Acne Vulgaris. This non promotional presentation has been sponsored and developed by Galderma for UK healthcare professionals only.

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1 Acne Vulgaris [Speaker Name] [Speaker Title] This non promotional presentation has been sponsored and developed by OTH DOP: August 2018 Learning Objectives Explain the pathophysiology of acne Demonstrate the assessment of acne Select individualised management and treatment based on the latest clinical data and guidelines Evaluate the psychological impact Recognize when to refer to a specialist Pre-Quiz 1 1. Where on the body is acne commonly found? 2. What is another name for an open comedone? 3. Name 2 types of acne lesions 4. What systemic treatment is recognised for severe or nodulocystic acne? 1

2 Pre-Quiz 2 1. Name the 4 pathogenic factors of acne 2. Cite 4 patients types with acne who should be referred 3. List 4 potential psychological aspects of acne 4. Which treatment is strongly recommended for comedonal acne by the Primary Care Dermatology Society (PCDS)? Background Acne is a common and chronic disorder of the pilosebaceous unit 1 Acne manifests in areas with larger, more numerous sebaceous glands, such as the face, neck, back, chest, shoulders and upper arms 1 Acne lesions can be separated into 1, : Inflammatory (papules, pustules or nodules/cysts) Non-inflammatory (closed or open comedones, microcomedones) Most people with acne have a mixture of inflammatory and non-inflammatory lesions 2 1. Williams HC, et al.. Lancet. 2012;379(9813): Nast A, et al. Epidemiology Acne is one of the most common skin conditions in the United Kingdom 1 Acne instigates 3.5 million visits to primary care practitioners every year 1 Acne affects 8/10 people aged years in the UK 2 1. Dawson AL, et al. BMJ May 8;346:f British Skin Foundation (BSF). Accessed June

3 Prevalence Almost 90% of teenagers have acne and half will continue to experience acne into adulthood 1 Acne is more common in males during adolescence but in adulthood, incidence is higher in women 2 Acne in males generally resolves during their 20 s 4 Age (y) Prevalence of female and male acne in different age groups 3 0.0% * 20.0% 40.0% 60.0% 80.0% 66.8% Teenager 68.5% 50.9% 20 29* 42.5% 35.2% 30 39* 20.1% 26.3% 40 49* * P < % 15.3% >50* Female Male 7.3% Adapted from Collier et al Dawson AL, et al. BMJ May 8;346:f NICE CKS 3. Collier et al. JAAD 2008;58(1): Goulden V, et al. 1999;41(4): The Acne Disease Pathway 1,2 Androgen Sebaceous glands hormone enlarge influences and stimulates Over production Pathogenic factors of acne sebaceous of epithelial cells gland lining follicles 1. Excessive sebum production 2. Hyperkeratinization (abnormal cell turnover) 3. Inflammation and immune Scars response 4. P. acnes colonization Goal of treatment: Formation of To target as many pustules and cysts pathogenic factors of acne as possible 1 Excessive sebum production Hyperkeratinization 2 3 Inflammation and immune response Propionibacterium acnes colonization in anaerobic environment 4 Microcomedone formation A thick hyperkeratotic plug White heads and black heads form 1. Nast A, et al NICE CKS Pathogenesis Sebum TG synthesis P. Acnes growth biofilm and QS TLR2 activation NLRP3 activation IL-1β IL-17 TH17 IL-17 Inflammation Comedogenesis Adapted from Melnik BC. Clin Cosmet Investig Dermatol. 2015;8: Melnik BC. Clin Cosmet Investig Dermatol. 2015;8:

