPO)
• Can bleach clothing/bedding
• Can cause contact dermatitis (irritant
> allergic);
• unlike topical antibiotics, bacterial
resistance does not occur
2. and/or antibiotic (e.g. clindamycin,
erythromycin, sodium sulfacetamide
/sulfur)
• bacterial resistance !!!
• Increased effectiveness when used in
conjunction with BPO or a retinoid
B Aksoy – Acne Vulgaris 4
Treatment of acne vulgaris
3. Combination preparations
• BPO + topical antibiotic
• (1-2 x 1, day or night)
• may also be used as
monotherapy
• especially as an initial
treatment in a younger
patient.

B Aksoy – Acne Vulgaris 5

Treatment of acne vulgaris
3. Combination preparations
• Topical antibiotics +
retinoid (1x1, at night)

• BPO + retinoid

• Azelaik asit

B Aksoy – Acne Vulgaris 6

 Treatment of acne vulgaris
Oral antibiotics
• first-line – tetracycline
derivatives (doxycycline,
minocycline); (1-2x1)
• alt. – azithromycin, (1x1, 3 d/wk)
trimethoprim–sulfamethoxazol
e
• Often used for max.
3–6 months
• tetracyclines are avoided in
children <8 years of age and
pregnant women
B Aksoy – Acne Vulgaris 7
 Treatment of acne vulgaris
OCPs : FDA-approved for acne –
• Ortho Tri-Cyclen ® (EE 35 microg,
norgestimate 180/215/250 microg),
• Yazz® /Loryna ® (EE 20 microg,
drospirenone 3000 microg),
• Estrostep ® (EE 20/30/35 microg,
norethindrone 1000 microg)
Antiandrogens :
• spironolactone (50–200 mg/day) /
cyproterone acetate (50 mg/day first
10 days of menstrual cycle)
• combine with OCP (Yazz® / Diane 35®)
B Aksoy – Acne Vulgaris 8
 Treatment of acne vulgaris
Oral isotretinoin (specialist prescription):
• Indications for Oral Isotretinoin.
Moderate, recalcitrant, scarring, nodular
acne.
• Contraindications for Isotretinoin is
teratogenic and effective contraception is
imperative. Concurrent tetracycline and
isotretinoin may cause pseudotumor
cerebri (benign intracranial swelling);
therefore, the two medications should
never be used together.
• Dosage. typically 0.5–1 mg/kg/day (lower
initially, especially if acne fulminans) given
in divided doses with food × 4–6 months
(cumulative dose 120–150 mg/kg)
B Aksoy – Acne Vulgaris 9
 Treatment of acne vulgaris
Oral isotretinoin (specialist prescription):
Warnings.
• Determine blood lipids, transaminases (ALT, AST)
before therapy.
• About 25% of patients can develop increased plasma
triglycerides / cholesterol.
• May develop mild-to-moderate elevation of
transaminase levels - normalize with reduction in the
dose of the drug.
• Severe teratogenicity; in the United States, prescribers
and patients must register in a risk management
program (iPLEDGE™) that requires monthly visits.

B Aksoy – Acne Vulgaris 10

 Treatment of acne vulgaris
Oral isotretinoin (specialist prescription):
Side Effects.
• Eyes:Night blindness, decreased tolerance to contact lenses.
• Skin: The most common side effects are cheilitis > mucosal
dryness (ocular, nasal) & xerosis.
– An eczema-like rash due to drug-induced dryness can
occur & responds dramatically to low potency (class III)
topical glucocorticoids.
– Dry lips & cheilitis almost always occur & must be treated.
– Reversible thinning of hair, paronychia may occur very
rarely.
• Nose: Dryness of nasal mucosa, nosebleeds occur rarely.
• Other systems: Rarely, depression, headaches, arthritis, and
muscular pain, pancreatitis.
B Aksoy – Acne Vulgaris 11
 Treatment of acne vulgaris
Other Treatments.
Alternative acne treatments
• Laser (e.g. 1450-nm diode),
• Light (e.g. blue, intense pulsed),
• Photodynamic therapies
• Superficial chemical peels (e.g. 20–30% salicylic acid,
30–50% glycolic acid)
Once active acne has been successfully treated, for
residual scarring
• Intralesional CS (for hypertrophic scars)
• Surgical modalities (e.g. fractional or traditional laser
resurfacing, dermabrasion, fillers)

B Aksoy – Acne Vulgaris 12

 Mild Acne
Comedonal Mostly Inflammatory
First-line Topical retinoid Topical antimicrobial+
topical retinoid
Second-line Alt. topical retinoid Alt. topical retinoid +
Azelaic acid alt. topical
Salicylic acid antimicrobial
Azelaic acid
Topical dapsone

Procedural options Comedo extraction

Maintenance Topical retinoid Topical retinoid ± BPO

B Aksoy – Acne Vulgaris 13
 Moderate Acne Severe Acne (e.g.
Conglobata,
Fulminans)
First-line Oral antibiotic + topical Oral isotretinoin (+ oral
retinoid ± BPO CS for acne fulminans)

