6 - Acne Flashcards
What is required for acne to occur?
Pilosebaceous unit (hair follicle)
What are some risk factors for acne?
- Hormones
- Stress
- Genetics, family history
- Environmental factors (oily hair on the face, exposure to aerosolized oil, pollution)
- Medication
What are the 4 stages of the pathophysiology of acne?
1) Increased follicular keratinization
2) Increased sebum production
3) Bacterial (P. acnes) lipolysis of sebum triglycerides to free fatty acids
4) Inflammation
What are the 2 types of non-inflammatory lesions?
- Open comedone (blackhead)
- Closed comedone (whitehead w/ no redness)
What are the types of inflammatory lesions?
- Papules (raised center w/ some inflammation)
- Pustules (larger b/c contents in hair follicle has ruptured and is spreading; 5 mm or less)
- Nodules (larger than pustule; 5 mm - 3 cm)
- Cysts (affects deeper tissue)
What are the 3 types of acne scars?
1) Depressed - ice pick, (triangular), boxed (rectangular), hypertrophic (extends above skin)
2) Hypertrophic (also called keloidal)
3) Atrophic
What are the types of acne?
- Drug-induced (same presentation throughout)
- Neonatal (2-3 months old; self-limiting)
- Acne conglobata (affects large area)
- Acne fulminans (severe, can lead to systemic symptoms like sore joints or muscles)
- Contact (same presentation, can be due to oil-based cosmetics)
- Endocrine (can be caused by excess glucocorticoids or androgens)
- Acne mechanica (localized, caused by mechanical reason)
- Acne excoriee (formed from px manipulating skin)
Which type of acne requires an immediate referral?
Endocrine acne
What are the classifications of acne?
1) Comedonal
2) Mild - moderate papulopustular
3) Severe papulopustular, moderate nodular
4) Severe nodular, conglobate
What is the presentation of comedonal acne?
- Open and closed comedones
- No more than 1 papule may be present
What is the presentation of mild - moderate papulopustular acne?
Numerous comedones, w/ few papules and pustules
What is the presentation of severe papulopustular / moderate nodular acne?
- Numerous comedones
- Papules and pustules present
- One nodule may be present
What is the presentation of severe nodular / conglobate acne?
- Numerous comedones, papules, and pustules
- Nodules present
What are some red flags that will cause referral?
- Evidence of scarring
- Moderate to severe acne
- Signs and symptoms of infection
- Drug-induced acne
- Symptoms consistent w/ endocrionpathy
- Atypical presentation (ex: rosacea; acne not in the normal peak age of 14-19)
- Patients who are non-responsive to non-Rx therapy
What kind of acne is self-treatable?
- Comedonal, mild - moderate papulopustular
- Only in onset age btwn 12-25, no scarring or risk of scarring, and presentation is typical
What are the goals of therapy for acne?
- Alleviate symptoms by decreasing # and severity of lesions
- Slow progression of signs and symptoms
- Limit duration and reoccurence
- Prevent long-term disfigurement associated w/ scarring and hyperpigmentation
- Alleviate psychological distress
- Avoid factors that exacerbate acne
- Minimize treatment failure due to poor compliance
- Educate px w/ emphasis on realistic expectations
What are some non-pharms for acne?
- Wash face w/ mild soap or soapless cleanser no more than twice a day
- Avoid vigorous scrubbing
- Be careful when shaving
- Shampoo hair regularly and keep off face
- Don’t pop, pick, or manipulate lesions
- Minimize cosmetic use, or use oil-free products
- Discontinue or avoid aggravating factors
- Eat a well-balanced diet and drink lots of water
- Try to minimize stress
What is the mechanism of action of topical benzoyl peroxide?
- Normalization of follicular keratinization
- Decrease P acne growth
- Decrease inflammatory process
What is the mechanism of action of oral isotretinoin?
- Normalization of follicular keratinization
- Decrease P acne growth
- Decrease inflammatory process
- Decrease sebum production
Which Rx treatments work by normalization of follicular keratinization?