4 Aetiology 1 Androgen-induced seborrhoea Comedone formation after follicular plugging P. acnes colonisation of the pilosebaceous duct Production of inflammation Seborrhoea Androgens Comedone formation Changes in the ductal micro environment results in P. acnes (ductal) colonisation Inflammation Figure adapted from PCDS Guidance: Acne Vulgaris 1. PCDS Guidance: Acne Vulgaris. Potential Triggers 1-3 Family History Hereditary factors seem to play a large role in acne development. Hormonal Factors Many women note that their acne tends to get better and worse in cycles, related to their menstrual period. Roughly 70% of female patients note acne flare-ups in the days leading up to their period. Hormonal changes during pregnancy may also result in temporary acne flares. Drugs Stress Certain medications containing corticosteroids, anabolic steroids, lithium, ciclosporin and iodides. Psychological stress may exacerbate acne, but data is limited. Diet The role of diet in acne is an evolving concept, as evidence is not strong, some people with acne have reported improvement in their skin following a lowglycaemic index diet. Cosmetics Caused by oil-based cosmetics 1. Thiboutot DM et al. J Am Acad Dermatol Feb;78(2S1):S1-S23.e1. 2. Dréno B. J Eur Acad Dermatol Venereol. 2017;31(Suppl 5): Bhate K et al. Br J Dermatol. 2013;168(3): Assessment Duration 1 Family History 1 Treatment Response 1 Therapy Adherence 1 Exacerbating Factors 1 Differential Diagnosis 1 Systemic Features 1 Underlying Cause 1 Persistent/Late-Onset 1 Lesion Type + Location 1 Lesion Severity 1 Psychosocial Impact 1 Scarring 2 Pigmentation 3 Patient Education 1 When to Refer 1 Key Patient/Prescriber Relationship 2 1. NICE CKS 2. Nast A, et al Bhate K, et al. Br J Dermatol. 2013;168(3):

5 Grading There is no universally agreed grading system 1 Acne is often categorised by lesion type and severity into 2 : MILD MODERATE SEVERE LESION TYPE Non-inflammatory: Comedones Inflammatory: Papules, Pustules or Nodules/ Cysts < >100 < >50 TOTAL < > NICE CKS 2. Gold MH, at al. J Clin Aesthet Dermatol. 2009;2(4): Psychological Aspects Patients quality of life issues 1 Significant psychological morbidity and, rarely, mortality 2 Stress 3 Embarrassment 4 Frustration and anger 4 Anxiety and depression 1 Social implications 2 Occupational implications 2 Self esteem 1 Body image 1 Severity of psychological impact 1 1. NICE CKS 2 Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S Tasoula E, et al. An Bras Dermatol. 2012;87(6): Nast A, et al Baldwin HE. Cutis. 2002;70(2): Comedonal Acne open and closed comedones 5

6 Comedonal Acne closed comedones Comedonal Acne hyperpigmentation Mild to Moderate Acne 6

7 Mild Acne on Back Moderate to Severe Acne Severe Acne nodules and scarring 7

8 Severe Acne - scarring Primary Care Dermatology Society (PCDS) Guidance Acne Treatment graded by the predominant present Comedones Papules Pustules Nodules/Cysts* Topical Retinoid Tretinoin, Isotretinoin & Adapalene Benzoyl Peroxide (BPO) Azelaic Acid 20% Topical Antibiotics Topical Retinoid/BPO Topical Retinoid/ Antibiotic Combination Topical Antibiotic/ BPO Combination Oral Antibiotics Combined Oral Contraceptives (for females only) Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation *Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Treatment. Practical Advice for Managing Acne Topical retinoids should be used for all grades of acne 1 Irritation with topical retinoids and BPO can be ameliorated by gradual introduction 1 Concurrent use with light non-comedogenic emollients may be useful 1 Azelaic acid may be beneficial in patients with darker skin 1 BPO can cause bleaching of fabric 1 Oral antibiotics should not be used as sole treatment 1 Combine systemic antibiotics with topical agents to reduce bacterial resistance 2 All treatments should be routinely reviewed at 12 weeks 2 Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne treatment NICE CKS 8

9 Practical Advice for Managing Acne Oral contraceptives: Second and third generation Combined Oral Contraceptives are preferred 1 Co-cyprindiol is used in moderate to severe acne where other treatments have failed 1 Topical retinoids and oral tetracyclines are contraindicated in pregnancy 2 Combining topical treatments is recommended for most people with moderate acne to improve adherence 1 Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne treatment NICE CKS Maintenance Treatment 1 Acne is a chronic condition topical retinoid is recommended for long term maintenance Occasional flares may require revisiting previously successful treatments 1. PCDS Guidance: Acne treatment. Oral Isotretinoin Vitamin A derivative 1 Effective treatment of severe nodular acne 2 Mandatory monitoring 3 Teratogenic effects 2 Dose - weight calculated 4 Pre-treatment counselling 4 Prescribed only by Consultant Dermatologist 3 Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. BAD 2. Williams HC, et al. Lancet. 2012;379(9813): Goodfield MJ, et al. Br J Dermatol. 2010;162(6): NICE BNF 9

