Acne Flashcards
what is acne
- increased sebsum rpoduction (androgens can paly rile) and inc follicular keratinization
- proliferation of bacteria (cutibacterium anes) resulting in lipolysis of sebum triglycerides to free fatty acids
*bacteria feast on triglycerides
- above processes result in inflammation
who deos acne affect
85-90% of Canadian teens
2-35% cases are moderate/severe
50% of cases (esp women) persist into adult years
acne is considered a ____ disease
– Relapses and recurrences
– Prolonged course
– Acute outbreaks
– Psychosocial impact
– Treat like other chronic conditions *want to contorl treatment early
what is a white head
closed comedone
first clincially visible lesion of acne
- completely obstructed
what is a black head
open comedone
- dark colour is due to contents of comedone being oxidized (lipid and melanin)
what is a papule
solid elevated lesion <5mm
what is a pustule
a vesicle filled with purulent liquid <5mm
what is a nodule
Deep lesion. Warm, tender, firm, >5mm diameter
Cyst
A nodule containing liquid
compare mild, moderate and severe acne
- Mild
- the rpesence of comedones, papules and pustules or a mix of them
- Moderate acne
- primarily several to many papules and psutules
- Severe
- several to many papules and pustules + few to several nodules/cysts
What are the categories of acne
- comedonal
- small white (closed comedones) or grey/white (open comedones) papules due to compelte or patrial ductal occlusion
- Mild-to-moderate (papulostular)
- inflammatroy lesions are mostly superficial with small papules, pustules
- Severe (papulopustular and nodular)
- deeper and larger papules, pustules and/or nodules
- can be painful or extended over large areas
effects of acne
gloabally there are scales to assess impact -> acne quality of life scales
- Social impact
- embarassment, humiliation, self consciousness
- inc unemployment rates (in those w/ severe)
- Physical
- soreness, itching, painful, scarring
- Psychosocial ipmact
- anxiety
- low self esteem
- withdrawing from society
- depressive symptoms
what needs to be considered when making an acne diagnosis
- Family history of derm conditions
- Duration of acne, timing of eruption
- Previous medication tried
- Relevant medical history
- histroy of atopic dermatitis, sensitive skin
- symptoms in relation to hormonal causes
- consider female sex contemplating pregnancy
- psychosocial impact of acne
- medications
- anabolic steroids, COCs high in progestin, coal tar products, crystal meth, gabapentin
- cosmterics, hair products, acnegenic skin products
- occlusive garmts, helmets and chin straps
classifications of skin colour
Type I: Ivory, always freckles, always burns/peels, never tans
Type II: fair or pale, usually freckles, often burns/peels, rarely tans
Type III: fair to beige, with goldren undertones. might freckle, burns on occasion, sometimes tans
Type IV: olive or light brown, doesnt really freckle, rarely burns, often tans
Type V: dark brown, rarely freckles, almost never burns, always tans
Type VI: deeply pigmented dark brown - darkest brown, never freckles or bunds, always tans
when should you consider referring for acne
- Age <12
- New onset at age >30
- widesread dsitribution of lesions beyond face
- severe scne (scarring)
- significant psycosocial impact
- sings of hyperandrogenism: hirsutism, infertility, infrequent menses, insluin resistant diabetes, middle age onset in female sex
- suddent onset of acne associated ith fever and arthralgias
- unresponsive to therapy or unclear diagnosis
scholar for acne
- Symptoms:
- itch, pain, systemic symptoms, psychological sympact, excessie hair growth, signs and symp of infection, scarring, hypo or hyperpigmentation
- characteristics:
- numer/type lesions, distribution of lesions? inflammation?
- History:
- how long? does it come/go? experienced before?
- Onset:
- when did it start? what were you doing? anything change in life?