Second-line Alt. oral antibiotic + alt. Oral dapsone

topical retinoid ± High-dose oral
BPO/azelaic acid antibiotic + topical
Oral isotretinoin (if retinoid + BPO
nodular, scarring or
recalcitrant)

Options for female OCP/antiandrogen OCP/antiandrogen

patients

B Aksoy – Acne Vulgaris 14

 Moderate Acne Severe Acne (e.g.
Conglobata,
Fulminans)
Procedural options Comedo extraction Intralesional CS
Intralesional CS (2–5 mg/ml
(2–5 mg/ml triamcinolone)
triamcinolone)

Refractory to Exclude gram-negative folliculitis

treatment
Female patient: exclude adrenal or ovarian
dysfunction
Exclude use of anabolic steroid or other
acne-exacerbating drugs

Maintenance Topical retinoid ± BPO

B Aksoy – Acne Vulgaris 15

 Treatment of acne vulgaris
Tips for Topical Therapy
• Lack of compliance is often an issue,
– common reasons include irritated skin, busy schedules, and giving
up when the response is not rapid;
– substantial benefit typically requires 6–8 weeks of treatment.
• The main side effect of topical medications is irritation, which is most
problematic in adolescents with atopic dermatitis and adults.
• Patients should be advised to avoid harsh scrubs, other irritating
agents (e.g. toners, acne products that are not part of the regimen),
and manipulation of lesions, especially inflammatory papulonodules
and closed comedones.
• Even if planning combination therapy, a gradual initial approach can
improve tolerance in patients with sensitive skin; for example, a single
agent may be used for the first 2–3 weeks (starting every other day for
retinoids), followed by slow introduction of a second medication (e.g.
transitioning from alternate days to daily).
B Aksoy – Acne Vulgaris 16
 Treatment of acne vulgaris
Tips for Topical Therapy
• Simplifying the regimen and considering combination
products (e.g. benzoyl peroxide + adapalene or clindamycin;
tretinoin + clindamycin) may improve compliance, especially
in less-motivated adolescents.
• In general, topical medications (especially retinoids) should
be used to the entire acne-prone region rather than as ‘spot
treatment’ of individual lesions.
• Patients should be instructed to select noncomedogenic
products (e.g. moisturizers, sunscreens, make-up) and to
avoid having oily hair or using pomades that may contribute
to acne.
• Having patients bring everything that they apply to their
face to a visit may help to determine the source of
problems.
B Aksoy – Acne Vulgaris 17
 Rosacea
• A common chronic
inflammatory acneiform
disorder of the facial
pilosebaceous units.
• Etiology is multifactorial,
including
– vascular hyperreactivity,
– alterations in innate
immunity, e.g. cathelicidins,
– Demodex plus its
commensal bacteria.
B Aksoy – Acne Vulgaris 18
 Rosacea - Epidemiology
• Occurrence. Common, affecting
approximately 10% of fair-skinned
people.
• Age of Onset. 30–50 years; peak
incidence between 40 and 50
years.
• Sex. Females predominantly, but
rhinophyma occurs mostly in
males.
• Ethnicity. Celtic persons (skin
phototypes I and II) but also
southern Mediterraneans; less
frequent in pigmented persons
(skin phototypes V and VI, i.e.,
B Aksoy – Acne Vulgaris 19
Rosacea- Staging (Plewig and
• The rosacea diathesis:
Kligman episodic
Classification)
erythema, “flushing and
blushing.”
• Stage I: Persistent erythema with
telangiectases.
• Stage II: Persistent erythema,
telangiectases, papules, tiny
pustules.
• Stage III: Persistent deep
erythema, dense telangiectases,
papules, pustules, nodules;
rarely persistent “solid” edema
of the central part of the face.

B Aksoy – Acne Vulgaris 20

 Rosacea - Clinical Features
• History of episodic reddening of the
face (flushing) in response to hot
liquids; spicy foods; alcohol; exposure
to sun and heat. Acne may have
preceded the onset of rosacea by
years but rosacea usually arises de
novo.
• Duration of Lesions. Days, weeks,
months.
• Skin Symptoms. Concern about
cosmetic facial appearance, pruritus.
• Distribution. Symmetric localization on
the face, especially its central portion.
Rarely, neck, chest (V-shaped area),
back, and scalp.
B Aksoy – Acne Vulgaris 21
 Rosacea - Skin Lesions
Highly variable degree of severity
• Early. Pathognomonic flushing—”
red face”; tiny papules and
papulopustules (2–3 mm), pustule
often small (≤1 mm) and on the
apex of the papule. No comedones.
• Late. Red facies and dusky-red
papules and nodules. Scattered,
discrete lesions. Telangiectases.
Marked sebaceous hyperplasia and
lymphedema in chronic rosacea,
causing disfigurement of the nose,
forehead, eyelids, ears, and chin
(phyma).
B Aksoy – Acne Vulgaris 22
Rosacea - Subtypes
• Erythematotelangiectatic
Rosacea: Recurrent
flushing/blushing, may
eventuate in fixed central
facial erythema and
telangiectasias
• Papulopustular Rosacea:
Intermittent pink to red
papules and inflammatory
pustules (no comedones)
B Aksoy – Acne Vulgaris 23
 Rosacea - Subtypes
• Phymatous Rosacea:
Hypertrophy and irregular
(lumpy) thickening of nose >>
forehead, cheeks, chin, or ears
Rhinophyma (enlarged nose)
• Eye Involvement – Ocular rosacea
Sx: Burning, stinging, pruritus,
foreign-body sensation in the eye,
photophobia, dryness, blurry vision
“Red” eyes as a result of chronic
blepharitis, conjunctivitis, and
episcleritis. Rosacea keratitis, albeit
rare, is a serious problem because
corneal ulcers may develop.
B Aksoy – Acne Vulgaris 24
 Rosacea Diagnosis (2017 NRS)
• Diagnostic phenotypes ≥1
– Fixed centrofacial erythema in a characteristic pattern that
may periodically intensify.
– Phymatous changes.
• Major phenotypes ≥ 2
– Papules and pustules.
– Flushing.
– Telangiectasia.
– Ocular manifestations.
• Secondary phenotypes
– Burning or stinging.
– Edema.
– Dry appearance.