10 Nodule and Cyst Self Care 1 Avoid picking and squeezing spots Early intervention can help avoid permanent scarring Treatments used correctly can take at least two months to show improvement Irritation may occur with treatments so build up treatments gradually Use oil-free or non-comedogenic soap substitutes, moisturisers and makeup Little evidence that foods cause acne, but a balanced diet will benefit health overall 1. BAD Acne Global Antibiotic Resistance Deaths attributable to antimicrobial resistance every year by North America 317,000 Europe 390,000 Asia 4,730,000 Latin America 392,000 Africa 4,150,000 Oceania 22,000 Adapted from: Review on Antimicrobial Resistance Tagliabue A. Front Immunol. 2018;9: Antimicrobial Resistance %20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf 10

11 A call to limit antibiotic use in acne 1 There is significant and often prolonged antibiotic use in acne P. acnes is only one of the 4 pathogenic factors Topical retinoid + antimicrobial is now first line treatment Reports that more than 50% of P. acnes strains are resistant Do not use antibiotics as monotherapy or combine topical and systemic antibiotics Benzoyl peroxide (BPO) and systemic antibiotics should be combined with a topical retinoid 1. Thiboutot D, et al. J Drugs Dermatol. 2013;12(12): Scarring Atrophic scars: the most common type, are caused by collagen loss and present as skin indentations 1 Ice pick scars: are usually narrow (<2 mm), deep, sharply demarcated tracts 1 Rolling scars: are usually wider (4 to 5 mm) and more shallow with an undulating appearance 1 Boxcar scars: are either shallow (<0.5 mm) or deep (>0.5 mm) round- to oval-shaped skin dimples with sharp margins 1 Hypertrophic acne scars and keloids: are firm, raised papule or plaque, characterized by collagen gain subsequent to an acne lesion resolution - hypertrophic scars do not extend beyond the original wound margin and keloids extend beyond the margin 1 Hyperpigmentation - not technically a scar, these are red or dark marks that remain after the spot has cleared 2 Atrophic: Involving tissue loss Deep Dermal Scarring Ice Pick Scars Rolling Scars Boxcar Scars Acne Scarring Not involving tissue loss Hypertrophic Scars Keloids Figure adapted from Ankit, et al Ankit S, et al. Int J Sci Invent Today. 2018;7(3): Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S1-37. Keloid Scarring 11

12 Ice Pick Scarring Atrophic and Ice Pick Scarring Nodules, Cysts and Scarring 12

13 Who to Refer Patients with severe acne refer early 1 Moderate acne only partially responding to treatment and starting to scar and/or causing significant hyperpigmentation 1 Patients with associated and severe psychological symptoms, regardless of physical signs 1 Patients where there is diagnostic uncertainty 2 Patients failing to respond to multiple therapeutic interventions 2 1. PCDS Guidance: Acne Vulgaris PCDS Guidance: Acne Treatment. web.pdf. The Key to Success Understanding the condition Understanding the treatments Build up tolerance to manage side effects Consider lifestyles when prescribing Good concordance with treatments No quick fix Flexibility in approach Ongoing psychological support 1. Nurse Team Experience In Summary Acne is a very common and chronic problem, that affects both adolescents and adults 1 It causes physiological and psychological scarring for many people 2 Patient education on the condition and treatments may improve their quality of life throughout the disease process 3 1. Williams HC, et al.. Lancet. 2012;379(9813): Gollnick H, et al. J Am Acad Dermatol. 2003;49(1 Suppl):S NICE CKS 13

14 Pre-Quiz 1 - Answers Acne mostly occurs on the face. However, acne can form 1. Where anywhere on there the is a body concentration is acne of oil commonly glands, including found? on the neck, back, upper chest, and shoulders What is another name Blackhead. for an 1 open comedone? 4. What systemic 3. Papules, Name 2 pustules, types of treatment is recognised Oral isotretinoin. nodules acne lesions or cysts. 1 for severe or 2 nodulocystic acne? 1. Williams HC, et al.. Lancet. 2012;379(9813): Bewley T, et al. Pre-Quiz 2 - Answers (1) Sebaceous gland hyperplasia with seborrhoea; (2) Altered follicular growth and 1. Name the differentiation; 4 pathogenic factors (3) Propionibacterium of acne acnes; (4) Inflammation and immune response. 1 (1) Patients with severe acne refer early 2 ; (2) Moderate acne only partially responding to treatment and starting to scar and/or causing significant hyperpigmentation 2. Cite 4 patients types 2 ; (3) Patients with associated and severe with psychological acne symptoms, who regardless should of be physical referred signs 2 ; (4) Patients where there is diagnostic uncertainty 3 ; (5) Patients failing to respond to multiple therapeutic interventions Stress; List anxiety 4 potential and psychological depression; social implications; aspects of occupational acne implications; self-esteem; body image Which treatment is strongly Topical recommended retinoid (Tretinoin, for comedonal Isotretinoin acne & by the Primary Adapalene). Care Dermatology 3 Society (PCDS)? 1. Nast A, et al PCDS Guidance: Acne Vulgaris PCDS Guidance: Acne Treatment. Case Studies* *all case studies presented are fictional for demonstrative purposes 14