- Topical BPO
- Topical SA/sulfur/resorcinol
- Topical retinoid and retinoid analogs
- Oral isotretinoin
- Oral contraceptive
- Topical/oral antibiotic
- Azelaic acid
Which Rx treatments work by decreasing P. acne growth?
- Topical BPO
- Oral isotretinoin
- Topical/oral antibiotic
- Azelaic acid
Which Rx treatments work by decreasing sebum production?
- Oral isotretinoin
- Oral contraceptives
- Oral anti-androgens
Which Rx treatments work by decreasing inflammatory process?
- Topical BPO
- Retinoid analogs
- Oral isotretinoin
- Topical/oral antibiotics
- Azelaic acid
- Oral anti-androgens
Acetone and alcohol are good for ____ skin
Very oily
Water based gels are better for ____ skin
Oily, but sensitive
Rank the formulations based on efficacy
1) Gels
2) Lotions
3) Creams
4) Bars/washes
Lotions are good for ___ skin types
All, especially sensitive
Creams are good for ___ skin
Dry
Bars/washes are good for ____ skin types
All
What do microspheres do?
- Localized in hair follicle and release medication over time
- Increase tolerability by decreasing concentration in skin, so less side effects
Microspheres are good for ____ skin
Sensitive
What type of acne is salicylic acid used for?
Mild acne when BPO is not tolerated
What is the concentration of salicylic acid in OTC products?
0.5-2%
What is the dosing of salicylic acid?
Once to twice daily
What are the side effects to salicylic acid?
- Redness
- Peeling
- Stinging
- Rare cases can cause contact dermatitis
Can salicylic acid be used for long-term treatment?
Yes
What is sulfur often combined w/ and why?
Salicylic acid or resorcinol to increase its effects
What are disadvantages to sulfur?
- Offensive odour
- Noticeable colour
- Comedogenic w/ continued use
Should resorcinol be used on its own?
No, has little effects
What is a side effect to resorcinol?
Dark brown scales on dark-skinned px
Which strength of glycolic acid is used for acne treatment?
8%
Can glycolic acid be used alone?
Yes, or can be used as a base for topical antibiotic preparations
Does salicylic acid or glycolic acid produce more skin irritation?
Salicylic acid
What is the first line OTC treatment for non-inflammatory or mild inflammatory acne?
Topical benzoyl peroxide
What are the available OTC strengths of benzoyl peroxide?
2.5 and 5%
What are the available Rx strengths of benzoyl peroxide?
Over 5%
What is BPO combined w/ for treatment of mild-moderate acne?
Topical retinoid and topical antibiotic
What is BPO combined w/ for treatment of moderate and moderate-severe acne?
Topical retinoid and oral antibiotic
Can benzoyl peroxide be used on a long-term basis?
Yes
What are side effects to benzoyl peroxide?
- Irritant dermatitis
- Redness
- Scaling
- Dryness
- Itching
- May cause photosensitization, bleaching, or odour on clothing/bed sheets
- Rare cases can cause contact dermatitis or a hypersensitivity reaction
What is the dosing of benzoyl peroxide?
Once or twice daily
What is self-care treatment for acne usually started w/?
2.5% BPO water-based product
What are some counselling points on topical acne products?
- Apply to entire affected area, do not spot treat
- Must be used regularly
- Skin may worsen before improves
- Allow 6-8 weeks before assessing improvement, may take 8-12 weeks to see full benefit
- Avoid washing area or using other skin products for 1 hour after application
- If missed dose, continue use as normal
- Don’t use other acne products that will further irritate skin
What strength of azelaic acid is available in Canada?
15% gel
Which type of acne is azelaic acid used to treat?
Mild - moderate acne in patients who don’t tolerate BPO or tretinoin
What is the dosing of azelaic acid?
BID
What are some side effects to azelaic acid?
- Burning
- Pruritus
- Stinging and tingling
What are monitoring parameters for azelaic acid?
Px w/ darker skin should be monitored for hypopigmentation
What is the dosing for topical retinoids and retinoid analogues?
