Acne Treatment and Therapeutic Strategies: Senior Instructor Family Medicine

Acne Treatment and Therapeutic Strategies
The Aga Khan University Hospital, Karachi
Dr. Marie Andrades

Senior Instructor
Family Medicine
One of the most common skin diseases

presenting to family physicians
Considerable psychological impact on the
quality of life
No cure, but the disease can be controlled
through medications
Pathophysiology
Four important factors

plugging of the hair follicle
hyperactivity of the sebaceous gland
proliferation of Propionobacterium
Acnes
inflammation
Stages of Development
Comedonal Lesions
Inflammatory Lesions
Nodulocystic Lesions
Scarring
Patient Evaluation
Key Elements in History
previous medications used
current products being used for acne
medical problems
other medications
use of cosmetics or hair pomades
recreational activities and occupation
Patient Evaluation
For Female Patients

menstrual history
hirsutism
use of hormonal contraceptives
Management
Patient Education (Dispelling Myths)

hygiene
diet
cosmetics
hair styles
Management
Patient Education
washing of lesions
picking lesions
premenstrual flare
hair care products
Management
Patient Education
improvement is not overnight
treatment must be used regularly
treatment is long term
Management
Topical Therapy (Indications)

comedonal acne
mild to moderate inflammatory acne
Management
Topical Therapy (Basic Rules)

avoid applying medication right after
washing face
avoid over use of medication
apply on all acne prone areas
if face gets dry apply oil free moisturizer
Management
Topical Therapy (Treatment Vehicle)

cream  sensitive or dry skin
lotion  any skin type
gel  oily skin
solution  oily skin
Management
Topical Therapy
(Anti Comedonal Agents)
Topical Retinoids
Azelaic acid
Salicylic acid
Management
Topical Retinoids 0.025% - 0.5% (application)
apply at night
always apply test dose
start at low concentrations
avoid in pregnancy
Management
Topical Retinoids 0.025% - 0.1% (side effects)
pustular flare
photosensitivity
skin irritation and erythema
dryness and peeling
Management
Azelaic Acid 20%

(application and side effects)
applied twice daily
erythema and irritation
decrease in pigmentation
Management
Salicylic Acid 0.5 - 2%

applied twice daily
skin dryness and irritation
Management
Topical Therapy (Anti Inflammatory Agents)

Benzoyl Peroxide
Topical antibiotics
Management
Benzoyl Peroxide 2.5 - 10%
apply once to twice daily
always apply test dose
avoid use at night
dryness of skin
Management
Topical Antibiotics, Clindamycin and
Erythromycin (application and side effects)
apply twice daily
skin dryness
Management
Combination therapy
5% Benzoyl Peroxide and 3% Erythromycin
5% Benzoyl Peroxide and 1% Clindamycin
Topical antibiotics and Azelaic acid or Tretinion
Management
Systemic therapy (Indications)

moderate inflammatory acne non
responsive to topical therapy
nodulocystic acne
Management
Systemic therapy
Oral Antibiotics
Isotretinoin
Hormonal Therapy
Management
Oral Antibiotics (used for 3-6 months)
Tetracycline 500mg X BD
Doxycycline 100mg X BD
Minocycline 100mg X OD
Eythromycin 500mg X BD
combined with topical therapy

Management
Isotretinoin (Accutane) indicated in
severe nodulocystic acne
non responsive acne
severe psychological distress
Only to be used by physicians with
experience in the therapy of severe
dermatological disorders
Management
Isotretnoin (RoAccutane) side effects
teratogenic
mucosal dryness
photosensitivity
arthralgias
alteration of liver enzymes
hypertriglyceridemia and hypercholesterolemia
Management
Hormonal Therapy indicated in

acne associated with hirsutism,
menstrual irregularity and alopecia
women desiring contraception
Management
Hormonal Therapy
Oral contraceptives containing low
androgenic progesterone
Cyproterone Acetate
Spironolactone
Lesion Type(s)
Comedonal
lesions
Lesion Type(s)
Comedonal
lesions
Topical
retinoid
Azelaic acid
Salicylic acid
Lesion Type(s)
Comedonal lesions
Topical retinoid
Azelaic acid
Salicylic acid
If results
unsatisfactory
Increase strength
or change
medications
Lesion Type(s)
Comedonal lesions
Mixed comedonal
lesions and
Topical retinoid papulopustules
Azelaic acid
Salicylic acid
If results
unsatisfactory
Increase strength or
change medications
Lesion Type(s)
Types
Comedonal lesions
Mixed comedonal lesions and
papulopustules
Topical retinoid
Azelaic acid
Salicylic acid Retinoid+topical antibiotics
Retinoid+benzoyl peroxide
Retinoid+benzoyl
peroxide+topical antibiotics
If results Azelaic acid+benzoyl peroxide
unsatisfactory Azelaic acid+topical antibiotics
Increase strength or
change medications
Lesion Types
Type(s)
Comedonal lesions
papulopustules
Topical retinoid
Azelaic acid Retinoid+topical antibiotics
Salicylic acid Retinoid+benzoyl peroxide
Retinoid+benzoyl peroxide+topical
antibiotics
Azelaic acid+benzoyl peroxide
If results Azelaic acid+topical antibiotics
unsatisfactory
Increase strength If results unsatisfactory prescribe
or change topical retinoid+course of oral
medications antibiotics
Lesion Type(s)
Comedonal lesions Mixed comedonal lesions and Papules and