- location
- where is it
- Remitting factors:
- what makes it better? probe w/ specific examples
- Explanatory model
- how does this symptom/condition affect you
what is perioral dermatitis
- due to excessive use of steroids on face
- erythema/violaceous hue, scaling and papulopustular lesions clustered around nasolabial folds, mouth and chin
- D/C topical steroids on face and refer to dermatology for management
what is rosacea
- chonic, relapsing condition invovling blood vessels
- flushing (erythema, violaceous hue) followed by developmen of inflammatory esions
- refer to dermatologist
what is neonatal acne
- developed in 1/5 infacts <3 months
- develop papules, pustules, closed or opn comedones on face
- due to placental transfer of maternal androgens (neonatal acne)
- usually resolves on its own but topical agents under advice of paediatrician may be used
what is acne conglobata
- acne cysts and nodules fuse together deep in the skin
- form a nodulocystic acne (rate but serious inflammatory skin condition)
- face, back and chest affected
- refer
what are the goals for treating acne
- clear existing lesions and prevent new ones
*do this by initating effective treatment at earlist opportunity
- lessen physical discomoft from inflamed acne lesions
- improve dermal appearance
- prevent/minimize potential adverse psychological effects
- preventing and minimizing any scarring or dyspigmentation
adhereence and acne treatment
- treatment is effective but adherence is poor
- 30-65% of patients do not adhere
- 50% do not achieve full benefit due to poor adherence
- to improve adherence tailor tratment based in skin type, sensitivity, risk of adverse and patients preference
- frame patietns expectations -> acne doesnt clear right away
considerations for topical vs systemic acne treatment
- Topical
- first line for mild-moderate acne
- good efficacy for most patients
- immediately targets affected site
- less adverse efects than systemic agents
- geat for maintenance
- Systemic
- usually reserved for moderate/severe
- lesions affecting large number of sites (back, chest, face)
- patient presents with scarrubg
- patients with significant psychosocial impact
- patients who fial topical therapy
therapeutic algorithm for mild acne
mild = comedones, few papules and pustules
- treat w/ benzoyl peroxide or topical retinoid or topical combo therapy
- if benzoyl peroxide or topical retinoid if not on already, swtich to diff topical combo therapy, or consider alternative topicals (dapsone or azelaic acid)
if none owrk move to moderate recs
describe moderate acne treatment
moderate = several pustules an dpapules, possible a few nodules
- topical therapy and oral antibiotic OR topical therapy and COC or spironolactone (females)
- switch to diff topical therapy or add oral antibiotic or add COC or spionolactone
if doest work do severe
describe severe acne treatment
severe acne = numerous paples, pustules, multiple nodules, cysts, scarring
- oral isotretinoin or topical therapy and oral antibiotic or topical therapy and COC (or) spironolactone for females
- switch to diff topical, or add COC or oral spironolactione, or stop oral antibiotics and topical therapy and start oral isotretinoin or stop iso tretinoin and change to oral antibioic & topical therapy &/or COC or oral spironolacone
what are the main treatments for acne
- Benzoyl Peroxide (BPO)
- Salicylic Acid
- Azelaic acid
- Dapsone
- Topical Retinoids
- Topical Antibiotics
- Oral Antibiotics
- Anti-androgen/OCP
- orl retinoids
acne treatment with benzoyl peroxide
when to use
MOA
strength
vehicles
response time
- when to use
- 1st line for mild/mod comedonal acne
- MOA
- antibacterial (oxidation of bacterial proteins, eliminates C.acnes on surface of skin and sebacious follicles
- keratolytic and antiinflammatory
- good at preventing bactieral resistance so ocmbined w/ antibiotics
- strength
- 2.5% most common -> some evidence suggests taht higher strength not more effective
- scheuldes wehn >5% or in combo w/ topical antibiotic or retinoid
- vehicles
- gel, cream, solution, lotion, wash soap
- dont rec soap bc little contact with skin
- gel, cream, solution, lotion, wash soap
- response time
- fast onset of action (within week but optimal in 8-12)
acne treatment with benzoyl eproxide
diretions
adverse effects