Apply once daily
Which type of acne are topical retinoids and retinoid analogues used to treat?
- Comedonal acne and mild-moderate inflammatory acne
* *Maintenance therapy
What are side effects of topical retinoids and retinoid analogues?
- Itching
- Stinging
- Redness
- Peeling
- Photosensitivity
- Skin discolouration
Can topical retinoids be used w/ isotretinoin?
No
Which type of acne are topical antibiotics used to treat?
Mild to moderate inflammatory acne in combination w/ topical retinoid and/or BPO
Should topical antibiotics be used alone?
No
Can topical antibiotics be used w/ oral antibiotics?
No
Can topical antibiotics be used for long-term treatment?
- No b/c of possibility of antibiotic resistance
- Should be used for no more than 6 months
What are side effects of topical antibiotics?
- Erythema
- Dryness
- Peeling of skin
- Stinging
If a px is allergic to an oral antibiotic, can a topical antibiotic of the same class be used?
No
What is clindamycin?
Lincosamide antibiotic
What are contraindications for use of topical clindamycin?
- Allergy to clindamycin or lincomycin
- Previous C. difficile-associated diarrhea
- Inflammatory bowel disease
- *Caution w/ atopic individuals
Which type of acne are oral antibiotics used to treat?
Treatment-resistant forms of mild to moderate inflammatory acne
Oral antibiotics are the first line treatment for ____
Moderate or moderate-severe acne in combination w/ topical retinoid and/or BPO
Can oral antibiotics be used for scarring?
Yes, if patient won’t take isotretinoin
Should oral antibiotics be used alone?
No, combine w/ topical retinoid and add BPO to reduce resistance
What are side effects to oral antibiotics?
- GI upset
- Nausea, vomiting
- Diarrhea
- Headache
- Tetracyclines - photosensitivity and esophagitis (rare)
- Monocycline - dizziness, drowsiness, ataxia
Which type of acne are oral contraceptives used to treat?
- Mild or moderate acne in combination w/ topical therapies
- Adult onset acne in females that have been treated unsuccessfully w/ other agents
- Severe acne for females on isotretinoin
What are side effects to oral contraceptives?
- Nausea, vomiting
- Weight gain (maybe)
- Breakthrough bleeding
- Breast tenderness
- Headache
Which type of acne are androgen-receptor blockers used to treat?
- Females who have adult onset acne that have been treated unsuccessfully w/ other agents
- Women who suffer from acne due to excess of androgen hormones
What are side effects of androgen-receptor blockers?
- Dizziness, drowsiness
- Nausea, vomiting, diarrhea
- Headache
- Mensstrul irregularities
- Spironolactone - hyperkalemia
What are the indications of isotretinoin?
- Severe nodulocystic acne
- Treatment failures
- Scarring
- Frequently relapsing acne
- Cases where psychological distress is severe
What is the duration of treatment for isotretinoin?
12-16 weeks
What are side effects of isotretinoin?
- Cheilitis (cracking of skin around lips)
- Facial redness
- Dry skin/itching
- Photosensitivity
- Depression
- Joint/muscle pain
What are some non-pharm recommendations for a px on isotretinoin?
- Non-comedogenic moisturizer
- Apply lip moisturizers
- Use humidifier
- Drink lots of water
What are contraindications of isotretinoin?
- Hyperlipidemia
- Diabetes
- Severe osteoporosis
- Breastfeeding or pregnancy
- Previous allergic reaction
- Hepatic or renal insufficiency
What are the monitoring parameters for isotretinoin?
- Lipid and blood glucose levels
- Liver function test
- Pregnancy test!!
- Signs of depression
What age should take isotretinoin?
About 12 years old
What should be the treatment approach for pregnant px w/ acne?
- Non-pharms are first line
- If deemed appropriate by physician – topical BPO, erythromycin, or clindamycin considered safe
What are short-term monitoring parameters for acne?
- Lesions decrease by 10-25% in 4-8 weeks of >50% in 2-4 months
- Comedones resolve by 3-4 months
- Inflammatory lesions resolve w/in few weeks
