Acne Flashcards
What is critical in each case of acne?
simple skin care
handling patient expectations
Amongst those who seek advice for acne, what is the % for pharmacists compared to MDs?
10% seek a pharmacist
90% seek an MD
What is the etiology for acne?
follicular changes (follicular wall becomes sticky, stuff plugs up)
increased sebum (due to puberty)
P. acnes (bacteria)
inflammation (redness and zits are inflammatory processes)
What is the difference between a blackhead and a whitehead?
blackhead:
-open comedo
-does not lead to more acne/inflammation
-mainly a cosmetic issue
whitehead:
-closed comedo
-due to sticky follicular wall
-can become worse
What are predisposing factors for acne?
puberty for boys and girls
pre-menstrual flares (acne especially on the jawline)
skin hydration (sweat clogs pores)
cosmetics
irritation and occlusion
dietary aspects
stress
occupation
hereditary
What are some of the symptoms of polycystic ovary syndrome (PCOS)? What should you do?
acne, hair loss, male pattern baldness
refer
What is PCOS?
hormonal disorder that causes enlarged ovaries, small cysts may form on the outer edges, can affect fertility
True or false: acne is common during pregnancy
true
more than one out of every two pregnant women can develop acne
How does diet contribute to acne?
diet high in sugar–>more insulin–>more oils
How does stress contribute to acne?
stress induces body steroid levels to rise–>stimulates more sebum production
What kind of jobs are more prone to acne?
fast-food workers (“McDonalds acne”)
Which type of adult acne are we not involved in?
adult-onset cases should be immediate referral
Where are some typical locations for acne to appear?
face
neck
chest
upper back
upper arms
Which acne lesions tend to be inflammatory?
papules
pustules
nodules
cysts
What is the definition of mild acne?
<20 comedones or <15 inflammatory lesions or <30 total lesions
True or false: pharmacists only deal with moderate acne
false
pharmacists only deal with mild acne
Which drugs can cause drug-induced acne?
topical steroids (improper use)
some birth control pills (most are helpful)
What % of adult acne cases are continuing from teenage years? What about adult onset cases?
80% are cases that continue from teenage years
20% are adult-onset cases
What is milia?
“baby acne”
not true acne
appears in the first few days of life and disappears in a few weeks without any treatment
What is rosacea?
a skin condition that affects the central face
no comedones
there can be ocular symptoms
transient flushing and warmth
blood vessels appear on skin
comes and goes
What triggers rosacea?
nobody really knows the exact cause
Which group of people are typically affected by rosacea?
usually people older than 30
rarely in kids
What is the treatment for rosacea?
topical agents
Are there any products in the OTC aisle to help with rosacea?
no
refer if you think the patient has rosacea
What is perioral dermatitis? What does it look like?
it is a facial rash that tends to occur around the mouth
appears red and slightly scaly or bumping, burning or itching is mild
NO BLACKHEADS
What is the treatment for perioral dermatitis?
oral/topical antibiotics
MD care
What are the non-medical measures for acne treatment?
basic skin care:
-washing face BID
-do not scrub
-minimize picking
eczema grade soaps
no need for astringents
acne cleansing pads are fine
True or false: over cleaning can increase sebum levels on the skin
true
BID washing is fine
What are the cornerstones of acne therapy?
BP and/or retinoids
How long should an acne patient expect to undergo therapy?
2-4 years
If parents had acne, then what could be a good move for their kid?
start treatment early to prevent mild acne from getting moderate or severe
How does salicylic acid work?
keratolytic
-dries out oils on the face
-reduces plugging on the surface
What strengths does salicylic acid typically come in?
0.5% or 2%
What is the active ingredient in oxy wipes?
salicylic acid
What is the main reason that salicylic acid is added to products?
allows the manufacturer to advertise their product as medicated
Other than our cornerstone acne treatments, what are some other therapies?
sulfur (antibacterial)
resorcinol (exfoliant, antibacterial)
tea tree oil (antibacterial)
topical nicotinamide (might be doing something)
Which strengths of BP are OTC? Which strength is Rx?
OTC: 2.5% (uncommon) and 5% (good starting point)
Rx: 10%
When should BP be used as a solo product? When should it be used as a combo product?
solo: mild acne
combo: moderate acne
What are the side effects of BP?
redness, peeling, dryness, burning, bleaches clothes
What is the mechanism of action of BP?
antibacterial (not an antibiotic)
-hits P acnes with a blast of O2
exfoliant action
True or false: it is necessary to use sunscreen while on BP
false
not as sun-sensitive as retinoids
Which vehicles are more valuable for BP? Which vehicles are less valuable for BP?
lotions and gel (acetone>alcohol>aqueous) are better
soaps/washes are less valuable due to concerns of contact time
True or false: gels are stronger than lotions but it is not a massive jump in therapy
true
If a patient has oily skin which vehicle should you go for? What about if the patient has sensitive skin?
oily skin go for a gel because it can dry it out
sensitive skin go for a lotion
How much BP should be applied to an affected area?
smaller than an FTU (pea-sized)
more is not better
What are the directions for use of BP?
start slowly
-ex: apply for 1-2hrs then wipe off for a few days and then apply
for 3-4hrs for a few days before moving to a full night of
contact
What is a good way to verbalize the “start slowly” directions?
