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PC Ado > Acne > Flashcards

Acne Flashcards

1
Q

Describe the cause of acne vulgaris to an adolescent patient.

A
  • Follicular keratinocytes become sticky & form a keratin plug

→

  • Occlusion of the follicle & sebum trapped

→

  • Trapped sebum causes inflammation and impaction

→

  • Rupture of the follicle causes bacterial invasion of the follicle and surrounding tissue
  • That’s why you should not pick*
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2
Q

What are available treatment options for acne in an ado?

A

Benzoyl Peroxide

Topical retinoids

Dapsone

Antibiotics

OCPs

Isotretinoin (Accutane)

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3
Q

How could you describe pathophys of acne to an ado?

A

follicle looks like a wine bottle with the neck. sticky skin cells stay near top of bottle – like a cork. Disrupt the cork, will get trapped inside

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4
Q

Is acne more prevalent in males or females?

A

Depends!

  • Adolescents: Male >Female
  • Adults: Females > Males
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5
Q

Types of acne

A

comedonal

inflammatory

mixed

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6
Q

Acne: what do you look for on PE?

A

Type and distribution of acne lesions

Ht, Wt, growth curve (d/t hormonal issues?)

BP (elevated - androgen prob?)

SMR

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7
Q

What are some signs of PCOS or androgen excess?

A

irregular periods (oligomenorrhea), hirsutism, obesity? (not always), acanthosis nigricans (insulin resistance)

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8
Q

Does genetics influence acne?

A

yes!

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9
Q

Do hormones influence acne?

A

Yes!

Hormones: estrogen is protective – E drops around period

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10
Q

Does menstruation affect acne?

A

Yes! hormones!

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11
Q

Does emotional stress affect acne?

A

Yes!

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12
Q

Does glycemic load affect acne?

A

maybe? Higher = more likely

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13
Q

Does chocolate affect acne?

A

no evidence for chocolate or dairy!

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14
Q

What is sebum?

A

product of the sebaceous glands and is secreted into the hair follicle via the sebaceous duct. Increased production in adolescents from increased androgen production

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15
Q

What is a keratin plug?

A

keratin is the protein secreted by keratinocytes

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16
Q

What are some microbial skin flora?

A

*Propionibacterium acnes, Staphylococcus epidermidis, Pityrosporum ovale

Acne is Not an infection. A common skin flora that likes sebum

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17
Q

Types of mild / noninflammatory acne lesions

A
  • Microcomedo (acne precursor): bumpy texture
  • Open comedone (black head)
  • Closed comedone (white head)
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18
Q

Types of Moderate to Severe Inflammatory acne lesions

A
  • Papules
  • Pustules
  • Nodules: hard painful lumps under skin. Nothing typically comes out but can cause scarring – “ice pick scars”
  • Cysts: softer. Lots of pus inside. Spills, causes redness and irritation
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19
Q

How does benzoyl peroxide work?

A
  • Lipophilic and penetrates the stratum corneum to enter the pilosebaceous unit
    • generates free radicals that oxidize the cell wall proteins of P. Acnes
    • Mild comedolytic and anti-inflammatory properties
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20
Q

Side effects of benzoyl peroxide

A

bleaching of hair & fabric. Increased risk of sunburn, dryness, erythema, peeling, allergy (1:500)

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21
Q

Concentrations of Benzoyl Peroxide

A

2.5% to 10%

no evidence that higher concentrations are more effective (but more SEs! So start low, go slow)

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22
Q

How does benzoyl peroxide work best?

A

Combo therapy

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23
Q

How do topical retinoids work?

A

Normalize desquamation of follicular epithelium, prevent the formation of new microcomedones (precursors of both comedones and inflammatory lesions), promote clearing of microcomedones, and some have anti-inflammatory activity

24
Q

3 topical retinoids on the market?

A

Tretinoin, Adapalene, Tararotene

mono or combo therapy

25
Q

What severities of acne are topical retinoids used for?

A

all

26
Q

Side effects of topical retinoids

A

tinging, dryness, burning, scaling

27
Q

How to reduce SEs of topical retinoids

A
  • Begin with lowest strength
  • using 3x per week
  • moisturizer & sunscreen
28
Q

Which topical retinoid is photostable?

A

Adapalene - the only one that does not get deactivated by sunlight

29
Q

What is Dapsone?

A

topical synthetic sulfone

30
Q

How does dapsone work?

A

Antimicrobial and anti-inflammatory effects
P. acne reduction

31
Q

When is Dapsone most effective?

A

with inflammatory lesions and when combined with a topical retinoid

32
Q

Side effects of Dapsone

A

erythema, dryness, temporary orange staining if used with benzoyl peroxide

33
Q

Why use antibiotics with acne?

A

Reduce P. acnes colonization of skin and follicles by inhibiting bacterial protein synthesis and decreasing inflammation

34
Q

What topical antibiotics are available for acne?

A

Clindamycin & erythromycin

35
Q

Disadvantages of topical antibiotics for acne

A

Slow onset and potential for resistance

36
Q

Recommendations for topical antibiotics used for acne

A
  • Use with benzoyl peroxide preferably with fixed combo product
37
Q

What oral antibiotics are available for the Tx of acne?