B Aksoy – Acne Vulgaris 25

 Rosacea – Variant: Periorificial dermatitis
• Occurs mainly in young women; can
occur in children and the old.
• Etiology. Unknown but may be
markedly aggravated by potent
topical (fluorinated) glucocorticoids.
• May initially improve with topical CS
but ultimately this treatment leads
to exacerbation and should not be
used.
• Distribution. Initially perioral. Rim of
sparing around the vermilion border
of lips, nasiolabial; at times, in the
periorbital area. Uncommonly, only
periorbital.
B Aksoy – Acne Vulgaris 26
 Rosacea – Variant: Periorificial dermatitis
• Skin Lesions. 1- to 2-mm
erythematous papulopustules on an
erythematous background,
irregularly grouped, symmetric.
Lesions increase in number with
central confluence and satellites;
confluent plaques may appear
eczematous with tiny scales. There
are no comedones.
• Skin symptoms. perceived as
cosmetic disfigurement; occasional
itching or burning, feeling of
tightness.
• Duration of Lesions. Lesions recur
over weeks to months
B Aksoy – Acne Vulgaris 27
 Rosacea
Course
• Prolonged. Recurrences are common. After a few years, the disease
may disappear spontaneously; usually it is for lifetime. Men and
very rarely women may develop rhinophyma, gnathophyma, etc.
Management
• Prevention: Marked reduction or elimination of alcohol, hot, cold,
sun exposure, spices, pepper, pickles, chocolate, stress may be
helpful in some patients.
• Topical: Metronidazole gel or cream, 0.75% or 1%, once or twice
daily. Topical antibiotics (e.g., erythromycin gel) less effective.
• Systemic: Oral antibiotics are more effective than topical treatment.
Minocycline or doxycycline, 50–100 mg once or twice daily, first-line
antibiotics; very effective. Oral Isotretinoin. For severe disease
(especially stage III) not responding to antibiotics and topical txs.
B Aksoy – Acne Vulgaris 28
General recommendations for facial skin care and education
in patients with rosacea
Facial Skin Care
• Wash with lukewarm water and use soap-free cleansers that are pH balanced
• Cleansers are applied gently with fingertips
• Use sunscreens with both UVA and UVB protection and an SPF ≥15
• Sun-blocking creams containing the physical barriers titanium dioxide and/or zinc
oxide are usually well tolerated
• Use cosmetics and sunscreens that contain protective silicones
• Water-soluble facial powder containing inert green pigment helps to neutralize
the perception of erythema
• Moisturizers containing humectants (e.g. glycerin) and occlusives (e.g.
petrolatum) help to repair the epidermal barrier
• Avoid astringents, toners, and abrasive exfoliators
• Avoid cosmetics that contain alcohol, menthols, camphor, witch hazel, fragrance,
peppermint, and eucalyptus oil
• Avoid waterproof cosmetics and heavy foundations that are difficult to remove
without irritating solvents or physical scrubbing
• Avoid procedures such as glycolic peels or dermabrasion
B Aksoy – Acne Vulgaris 29
General recommendations for facial skin care and education
in patients with rosacea

Patient Education

• Reassure the patient about the benign nature of the disorder and
the rarity of rhinophyma, particularly in women
•Emphasize the chronicity of the disease and the likelihood of
exacerbations
•Advise to avoid recognized triggers
•Explain the importance of compliance with topical regimens
•Educate on the importance of sun avoidance

B Aksoy – Acne Vulgaris 30

 Summary
What we learned:
• Acne
• Rosacea
• Periorificial dermatitis
• Learning Goal:
• TT: tanı koyabilmeli, tedavi edebilmeli (Should
diagnose and treat)
• İ: birinci basamak şartlarında uzun süreli takip (izlem)
ve kontrolünü yapabilmeli (Should do long term follow
up and controls in primary health care facilities)
B Aksoy – Acne Vulgaris 31