Acne Flashcards
Patho of acne
Blockage in hair follicle of dead skin –> excess keratin in the hair shaft mixes with excess sebum and creates a plug of cells and oil –> bacteria rush to the site –> WBCs rush in to respond and inflammation occurs –> pocket of pus forms
Other factors that can cause acne
Makeup, sweat, other external factors
Factors in acne pathogenesis
Follicular keratinization, androgens, sebum formation, C. acnes, inflammation
Signs/symptoms of mild acne
Few to several papules/pustules (<10), no nodules
Signs/symptoms of moderate acne
Several to many papules/pustules (10-40) along with comedones (10-40) and few to several nodules
Sign/symptoms of severe acne
Numerous or extensive papules/pustules and many nodules
pH of healthy skin
4.7-5.7
Medications to treat acne
Topical retinoids Azelaic acid Topical antimicrobials PO ABX Salicylic acid Sulfur AHAs Tea tree oil PO isotretinoin
Types of topical retinoids
Tretinoin (Atralin)
Adapalene (Differin)
Tazarotene (Tazorac)
When are topical retinoids used?
Used as initial management
What do topical retinoids do?
Normalize follicular hyperkeratosis and improves inflammatory acne
Also enhances penetration of other topical acne medications and decreases hyperpigmentation of acne scars
How long does it take for topical retinoids to work?
8-12 weeks
Counseling on topical retinoids
At night: clean skin, pat dry, apply the retinoid, apply moisturizer
Acne may get worse before it gets better
Avoid OTC irritating products
START LOW AND GO SLOW
ADEs of topical retinoids
Skin irritation, skin flaking, dryness, “photosensitivity”
When should topical retinoids be avoided?
Pregnancy and in patients with fish allergies (Atralin/Tretinoin)
Topical antimicrobial products
Benzoyl peroxide, clindamycin, erythromycin, dapsone, minocycline
What do topical antimicrobials do?
Decrease C. acnes colonizing skin and decreases inflammatory response
What should topical antimicrobials be combined with to make them more effective?
Topical retinoid
Benefits of benzoyl peroxide
Comedolytic and antibacterial
How long does it take for benzoyl peroxide to be effective?
Benefits within 3 weeks, but max effects in 12 weeks
Dosing for benzoyl peroxide
Apply daily, then increase to twice or three times daily after 2 weeks
Strength titration for benzoyl peroxide
Start at 2.5%, increase weekly as needed to 5%, then 10%
ADEs of benzoyl peroxide
Erythema, scaling, xerosis, stinging/burning, bleaching of hair and clothing, rare hypersensitivity
Least irritating topical retinoid
Adapalene
Properties of azelaic acid
Antimicrobial, comedolytic, mild anti-inflammatory properties
Benefits of azelaic acid
Can improve acne-induced post-inflammatory hyperpigmentation
Dosing frequency of azelaic acid
QD
ADEs of azelaic acid
Burning, itching, redness, hives and anaphylaxis rare
How to reduce resistance to PO ABX
Limit duration, avoid changing too soon, restart same ABX if still effective and it was stopped, don’t combine MoAs, use with benzoyl peroxide or topical retinoids
PO ABX products
TTC, doxycycline, minocycline, sarecycline, erythromycin, Bactrim, azithromycin
Salicyclic acid properties
Comedolytic effects, mild anti-inflammatory properties
Salicyclic acid has a synergistic effect with what other acne medication?
Benzoyl peroxide
What class does salicylic acid belong to according to the makeup industry?
BHAs (0.5%-2% available commercially)
Properties of sulfur
Keratolytic effect, inhibits proliferation of C. acne
Not used as often anymore due to the odor
Properties of AHAs
Improve post-inflammatory hyperpigmentation and diminishes signs of aging skin
AHAs may work synergistically with what acne medication?
Retinoids
Properties of tea tree oil
Antimicrobial and anti-inflammatory properties
When should a patient seek a provider for acne?
Comedogenic drugs
Moderate-severe acne
Pregnancy
Treatment doesn’t work
When can you use hormonal agents for acne?
Moderate-severe acne in women who aren’t trying to get pregnant
Benefits adult women who present with inflammatory acne following lower face/neck with premenopausal flares
Hormonal acne agents
Ethinyl estradiol/progestin
Spironolactone and drospirenone
What can happen to a male fetus if spironolactone is taking during pregnancy?
Feminization of the fetus
Minimum amount of therapy required for evaluation of hormonal acne therapy efficacy
3-6 months
COC ADE
thromboembolism (especially in smokers)
Spironolactone ADEs
Breast tenderness, menstrual irregularities, GI upset, orthostatic hypotension, HA, dizziness, fatigue
Spironolactone dosing for acne
50-100mg PO BID
Spironolactone CIs
renal failure, liver dysfunction
Spironolactone monitoring
Serum K+, make sure patient is on concomitant BC
Brand names for PO isotretinoin
Zenatane, Amnesteem, Claravis, Sotret, Absorica, Absorica LD is micronized form
Indications for PO isotretinoin
Moderate-severe, recalcitrant, nodular acne
MoA of PO isotretinoin
Shrinks sebaceous glands
Dosing for standardized PO isotretinoin
0.5-1 mg/kg/day in divided doses with food
Alternate dosing for standardized PO isotretinoin
0.5mg/kg/day x1 month, then 1 mg/kg/day
Micronized PO isotretinoin dosing
0.4-0.8 mg/kg/day in divided doses for 15-20 weeks MAX
PO isotretinoin CIs
PREGNANCY, psychiatric conditions (taking it is associated with depression and suicide), use with tetracyclines
What should you avoid taking while on isotretinoin?
Vitamin A supplements
Lab monitoring for PO isotretinoin
LFT and FLP
If LFTs and FLPs are normal, what happens next?
Take again in 2 months; if it’s still normal after that, no monitoring needed unless there’s a dose increase
If LFTs and FLPs are elevated, what happens?
If it’s x3 ULN, D/C
What should you avoid for ≥6 months after stopping isotretinoin?
Dermabrasion, laser epilation
ADEs of PO isotretinoin
Night blindness, skin photosensitivity, eczema-like rash, dry lips, eyes, nasal passages; muscle pain, calcification of ligaments and tendons, hair thinning, headache, stunted growth, bone marrow suppression
iPLEDGE program
Program that prevents patients from getting pregnant while taking isotretinoin and prevents pregnant patients from taking it
Who must be enrolled in iPLEDGE?
Patient, provider, and pharmacy
How should a doctor write a script for isotretinoin?
No more than a 30 days supply with no refills
What happens if a patient needs a refill on isotretinoin?
Get a new script, but have to verify that they’re not pregnant
When do you put the isotretinoin back in inventory when the patient hasn’t picked it up?
Patients who can’t get pregnant: >30 days
Patients who CAN get pregnant: >7 days
Number of pregnancy tests to take over the course of isotretinoin treatment
N+4, with N being the number of months the patient is on treatment
How many forms of BC should a patient be on while taking isotretinoin?
At least 2
