Acne Flashcards
key factors in acne pathogenesis
follicular keratization
androgens/sebum formation
cutibacterium acnes
inflammation
acne vulgaris
causes
emotional stress rpetitive stress occlusoin and pressure heat and humidity occupational acne
drugs that casue acne-like acneiform lesions
Lithium valproic acid isoniazid GCs po contracept. cyclosporine azathioprine disulfuram phentermine iodides, bromides danazol high dose vitamin B and D
mild acne definitition
few to several papules/pustules (<10) and no nodules
moderate acne definition
10-40 papules/pustules along with 10-40 comedomes and few to several nodules
severe acne definition
numerous or exensive papules/pustules and many nodules
exclusions to self tx
comedogenic drugs
mod-severe acne
pregnancy
when tx does not work
mild acne 1st line tx options
alternative?
BP or TR
OR
TCT (BP + ABX), (BP + R), (BP + ABX + R)
Alt? add topical R or BP or consider diff retinoid or consider topical dapsone
goals of acne tx
remove keratin plug
reduce bacterial inflammation
reduce sebum production
reduce/eliminate scarring
acne home care
gentle synthetic cleansers BID wash with fingers avoid scrubs water-based lotions dont pick at lesions skin should be dry before applying topicals
dry skin = oily skin = hairy areas = solutions = pledgets
dry skin use lotions or creams oily skin use gels or foams hairy area use foams solns are drying but cover large areas pledgets cover large areas
tx that target follicular hyperproliferation
oral/topical retinoids
azelaic acid
salicylic acid
hormonal therapies
tx that target inc sebum production
po retinoids
hormonal tx
clascoterone cream
tx targeting c. acnes prolif
benzoyl peroxide (BP)
ABX
Azelaic acid
dapsone topical
tx for inflammation
po/topicla retinoids po TTCs azelaic acid clascoterone cream dapsone topical
topical retinoids
use
onset
initial management in most patients monotherapy w comedonal acne normalize follicular hyperkeratosis prevent formation of microcomedo may improve inflammatory acne maytake 8-12 weeks to work
clascoterone cream
moa
storeage
androgen receptor inhibitor
HPA suppression has been reported
store at 2-8C before dispensing, patient cans tore at room temp, discard 180 days after dispensing, 30d once opened
topical retinoids for acne treatment
tretinoin (Atralin, Renova) Adapaline (Differin) Tazarotene (Tazorac, Fabior foam, Avage) TWYNEO (tretinoin/BP) Trifarotene (Aklief) Epiduo Forte (Adapalene and BP) VELTIN
topical retinoids
admin
with BP?
gently clean area, pat dry, apply retinoid and then moisturizer
thin layer, qd hs, no not apply tretinoin the same time as BP, applied to entire effected area
topical retinoids AE
irritation, dryness, flaking of skin, transient worsening of acne, photosensitivity, titrate up frequency
avoid use in preggo
Moderate acne 1st line tx
Alternative?
TCT (BP + ABX), (BP + R), (BP + ABX + R)
OR
(BP + po ABX + R)
OR
(BP + po ABX + topical ABX + R)
Alternative:
consider alt combo tx or consider diff po ABX or add COC or po Spironolactone (female) or consider po isotretinoin
Severe acne 1st line
Alternative?
po ABX + TCT (BP + ABX), (BP + R), (BP + ABX + R)
OR
po isotretinoin
Alternative: consider diff po ABX or add COC or po Spironolactone (female) or consider po isotretinoin
Topical ABX options
BP Clinda Erythro Dapsone Minocycline
topical BP freq and AE
twice daily
local skin irritation, may bleach hair or clothing
topical clinda freq and AE
twice daily (qd if foam) rare risk of pseudomonas colitis usually prescribed w BP to decrease resistance
topical erythromycin freq and AE
twice daily
usually prescribed w BP to decrease resistance
topical dapsone freq and AE
5% - BID
7.5% - QD
yellow-orange skin discoloration when applied at the same time as BP
Minocycline freq and AE
QD!