papulopustules pustules
Topical retinoid Retinoid+topical antibiotics

Azelaic acid Retinoid+benzoyl peroxide
Salicylic acid Retinoid+benzoyl
Azelaic acid+topical antibiotics
If results
unsatisfactory
Increase strength If results unsatisfactory prescribe
or change topical retinoid+course of oral
medications antibiotics
Lesion Type(s)
Comedonal Mixed comedonal lesions and Papules and

lesions papulopustules pustules
Topical Retinoid+topical antibiotics
retinoid
Azelaic acid Benzoyl
Retinoid+benzoyl
Salicylic acid
peroxide
If results Azelaic acid+topical antibiotics If results
unsatisfactory unsatisfactory
If results unsatisfactory
Increase switch to or
prescribe topical
strength or add topical
retinoid+course of oral
change
antibiotics antibiotics
medications
Lesion Type(s)
Comedonal
Mixed comedonal lesions and Papules and pustules
lesions
papulopustules
Topical retinoid Benzoyl peroxide

Retinoid+topical antibiotics
Azelaic acid
Salicylic acid If results
Retinoid+benzoyl
peroxide+topical antibiotics unsatisfactory switch
to or add topical
If results Azelaic acid+benzoyl peroxide
antibiotics
unsatisfactory Azelaic acid+topical antibiotics
Increase
If results unsatisfactory If results
strength or
prescribe topical unsatisfactory add
change
retinoid+course of oral course of oral
medications
antibiotics antibiotics
Lesion Type(s)
Comedonal Papules and Cystic

lesions pustules lesions
papulopustules
Topical retinoid Benzoyl peroxide

Retinoid+topical antibiotics
Azelaic acid
Salicylic acid If results
Retinoid+benzoyl unsatisfactory
peroxide+topical antibiotics switch to or add
Azelaic acid+benzoyl peroxide topical
If results
unsatisfactory Azelaic acid+topical antibiotics antibiotics
Increase
If results unsatisfactory
strength or If results
prescribe topical
change unsatisfactory
medications add course of
antibiotics
oral antibiotics
Lesion Type(s)
Comedonal Mixed comedonal lesions and Papules and Cystic lesions

Topical Retinoid+topical antibiotics Benzoyl peroxide

retinoid Retinoid+benzoyl peroxide Prescribe course
Azelaic acid Retinoid+benzoyl If results of oral antibiotics
Salicylic acid peroxide+topical antibiotics unsatisfactory + mixed
switch to or add comedonal-
topical papulopustular
If results Azelaic acid+topical antibiotics antibiotics topical therapy
unsatisfactory
Increase If results unsatisfactory If results
strength or prescribe topical
unsatisfactory
change add course of
antibiotics
medications oral antibiotics
Comedonal Mixed comedonal lesions and Papules and Cystic lesions

Prescribe course
Benzoyl of oral antibiotics
Topical retinoid Retinoid+topical antibiotics peroxide + mixed
Azelaic acid Retinoid+benzoyl peroxide If results comedonal-
Salicylic acid Retinoid+benzoyl unsatisfactory papulopustular
peroxide+topical antibiotics switch to or topical therapy
Azelaic acid+benzoyl peroxide add topical
If results antibiotics
Azelaic acid+topical antibiotics If results
unsatisfactory
unsatisfactory
Increase If results unsatisfactory If results consider referral
strength or prescribe topical unsatisfactory to dermatologist
change retinoid+course of oral add course of for oral
medications antibiotics oral isotretinoin
antibiotics therapy

Acne Treatment and Therapeutic Strategies: Senior Instructor Family Medicine

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Acne Treatment and Therapeutic Strategies: Senior Instructor Family Medicine

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Acne Treatment and Therapeutic Strategies

The Aga Khan University Hospital, Karachi

Dr. Marie Andrades

One of the most common skin diseases

Four important factors

For Female Patients

Patient Education (Dispelling Myths)

Topical Therapy (Indications)

Topical Therapy (Basic Rules)

Topical Therapy (Treatment Vehicle)

Azelaic Acid 20%

Salicylic Acid 0.5 - 2%

Topical Therapy (Anti Inflammatory Agents)

Systemic therapy (Indications)

combined with topical therapy

Hormonal Therapy indicated in

Comedonal lesions Mixed comedonal lesions and Papules and

Topical retinoid Retinoid+topical antibiotics

Comedonal Mixed comedonal lesions and Papules and

Topical retinoid Benzoyl peroxide

Comedonal Papules and Cystic

Topical retinoid Benzoyl peroxide

Comedonal Mixed comedonal lesions and Papules and Cystic lesions

Topical Retinoid+topical antibiotics Benzoyl peroxide

Comedonal Mixed comedonal lesions and Papules and Cystic lesions

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