Acne Flashcards
Risk Factors/Exacerbating Factors
• Environmental
- High humidity
- Dirt, oil, chemicals
- Chlorine
• Hormonal
- Puberty
- Ovulation & pregnancy
- Oral contraceptives
- Acne mechanica
- Extreme emotion and stress
- Drug-induced
- Phenytoin
- Isoniazid
- Moisturizers
- Phenobarbital
- Lithium
- Ethionamide
- Steroids
Grading and Classification of Acne
Mild
- Few erythematous papules and occasional pustules mixed with comedones.
Moderate
- Many erythematous papules and pustules and prominent scarring.
Severe
- Extensive pustules, erythematous papules, and multiple nodules in an inflamed background.
Exclusions for Self-treatment
• Moderate-severe acne • Exacerbating factors - Comedogenic drugs (PIMPLES) - Acne mechanica (mechanical irritation) • Possible rosacea
Self-treatment only appropriate for MILD acne
Non-pharmacologic Therapy
- Gently wash affected area twice daily thoroughly, pat dry
- Warm water and non-oily medicated or unmedicated soap
- No washcloths or abrasive/harsh products
- Use cleansing pads if unable to wash with soap and water
- Wash after a meal to remove oil around mouth
- Facial toners may decrease oily skin and remove makeup and dirt but overuse can increase irritation
- Eliminate/cut back on high glycemic index foods
- Stay hydrated
Pharmacologic Treatment
• Benzoyl peroxide (BP) • Adapalene gel (Differin®) • Others - Hydroxy acids - Sulfur - Sulfur/resorcinol
Benzoyl Peroxide (Admin, AE, Avoid)
DRUG OF CHOICE!
- Avoid co-administration with retinoids if possible
- Test x3 days on 2-3 areas, wash w. warm water/non-oily soap, 15-20 min after = apply thin layer
- ADRs: drying, peeling, redness, burning during first days, subsides within 1-2 weeks
- Rare but serious allergic reactions including hypersensitivity and anaphylaxis
- Do not use if you have very sensitive skin or are sensitive to BP
- Avoid eyes, lips, mouth, nose, cuts, scrapes, and abrasions
- Avoid contact with clothes or hair
- Avoid excessive sun and use sunscreen
- Alcohol-based after-shave may worsen stinging
- Separate if also using a retinoid
- Slight improvement in a few days; max effect takes 8-12 weeks
- Continue treatment regimen even after lesions have cleared
Adapalene (Age, AE, Avoid/Do)
- 1st line topical drug for acne and 1st OTC retinoid
- For age 12 and older
- Apply once daily at bedtime to affected areas
- ADE: redness, scaling, dryness, itching, burning (diminishes after 1st month of therapy)
- Acne may worsen during first weeks; full effect in 8-12 weeks
- Data lacking in pregnancy
- Do not use on damaged skin
- Must apply sunscreen while using
• MOA: vitamin A derivative that controls cellular change, overgrowth of keratinocytes, and inflammation
Hydroxy Acids (when to use/agents)
- Less potent, use when cannot tolerate other products
- Moderately effective for acne
- Keratolytic agents
AHAs (+ Polyhydroxyl acids)
- Natural exfoliating acids in sugar cane, milk, and fruits
- Most common are glycolic, lactic, and citric acids
- Unable to penetrate pilosebaceous unit (not comedolytic)
- Light chemical peel once acne is controlled may help with scarring and hyperpigmentation
- Dosed once every 15 days x4-6 months
• Polyhydroxy acids
- Fewer adverse effects such as irritation and stinging
- Marketed for clinical sensitivity
- Moisturizing/humectant properties
Glycolic Acid Contraindications
- Infection or open wounds
- For medium/deep peels:
- Resurfacing procedure (3-12mo) or facial surgery - Hx of abnormal scar formation or delayed wound healing
- Hx of rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, vitiligo, active retinoid dermatitis
- Hx of therapeutic radiation exposure
- Isotretinoin therapy within last 6 months
- Lack of psychological stability/mental preparedness
- Poor general health and nutritional status
- Unrealistic expectations
BHAs - Salicylic acid (Limit, FDA, Contra)
• Comedolytic due to lipid solubility
• Milder, less effective alternative to rx products (BP)
• Considered adjunctive tx. in cleansing preparations
• Prevents/reverses wrinkles due to aging/sun but must wear sunscreen, SPF ≥15
- Unclogs pores via slight peeling
• Limit use to affected area (toxic on large areas for long periods)
• Potentially life-threatening hypersensitivity reactions (FDA)
• Contraindications
- Diabetic patients
- Poor blood circulation
Salicylic Acid Important DDIs
- Anticoagulants: increases anticoagulation
- Anti-diabetic agents: increases activity of glyburide (hypoglycemia)
- Aspirin: increases anticoagulation and serum K+
- Corticosteroids: prednisone may increase renal clearance; increased risk of GI ulceration
- Diuretics: increases effect of salicylates
- Methotrexate: increases serum level of methotrexate
- Heparin: decreases platelet adhesiveness and interferes with hemostasis
Sulfur (Effect, AE)
• Keratolytic and antibacterial
• Promotes resolution of existing comedones but…
- May have comedogenic effect with continued use!
• Apply thin film 3x daily
• Side effects are rare
- Noticeable odor
- Dry skin
Sulfur Combinations
- Sulfur 3%-8% + resorcinol 2%
- Sulfur 3%-8% + resorcinol monoacetate 3%
- Resorcinol enhances effect of sulfur, ineffective alone
- Keratolytic, fosters cell turnover, and desquamation
- antibacterial and antifungal effects with sulfur
- Reversible, dark brown scales on darker-skinned patients
Sulfur Counseling
- Believed to work by inhibiting bacterial growth
- Apply 1-3x daily but use is limited by chalky yellow color and unpleasant odor
- Use is mostly adjunctive, not as effective as BP
- Do not use in patients with allergy to sulfa drugs