4% foam
Headache
Azelaic acid
MOA
use
AE
20% cream, 15% gel
antimicrobial - limits melanin prod via inhibiting tyrosinase
QD
burning, itching, redness, hives, anaphylaxis v rare
po ABX
TTC Doxy Minocycline Sarecycline Erythromycin TMP/SMX Azithro
TTC po dose and AE
500mg po bid
photosens, GI distress, CI preggo and yoing children
Doxy po dose and AE
50-100mg bid
photosens, GI distress, CI preggo and yoing children
Minocycline po dose and AE`
50-100mg bid
dizziness, drug-ind skin discoloration, CI preggo and yoing children
Sarecycline po dose and AE
weight based dosing 33-54 kg = 60mg qd 55-84kg = 100mg qd 85-136kg = 150mg qd photosens, GI distress, CI preggo and yoing children
Erythro po dosing and AE
500mg bid, GI distress
TMP/SMX po dosing and AE
160/800mg po qd-bid, SJS/TEN
benzoyl peroxide
onset?
AE
onset within 3 weeks, max is 12 weeks
erythema, acaling, xerosis, stinging/burning, bleaching of hair and clothing, hypersens is rare
differen cleanser vs gel
cleanser is BP, gel is adapalene 0.1%
salicylic acid
MOA
with BP?
desquamating agent, lipophilic properties penetrate pilosebaceous follicle to provide comedolytic effects
synergistic effects with BP!
hormonal agents
for who?
for women with oderate to severe acne who are not trying to become pregnant
good in adult women who present w inflammatory acne of lower face/neck with premenopausal flares
Hormonal agents?
moa
products
inhibit androgen actoin in pilosebaceous unit
estrogen suppresses ovarian androgen production
spironolactone and drosperinone competitively inhibit binding of adnrogens to receptors in pilosebaceous unit
Ethinyl Estradiol used to inhibit sebum production
**a progestin only contraceptive ineffective for acne
spironolactone for acne dose pearl onset AE CI
50-100mg BID
concominant use of birth control is recommended d/t femininization of male fetus
AE: menstrual irregularities, breast tenderness, GI upset, orthostatic hypotension, HA, dizziness, fatigue
CI: renal or hepatic dysfunction, monitor serum K in first cycle!
po isotretinoin products MOA use CI dosing
Zenatane, Amnesteem, Claravis, Sotret, Absorbica, Absorbica LD is micronized
use: mod-severe acne, recalcitrant nidular acne
CI: pregnancy, underlying psychiatric conditions, concominant use of TTC ABX
MOA: shrinks sebacous glands, normalizes desquamation
dose: 0.5-1 mg/kg/day in divided doses WITH FOOD x20 weeks, micronized Absorbica LD is 0.4-0.8mg/kg/day in divided doses 15-20 weeks max; swallow capsule whole with a full glass of water
isotretinoin monitoring
take baseline LFT and FLP, if normal take again in 2 months and if normal again no more monitoring
CK elevation (joint/muscle pain)
Hepatotoxicity : if 3xULN–> D/C recommended
po isotretinoin warnings
night blindness skin photosensitivity aczema-like rash dry lips and cheilitis dry eyes muscle pain calcification of ligaments and tendons thinning of hair dry nasal passages HA stunted growth bone marrow suppression IBS?
contraception and isotretinoin
pregnancy tests (n)
script limitations
at least one primary and one secondary (condom, cervical cap diaphragm or sponge) method of birth control
cannot dispense isotret more than 30d after for patients who cannot become preggo, 7d from test
for patients who took a pregnancy test
no automatic refills
no more than 30d supply
acne conglobata
s/sx
tx
inflammatory, acne nodules and cysts that grow together deep below skin, severe scarring
tx:
isotretinoin
systemic ABX
Intralesional steroids
Acne Fulminans
s/sx
tx and duration
rare, severe, painful, ulcerating, hemorrhagic +/- fever +/- bone lesions
if d/t isotretinoin –> D/C
if systemic sx–> po glucocorticoids x4wks then isotretinoin for at least 4wks
w/out systemic sx –> po glucocorticoids x2wks then isotretinoin for at least 4wks
PIH
tx
post inflammatory inflammation, presence of excess melanin, improves slowly with time
tx
1st line = Hydroquinone 2% (avoid spot tx), BID
2nd line = topical retinoids (tretinoin, tazarotene or adapalene), azelaic acid 20%, chemical peels or laser resurfacing (glycolic, salicylic acids)