15 Mild - Moderate Acne 19 year old female Developed lesions aged 15 Used many OTC products which have not helped GP has given her topical treatments which sting and bleach; she has stopped using them Oral antibiotics upset her stomach Her appearance is having a negative impact on her quality of life (QOL) Primary Care Dermatology Society (PCDS) Guidance Acne Treatment graded by the predominant present Comedones Papules Pustules Nodules/Cysts* Topical Retinoid Tretinoin, Isotretinoin & Adapalene Benzoyl Peroxide (BPO) Azelaic Acid 20% Topical Antibiotics Topical Retinoid/BPO Topical Retinoid/ Antibiotic Combination Topical Antibiotic/ BPO Combination Oral Antibiotics Combined Oral Contraceptives (for females only) Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation *Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Treatment. Comedonal acne 11 year old girl History of acne for about 8 months Has a family history of acne Only around forehead area 15

16 Primary Care Dermatology Society (PCDS) Guidance Acne Treatment graded by the predominant present Comedones Papules Pustules Nodules/Cysts* Topical Retinoid Tretinoin, Isotretinoin & Adapalene Benzoyl Peroxide (BPO) Azelaic Acid 20% Topical Antibiotics Topical Retinoid/BPO Topical Retinoid/ Antibiotic Combination Topical Antibiotic/ BPO Combination Oral Antibiotics Combined Oral Contraceptives (for females only) Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation *Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Treatment. Moderate to severe acne 17 year old male Embarrassed by spots on face Doesn t want to change for PE and wears a T-shirt under school shirt Mum has bought some OTC topical treatment Dad had severe acne as a teenager and has scars Primary Care Dermatology Society (PCDS) Guidance Acne Treatment graded by the predominant present Comedones Papules Pustules Nodules/Cysts* Topical Retinoid Tretinoin, Isotretinoin & Adapalene Benzoyl Peroxide (BPO) Azelaic Acid 20% Topical Antibiotics Topical Retinoid/BPO Topical Retinoid/ Antibiotic Combination Topical Antibiotic/ BPO Combination Oral Antibiotics Combined Oral Contraceptives (for females only) Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation *Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Treatment. 16

17 Severe Acne 20 year old man Had acne since the age of 14 years Has been self-conscious about it for 6 months Has had one short course of antibiotics worked initially but when discontinued came back Doesn t use topicals Primary Care Dermatology Society (PCDS) Guidance Acne Treatment graded by the predominant present Comedones Papules Pustules Nodules/Cysts* Topical Retinoid Tretinoin, Isotretinoin & Adapalene Benzoyl Peroxide (BPO) Azelaic Acid 20% Topical Antibiotics Topical Retinoid/BPO Topical Retinoid/ Antibiotic Combination Topical Antibiotic/ BPO Combination Oral Antibiotics Combined Oral Contraceptives (for females only) Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation *Treatment can be initiated, but patients should be referred. Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Treatment. Top Tips in Managing Acne 1,2 Main aim of treating acne is to prevent scarring, so monitor the patient for evidence of scarring Discuss key elements with the patient - family history and no cure for acne Explore how acne affects the patients quality of life Examine the areas affected and grade as mild, moderate, severe or use Leeds acne grading system including back and chest if affected Explain to the patient the 4 pathogenic factors of acne: (1) Excessive Sebum; (2) Abnormal skin cell turnover; (3) Inflammation; (4) P. Acnes Explain how the treatment fits in with the above factors Educate on topical treatments and how to build them up slowly Use non comedogenic moisturiser/make-up Discuss antibiotics and length of use no longer than 3 months Do not use antibiotics as monotherapy Do not combine topical and oral antibiotics Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Acne Vulgaris PCDS Guidance: Acne treatment. web.pdf. 17

18 Thank you for listening 18