A

Tetracycline 500 mg BID, doxycycline 50-100 QD or BID or 150mg QD, minocycline IR 50-100 mg QD-BID ER 1mg/kg QD (start low)

38
Q

What makes oral antibiotics effective?

A

Greater lipophilicity augments follicular penetrations
Lower resistance than topical

39
Q

What side effects should you assess for if Rxing antibiotics for acne?

A

dizziness, vision changes, headaches, photosensitivity, esophagitis (doxy – at least an hour before bed w/full glass water), hypersensitivity, lupus-like syndrome (arthralgias, no lupus rash)

40
Q

On PO antibiotics with vision changes, HAs, what are you worried about?

A

pseudotumor cerebri, esp minocycline

41
Q

Initial Tx for mild acne

A

Option 1 - microcomedones, not inflammatory

  • Benzoyl peroxide or
  • Topical Retinoid or
  • (Dapsone)
  • Option 2 – more comprehensive
    • Topical Combination Therapy
      • Benzoyl peroxide + antibiotic or
      • Retinoid + Benzoyl peroxide or
      • Retinoid + Antibiotic + Benzoyl per
42
Q

Mild acne: what if you get inadequate results w/initial tx?

A
  • Proper use? Adherence? Side effects?
  • Consider changing concentration, type or formulation or combination therapy if inadequate results
43
Q

Initial tx for moderate acne

A
  • Topical Combination Therapy
    • Retinoid + benzoyl peroxide Or
    • Retinoid + (benzoyl peroxide + antibiotic) Or
    • Retinoid + Antibiotic + benzoyl peroxide

OR

Oral antibiotic

+

Topical Retinoid + benzoyl peroxide Or

Topical Retinoid + Antibiotic + benzoyl peroxide

Consider OCPs for ladies. If on tetracycline, remember will reduce efficacy

Consider Dermatology Referral / Isotretinoin

44
Q

Moderate acne: What if you get an inadequate response w/initial tx?

A
  • ? Correct and consistent use
  • Side effects
  • Able to get rx (copays may be high- strategize. Maybe fancy new combo product won’t work)
  • Change retinoid concentration, type and/or formulation
  • Change topical combination therapy

AND/Or

  • Add or change oral antibiotic
  • Consider hormonal therapy
  • Consider Isotretinoin
45
Q

OCPs for acne: how do they work?

A
  • suppression of androgen production and gonadotropin levels
  • decrease in free testosterone (­ SHBG)**, inhibition of 5-α-reductase and androgen receptor binding
46
Q

What works best for OCPs?

A

Low androgen progestin component work best

depo could cause flare!

47
Q

How long should you wait w/OCPs to see results in reduction of acne?

A

3-6mths

48
Q

Initial Tx for severe acne

A
  • Combination Therapy
    • Oral Antibiotic +
    • Topical Retinoid +
    • Benzoyl peroxide +/-
    • Topical antibiotic
49
Q

Severe acne: what if you get an inadequate response to the initial tx?

A
  • Consider changing oral antibiotic
  • Consider Isotretinoin
  • Female adolescents consider hormonal therapy
50
Q

What is special about the MOA of accutane (Isotretinoin)?

A

Only acne treatment that addresses all 4 pathogenic factors

  • Normalization of epidermal differentiation
  • Sebum excretion decreased by 70%
  • Anti-inflammatory
  • Reduces the presence of P acnes
51
Q

what do you need to monitor for if ado is on isotretinoin?

A

Pregnancy

  • Teratogen - must sign forms
  • Birth Control: 2 forms for females

Side Effects

  • ?Physical—bone effects, IBD
  • ??Mental

Monthly Labs

  • CBC
  • Hepatic function: Transaminases
  • Serum pregnancy test: before initiation. Maybe every time in.
52
Q

Important counseling points for teens with acne: length of tx

A
  • DOES NOT WORK OVERNIGHT!!
    • 4 – 8 weeks
    • May need to try many different combinations
53
Q

Important counseling points for teens with acne: cleaning face

A
  • Gentle Cleansing
    • No over scrubbing
    • Hygiene : emphasize acne not d/t dirty
54
Q

Important counseling points for teens with acne: diet

A
  • Food does not cause acne – girls often think this b/c eating more of this stuff before period
55
Q

Important counseling points for teens with acne: cosmetics

A
  • they can wear makeup! Noncomedogenic
    • Oil free
    • Moisturizers
    • Sunscreen – everyone but esp if can make photosensitive
56
Q

What do you need to consider before Rxing tx for a teen with acne?

A

Their thoughts, opinion!

  • Concerned?
  • Want treatment? If not – hard sell.
  • What have they tried? Heard?
57
Q

What are some sequelae to acne in teens?

A
  • Dyspigmentation
    • hyper
    • hypo
  • Scarring
  • Psychological
    • Poor Self Esteem
    • Social Isolation
    • Depression
  • Economics
    • OTC Products (multiple products)
    • Prescriptions

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