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Bacterial Infections & Acne Disclaimer Perspective Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Bacterial Infections & Acne Chad Hivnor, MD Associate Program Director Chief, Pediatric Dermatology San Antonio, Tx Disclaimer All authored materials and statements constitute the personal statements of Chad Hivnor, MD and are not intended to constitute an endorsement by Wilford Hall Medical Center, the US Air Force, or any other Federal Government entity." Perspective Patients Parents Jrnl Am Acad Dermatol Apr 2007 This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Epidemiology Physiologic 85% Familial Only 20% visit dermatologist Pro-active/OTC Primary physicians Pathophysiology Skin cells Follicular hyperkeratinization Oil production Bacteria Propionibacterium acnes Inflammation Increase cell turnover Androgens may play role This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Sebum secretion higher Decreased sebum production improves acne Free fatty acids may play a role Balloon P. acnes Chemotactic factors Lipases and enzymes Culture: Not necessary unless G – suspected This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Aggrevating Factors Popping Occlusion Friction/ Pressure Medications Stress Other: Drugs (steroids, lithium, INH) Androgens (menses as example) Aggrevating Factors Endocrine Testing Not indicated in most patients Young child Body odor, axillary/pubic hair, clitoromegaly Adult women (PCOS) Late-onset acne, menses, hirsutism, alopecia, infertility, acanthosis nigricans Acne Subtypes Semantics Recent Consensus Statement Most employ lesion counting & Global 5 point scale; mild mod severe Non-inflammatory Closed comedo Open comedo Inflammatory Papules Pustules Nodules This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Open comedomes Inflammatory Acne Differential: Syndromes SAPHO (synovitis, acne, pustulosis, hyperostosis, osteomyelitis) Keratosis pilaris Tuberous sclerosis Other genetic conditions Polycystic Ovarian Syndrome Testosterone (Free/Total), LH/FSH, DHEA-S This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Acne Treatment Multifactorial Multiple pronged approach: EDUCATION Previous Treatment Compliance Acne Treatment Compliance Teenagers Treatment failure Compliance #1 reason You have to ask: What are you USING? How often? 5 of 7 vs 2 of 7 Expect non-compliance Acne Treatment Multifactorial Multiple pronged approach: EDUCATION Previous Treatment Severity - scarring Duration Perspective This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Acne Treatment: Washing Not a dirty problem: ―Fine china‖ Process: Water Salicylic acid wash – lather Comedolytic Lipophilic Splash Pat dry air dry Acne Treatment Retinoids Benzoyl peroxide Topical antibiotic Combo of these 3 Work horse of acne Combo is more effective than alone Pathophysiology Follicular hyperkeratinization Alter keratinization (Retinoid, Salicylic Acid, BP) Oil production Alter sebaceous gland (Retinoid, Salicylic Acid) Bacteria Decrease load (BP) Inflammation Anti-inflammatory (Retinoid) This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Acne Treatment: Retinoids Under utilized 46.1% of acne visits for dermatologists vs 12.1% for pediatricians Pediatr Dermatol. 2008 Nov-Dec;25(6):635-9. Early and often Most effective comedolytic Anti-inflammatory Enhances penetration of other drugs Synergism PREVENTATIVE Retinoids: Education Compliance can be difficult Use at Night dry face Every other night or short contact Moisturize SPF Creams and lotions Not gels This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Acne Treatment: Benzoyl peroxide GREAT: anti-bacterial Decrease bacterial population Decrease hydrolysis of triglycerides NO antibiotic resistance Combo with oral and topicals essential Consensus confirms Treatment Retinoids Benzoyl peroxide Topical antibiotic Azelaic acid Acne Treatment: Azelaic Acid Inflammatory > comedomal Less irriation Post inflammatory hyperpigmentation Pregnancy Cat B Consensus Trial efficacy Practice: not so much Subset This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Treatment Retinoids Benzoyl peroxide Topical antibiotic Azelaic acid Oral Antibiotic Oral Antibiotic Tetracycline Doxycycline Minocycline Bactrim Azithromycin 3-6 months Use in combination Oral Antibiotics Erythromycin Effective High resistance rate Pregnancy/ <8 yo No ampicillin, amoxicillin or cephalexin Should be avoided Consensus This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Bacterial Resistance Propionibacterium acnes Clinically relevant Cross resistance S. aureus in nares Streptococci in oral cavity Enterobacteria in gut ―S. pyogenes colonization and resistance in the oropharynx are associated with antibiotic therapy in patients with acne.‖ Antibiotics Two fold risk URI/ UTI Margolis DJ et al. Arch Dermatol 2005;141:1132-6 ―Benzoyl-peroxide-based treatment is the most evidence-based approach‖… to prevent antibiotic resistance Expert Opin Pharmacother. 2011 Feb 29 (Epub) Bacterial Resistance Propionibacterium acnes Clinically relevant Cross resistance S. aureus in nares Streptococci in oral cavity Enterobacteria in gut Benzoyl peroxide use Compliance This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Treatment Retinoids Benzoyl peroxide Topical antibiotic Azelaic acid Oral Antibiotic Others (Dermatologist) Spironlactone Accutane Accutane Dryness May lead to S. aureus colonization Depression Some patients with challenge/ rechallenge No causal relationship Lipids Arthralgias Hyperostosis & epiphyseal closure No screening Acne Summary Follicular hyperkeratosis Bacterial proliferation Excess sebum Inflammation Excess androgen stimulation Decrease manipulation Compliance with medications This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Acne - Mild Comedomal Retinoid Salicylic Acid Papular/ Pustular Retinoid Combination (benzoyl peroxide/clindamycin) Salicylic Acid Acne - Moderate Oral antibiotic Retinoid Benzoyl peroxide (combination) Salicylic acid Women – spironlactone OCP Acne - Severe Isotretinoin This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011 Gram Positive Organisms Staphylococcal Infections Staphylococcal Cutaneous Manifestations Impetigo—bullous and nonbullous Folliculitis/Furunculosis Pyodermas Botromycosis Paronychia Pyomyositis Staph Scalded Skin Syndrome Toxic Shock Syndrome Septic Emboli Staphylococcal Infections S. aureus is a normal inhabitant of the anterior nares in 20% -40% of adults MRSA Suspected
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