Acne Flashcards
What is the patient perspective in regards to acne?
- Tried many various therapies
- Majority expect to see improvement in a month
Describe the etiology of acne?
- As hit puberty, follicular wall of skin gets thicker (more skin oils) and that means things plug up
- Increase in sebum
- P. acnes
Inflammation
Black heads
- open comedo
- rarely become inflammed
White heads
- Closed comedo
Pimple
- small, inflammed white or yellow lesion
What are some predisposing factors for acne?
- Hormonal changes:
–> Puberty
–> Pre-menstrual flares
Polycystic Ovary Syndrome
- Need to consider
- Acne a symptom
Headaches, pelvic pain, hair growth, weight gain
Skin Hydration Acne
- Heat and hydration tends to make acne worse
Irritation Acne
- Irritation - Chin gaurd acne
Occlusion –> Mechanical irritation
Cosmetics
- Can make acne worse
- Most anti-comedogenic
Dietary aspects and acne
- sugary diets –> insulin –> more oils
Stress Acne
- Body steroid levels –> Stimulates sebum
Acne progression (age)
- Typically starts at puberty
- Increases in severity until the late teens then slowly abates
Adult onset of acne?
- Cases that continue from teenage years - 80%
- Adult onset cases - 20% –> not key players
Where does acne typically affect?
Face, neck, chest, upper back, upper arms
Inflammation and Black/White Heads
White heads –> Closed comedo –> Will usually become inflammed
Black Heads –> Open comedo –> Usually will not become inflammed
Describe the stages of acne
Comedone –> White/Black Head –> Non-inflammatory
Papule
Pustule
Nodule
Cyst
- Last 4 –> Inflammatory lesions –> P. acnes bacteria
Mild Acne
- <20 comedones or < 15 inflammatory lesions or < 30 lesions
Moderate/Severe
- Refer to MD
When should we be nervous about acne onset?
Acne onset:
Drug Induced –> Topical steroids and birth control pills
Adults –> Adult onset
Millia
- appears during the first few days of life
- normal for newborns
- diasppears w/t tx in 2 weeks
Roscea
- Differential Diagnosis
- Affects the face like acne
- No comedones
Can have ocular symptoms
Transient flushing and warmth - 5 mins
Blood vessels appear on skin
Comes and goes over time
Triggers: sun, stress, alcohol
Pt’s usually older than 30; rarely affects kids
How is roscea treated?
- In pharmacy –> Nothing of value
- Medical care with topical agents
Perioral Dermatitis
- Dermatitis around the mouth
- Can happen in kids
- No blackheads
Treatment of perioral derm
- MD Care
- Remove suspected causes
Oral/topical antibiotics –> via anti-inflammatory action
Patients should be ready for frustration re-treatment
Basic Skin Care for Acne
- face washing BID
- Do not scrub –> over-cleaning can increase sebum levels on skin
Minimize picking - Ecezma grade soap (unsecented glycerin soap)
- No need for astringents
ACne cleansing pads –> Not a problem
Therapy for Acne
- BP and/or retinoid
- 2-4 years of tx
- Starting earlier and being more aggressive
Salicylic Acid
- Kertalolytic
- 0.5%/2.0%
- Not much contact time –> Directions for use
- Okay agent; but minor role
- Non-medicated acne pads okay
Sulfur
Anti-bacterial
Rescorinol
Exfoliant
Tea Tree Oil
- May have anti-bacterial but how much, how often, etc.
Topical Nicotinamide
- Future of otc
Benzyl Peroxide Strength, Use, and MOA
2.5%, 5% –> OTC
10% –> Rx
- Solo for mild acne
- Combo for moderate acne
Anti-bacterial Action (O2) –> Blast of oxygen that decreases P. acnes
Exfoliant Action –> Closed comedos opened up and have less build up –> mild surface peeling
S/e of Benzyl Peroxide
Redness, peeling, dryness, burning, bleaches clothes
Benzyl Peroxide Vehicle
Soap/Wash –> Not much contact time
Lotion
Gel (Acetone >alcohol>aqeous)
Only one product needed
What is a good starting point for benzyl peroxide?
- BP 5% lotion
Can upgrade or downgrade - Gel stronger than lotions
BP and Skin tone
- Sensitive skin –> Lotion more so than gel
Bp and Winter/Summer
Winter –> Lotion
Summer –> Oilier skin –> Gel
When starting BP should they keep using their other products?
No. Skip all that if can.
How much BP should be applied?