“This will eventually be left on overnight. Now, how you get there is this way…”
True or false: we should resist the temptation to spot treat with BP
true
What can be done for overly dry skin that is the result of BP?
add dry skin lotion (non-cometogenic)
go slower
change % or formulation base
As a pharmacist, what is critical during an OTC consult with regards to acne?
expectations in regards to improvement
Explain the once-a-day regimen for BP.
wash face in the morning
wash face in the evening
let skin dry
apply BP (thus contact time is 8-10hrs)
Explain the BID regimen for BP.
wash face in the morning
let skin dry
apply BP
around 8pm, wash face
let skin dry
apply BP (thus contact time is ~24hrs)
What is the mechanism of action of topical retinoids?
they decrease the cohesiveness of the follicular wall
they increase the penetration of other agents like BP
Which vitamin are topical retinoids a derivative of?
vit A
What are the dosing and formulations for tretinoin?
0.01% cream and 0.025% cream
0.025% gel and 0.05% gel
What are the side effects of tretinoin?
erythema or irritation
What are the directions for use of tretinoin?
skin needs to be dry before application
pea-sized amount
start slowly (start with low strength aka cream and then re-asses)
apply at night
Why should topical retinoids be applied at night?
tretinoin is a sun sensitive agent
if applied at night, it should all be gone by the morning
Why might your acne worsen upon initial usage of topical retinoids?
retinoids bring “soon to be” acne up to the surface
What are the choices of topical retinoids?
adapalene (least irritating)
tretinoin (most photosensitizing)
tazarotene (most potent)
Which product is advertised as being for truncal acne? Would agents like retinoids be fine for truncal acne?
Aklief, it just a marketing move
yes they would
What do we do in regards to topical retinoids and pregancy?
referral
vit A in as retinoids can be teratogenic for unborn kids
adapalene: Category C (caution)
tazarotene: Category X (contraindication)
When are the BP and retinoid combos used?
moderate acne
What is starting to become the recommended first line approach in most acne cases?
combination therapy
Should BP and a retinoid be applied at the same time?
no there is a drug interaction
BP oxidizes the retinoid making it almost not useful
If a patient is using BP and a retinoid, when should each agent be applied?
BP in the morning
retinoid at night
Which formulations bypass the BP-retinoid drug interaction, allowing for BP and the retinoid to both be used at night?
micronized tretinoin gel
adapalene+BP
If we are really trying to get to the nuances, which situations are BP and retinoids better for as lone agents?
BP: actual pimple formation, inflammation
retinoids: prevent white head formation, non-inflammatory
Which topical antibiotics are used for acne?
clindamycin (more common)
erythromycin
Why are topical antibiotics for acne always a combination product?
to prevent resistance
In terms of topical antibiotics for acne, what is used for mild-moderate cases? What about severe cases?
mild-moderate: BP+antibiotic or retinoid+antibiotic
severe: clindamycin+BP (am) and tretinoin (hs)
How do you explain “apply a pea-sized amount”?
apply 1 pea-sized amount of product onto your fingertip and then dot the 1 pea-sized amount onto 6 areas of your face
this should be enough to cover your entire face
When should topical antibiotics be discontinued?
after resolution of inflammatory symptoms
True or false: pharmacists can prescribe for antibiotic and BP combination products as they are indicated for mild acne cases
false
antibiotic+BP is for moderate acne
we can prescribe clindamycin+tretinoin (indicated for mild acne)
What is the mechanism of action of oral antibiotics for inflammation?
antibacterial and anti-inflammatory
-killing P.acnes, thus reducing inflammation
Which acne cases need oral antibiotics?
moderate to severe cases (alone or in combo)
-oral agents must be used with a topical retinoid or BP to
increase efficacy and decrease resistance
Which oral antibiotics are typically used for acne? List a few things about each of these antibiotics.
tetracycline:
-avoid food/dairy
-avoid antacids
-photosensitive
minocycline:
-less problems with food
-avoid antacids
-less photosensitive
doxycycline:
-give with food
-avoid antacids
-greater photosensitivity
True or false: if oral antibiotics have been used for 3 months and there is no improvement, then we should increase the dose or frequency
false
if no improvement, there is no benefit to increase dose and frequency
True or false: there is no benefit to using topical and oral antibiotics at the same time
true
What is the role in therapy for isotretinoin?
severe acne (very effective agent)
-nodular cystic acne
What is the action of isotretinoin?
hits all 4 actions
What is the dosing for isotretinoin?
0.5-1mg/kg for 12-16 weeks
What are the side effects for isotretinoin?
red eyes and dry lips (dries mucous membranes)
maybe depression but this might be due to the acne
True or false: isotretinoin is not used in pregnancy
true
if used, the woman has to sign off a waiver
In terms of diet, what might a patient be asked to do in order to help with absorption of isotretinoin?
consume high fat meals
-Epuris does not need fat to be absorbed
How do oral contraceptives work for acne?
estrogen can have a beneficial effect on acne, progestin is thrown in to help the formulation
How can progestins worsen acne? Name some progestins.
due to the androgenic properties
norgestimate and levonorgestrel
When would an oral contraceptive be a first line acne therapy?
if the girl has acne and wants birth control
Differentiate between mild, moderate, and severe acne.
mild: <20 comedones, <15 inflammatory, <30 total
moderate: 20-100 comedones, 15-50 inflammatory, 30-125
total
severe: >5 pseudocysts, >100 comedones, >50 inflammatory,
>125 total
What is the role of Diane-35 in acne?
Diane-35 contains a very potent agent against androgenic acne
-hormonal based acne or PCOS (severe acne)
must be stopped after acne clearing
-rarely seen for this reason
-can cause cardiovascular damage if used long term
-not indicated for contraception