additional notes
- directions
- apply topically to entire affected area
- to minimize irritation: app 15 min on 1st night, then 30 min on 2nd, eventually increase to overnight
- adverse
- dryness, peeling, irritation, bleaches clothing, smell that lingers (body odor)
- contact dermatitis possible
- Additional notes
- 30 SPF uring day, BP apply at night
- clinical worsening for first 2-4 weeks possible
- can stain lcothes -> use at night
- can be used in preg and breast feeding
- Always added to oral OR topical antibiotic regimen to decrease resistance to ABX
salicclic acid for acne treatment
when to use
MOA
strength
vehicles
response time
directions for use
adverse
- when to use
- avail as non Rx for comedonal acne
- MOA
- Mildly comedolytic,keratolytic, mildly antibacterial, mildly anti-inflammatory
- strength
- 0.5-3.5% BID (strengths under 20% are unschedules)
- vehicles
- gels, toners, cleansers, washes, pads
- response time
- variable, optimal ipmorvement in 8-12 w
- directions for use
- most BID but checl product
- adverse
- burning, stinging, drying
azelaci acid for acne treatment
when to use
MOA
strength/vehicle
response time
directions
adverse
notes
- when to use
- prescription product for comedonal acne
- helps reduce hyperpigmentation
- less irritation then BPO but less efficacy
- MOA
- comedolyic and antibactieral but does not promote resistance orgnaisms
- strength/vehicle
- 15% gel
- response time
- 8-12 w
- directions
- BID
- adverse
- well tolerated
- notes
- can be used during pregnancy
Dapsone for acne treatment
when to use
MOA
strength/vehicle
response time
directions
adverse
notes
- when to use
- prescritpion topical product to terat inflammatory acne
- MOA
- synthetic sulfone that is antiinflammatory and antibacterial
- Cannot use orally due to side effects
- strength/vehicle
- 5% gel
- response time
- 8-12 weels
- directions
- BIG
- adverse
- midly irrittating, may discolour skin
- notes
- safey in pregnancy not established
topical retinoids for acne treatment
- when to use
- can be used as first line for all types of acne in monotherapy or combination
- MOA
- dec inflammatory and non inflammatroy lesions
- normalizes follicular desquamation
- rach retinoid binds diff set or retinoic acid receptors, so each has slightly diff activity, tolerability and efficacy
- strength/vehicle
- all schedule 1 as single entity or combo
- avail as gel or cream
- response time
- max response in 12w, acne will worsen during first few weeks
- directions
- apply pea sized amount to enitre affected area (not on damp skin)
- to minimize irritation, start applying 12 min 1st night, 30 2nd etc
- use at night due to sen sensivityity
*
retinoid potency
adapalene < tretinoin < tazarotene; trifarotene not established
topical retinoids for acne treatment
adverse effects
additional notes
exmaples
- adverse
- irritation, burning, hypopigmentation, photosensitivity
- start slow go slow
- Additional notes
- need sunscren SPF 30 during say
- discontinue 1 week b4 sunny vacation or dermal procedure
- adapelene and retin-a micro are better tolerated
- helpful to address scarring and hyperpigmentation
- do NOT use on atopic dermatitis
- odo NOT use in pregnngacy (esp if applcition >20% BSA)
- good for anti aging
- Examples
- adapalene, tazarotene, trifarotene, and tretinoin
Clindamycin and erythromycin for acne treatment
when to use
MOA
strength.vehicle
response time
directiosn for use
Adverse effects
Additional notes
- when to use
- prescription product for inflammatroy acne
- MOA
- dec skin colonization of C. acnes and decreases inflammation
- strength.vehicle
- 1% topical solution or pads
- response time
- 8-12 weks
- directiosn for use
- BID, must use with BPO
- Adverse effects
- CI in history of colitis! **only in clindamycin
- midly irritating, peeling, itching, dryness
- Additional notes
- can be used in pregnancy
what combination topical products are available
- Antibiotic + retinoids
- Biacna Gel (clindamycin 1.2% + tretinoin 0.025%)
- Stievamycin Gel (0.01-0.05% tretinoin + 4% erythromycin)
- Benzoyl peroxide + retinoid
- Tacupump gel (adapalene 0.1%+ BP 2.5%)
- Tactupump FORTE gel (adapalene 0.3% +BP 2.5%)
- Benzoyl peroxide + antibiotics
- BenzaClin, Clindoxyl (benzoyl peroxide 5% + clindamycin 1%)
- Benzamycin (benzoyl peroxide 5% + erythromycin 3%)