- Small amount
- NOT FTU’S
- More is not better
Directions for BP Use
- Start slowly
1-2 hrs x few days
3-4 hours x few days - Eventually be left on overnight
Is spot tx valuable?
No. DO not spot tx.
How can dry skin in BP tx be handled?
- Add a dry skin lotion –> Ecezma grade
- Go slower
- Change BP strength or formulation base (lotion vs gel)
- Avoid contact around eyes/mouth/nose
BP OD vs. BID Dosing
- Start with OD Dosing
- Wash face in evening, let skin dry, apply BP, do nothing until morning
- After a month, move to BID dosing
- Was face in morning, let skin dry, apply
- Evening –> wash face, let skin dry, apply BP
Topical Retinoids
- Vitamin A derivatives
- Decrease cohesiveness of follicular wall –> Less stickiness, less leisons forming
- Increase penetration of other agents
First line agents or added to others
Tretinoin Tx
- Start slow, then reasses in 2 months
0.001% cream –> 0.025% cream –> 0.025% gel –> 0.05% gel
- HS –> use at night
S/e of tretinoin
Ertheyma, etc
Directions for use of tretinoin
- Start slow
- Skin needs to be dry before application
- Pea-sized amount (should disappear in one min)
- HS –> apply at night –> Phostosensitive
- Initial worsening of condition
Topical retinoid choices and charcateristics
Adapelene –> least irritating
Tretinoin –> Most photo sensitizing
Tazarotene –> Most potent –> psoriasis
Retinoids in Pregnancy
- Likley safe but can be teratogenic
- Always refer
Can BP and a retinoid be used together in tx?
Yes
Directions for tretinoin and BP tx. Exceptions
- Tretinoin and BP applied at same time = drug interaction –> Sun sensitivity issue
- BP oxidizes retinoid
- Daily ritual two agents –> retinoid HS and BP AM
Exceptions –> retin-A-Micro, tactupump, epiduo –> Combo products that avoid intercation
When is BP better for use?
- ANti-bacterial
- need to see pimples for it to be effective
- Not the best choice for non-inflammatory acne (blackheads and white heads) because no inflammation occuring
When is a retinoid better for use?
- Non-inflammatory –> Prevents formation
Topical Antibiotics in Acne and Dosing
- Clindamycin
- Erthyromycin
OD or BID
Topical ANti-Biotic Consideration
- combination with BP or retinoid needed to decrease bacteria resistance
Mild-moderate ACne tx
BP + anti-biotic
Retinod + a-biotic
Severe acne tx (antibiotic)
Clind + BP (am)
Tretinoin (HS)
Anti-biotic Cream Directions for Use and S/e
- apply a pea-sized amount to each area (forehead, cheeks, chin)
- not adding more s/e
How much cream/gel should be applied?
- 4 pea sized amounts –> cheeks, chin, forehead
- 6 pea sized amount –> 2 forehead, cheeks, chin and nose
-GO WITH WHAT MANUFACTURER SAYS
Should anti-biotics be used long term?
- topical anti-biotics should be discontinued after resolution of inflammatory lesions
Azelaic Acid
- MOA = antibacterial (normalizize keratin stickiness)
- Mild to moderate acne
- BID
Can pharmacists prescribe topical anti-biotics?
NO
Oral ANtibiotics MOA
Antibacterial
- Anti-inflammatory
- Moderate to severe acne (alone or in combo)
- Oral agents must be used with retinoid or BP –> Increase efficacy, decrease resistance
Oral Anti-biotics Exampes and Interactions
Tetracycline –> avoid food/dairy, avoid antacids –> Photosens
Minocycline –> Less food int, avoid antacids –> less photosens
Doxycycline –> Give with food, avoid antacids –> greater photosens
How long should oral anti-biotics be used for? Should a topical also be used?
- 3 months
- No improvement, increasing dose or frequency does not add any benefit
- Oral and topical at same time not beneficial
Isotretinoin Use, Dosing, S/e, pregnancy?
- Severe acne
- Very effective
- Nodular/Cystic Acne
0.5-1 mg/Kg x 12-16 weeks
S/e –> Significant –> Depression, drying on mucous membranes (lips, eyes)
Pregnancy Concerns –> Two reliable forms of Contraception and 2 negative preganncy tests
Oral Contraceptives
- Estrogen has beneficial effect on acne
- Alesse, tricylen, yasmin, etc.
- Not first line uses
Ethinyl + norgestimate/levonorgestrel
- Progesterone may make acne worse –> different androgenic properties
Back Acne
- refer to MD
