Acne Flashcards
What is acne?
A skin condition that occurs where there’s a hair follicle
Teenagers are prone to acne but so are adults (there is also neonatal acne)
90-100% of people experience acne at some point in their life
What are the peak ages for acne?
14-19 years
Does acne resolve?
Most of the time it will resolve before the age of 25 but it can persist
Where do lesions appear?
Face, neck, check, back (upper back and upper chest)
What are aggravating factors of acne?
Stress/emotions (range of extreme emotions)
Family history
Diet (possibly - low glycemic index, low levels of processed sugar, more protein may lead to less acne)
Medications (occlusive agents)
Environmental factors
Hormones
How does acne affect people?
It can have significant psychological morbidity
It’s a visible condition so people are often self-concious about it
Describe the pathology of acne?
There are 4 major stages:
- Increased follicular keratinization (sticky plug that forms at the top of the follicle and blocks it)
- Increased sebum production (due to hormone changes)
- Bacterial (Propionibacterium acnes) lipolysis of sebum triglycerides to free fatty acids
- Inflammation (redness and swelling)
What are the non-inflammatory lesions?
Closed comedones (whitehead) Open comedones (blackhead)
Describe a blackhead
Open comedone - the sebum is exposed to oxygen and light, which turns it dark
The follicle is still open
Describe a whitehead
There’s a layer of tissue or epithelial cells cover the trapped sebum underneath
How long does it take before a close comedone appears?
5 months
What are the inflammatory lesions?
Papules
Pustules
Nodules
Cysts
What is a papule?
It involves the epidermis and the dermis
This lesions extends deep within the layers of the skin
It is often a small, pink/reddish bump that is tender to the thouch (they’ve gone nerve deep)
The opening is still closed
What is a pustule?
A pus-filled papule
Often red and inflamed at the base
What are the 3 types of acne scars?
Depressed (classic icepick, boxed, rolling)
Hypertropic (aka keloidal; it’s a raised scar due to hyperproliferation)
Atrophic
There can also be pigmentary alteration
What are the different types of acne?
Drug-induced acne Neonatal acne Acne conglobata Acne fulminans Contact acne Endocrine acne Acne mechanica Acne excoriee Acne rosacea
Describe drug-induced acne
It can be a side effect (ask patients if they’ve been on any new medications recently)
It often has a very consistent presentation (there isn’t a variety of close and open comedones, there isn’t a variety in size)
Describe neonatal acne
Presents usually in the first 2-3 months of life
Affects more boys than girls
Might be due to the transfer of maternal androgens
We do not treat this (self-limiting)
Infants who have neonatal acne may have more severe form of acne when they’re in their teens
Describe acne conglobata
A very serious form of acne
Nodulocystic
Can be extremely painful
Describe acne fulminans
Very serious form of acne
The nodules and cysts ulcerate
There are often systemic symptoms (joint pain, fever, muscle pains)
Describe contact acne
Can occur when you come into contact with an occlusive agent (e.g., oil-based cosmetic, hair bangs, industrial agents such as aerosolized oils)
Describe endocrine acne
Related to a syndrome in which there’s androgen production or an off balance of hormone production
Sometimes occurs in females with polycystic ovarian syndrome
Describe acne mechanica
Localized acne from physical stress (e.g., bangs, bike helmet, etc.)
Describe acne excoriee
The patient will pick at the comedones that it actually ends up in chronic erosions
Describe acne rosacea
Generally appears later in life (over 30 years)
Redness, inflammation
Capillaries are close to the surface (spider veins)
Sometimes the patient also has eye symptoms (red, gritty eyes)
Certain things can cause a flare (sun, extreme temperatures, spicy foods, alcohol)
It is important that the patient seeks treatment for the condition because there’s a potential for negative side effects (the tissue can become so inflamed that the patient’s nose will enlarge and appear red; it’s very difficult to return it back to normal)
What is perioral dermatitis?
Treated very similarly to acne
More of an inflammatory condition
Specifically around the chin and nose area
What is gram negative folliculitis?
Lesions have a sudden onset
Often mistaken for flares of acne
Treated slightly different
How is acne classified?
Mild
Moderate
Severe
Describe mild acne
Many comedones
Few to several papules and pustules
No noodles or scarring
Under 50% of affected area is involved
Describe moderate acne
Numerous comedones, papules and pustules
Few nodules may be present
Scarring possible or may be present
Over 50% of the affected area is involved
Describe severe acne
Numerous comedones Numerous and extensive papules and pustules Nodules and cysts are extensive Scarring is probable or present Entire area is involved
What are red flags of acne?
Evidence of scarring
Moderate to severe acne
Signs and symptoms of infection
Acne is drug-induced
Symptoms consistent with endocrinopathy (e.g. POS)
Atypical presentations (e.g., rosacea)
Patients who are non-responsive to non-prescription therapy
What kind of acne is self-treatable?
Mild-moderate acne vulgaris, contact ance and acne mechanica Only if: onset age is between 12-25 no scarring or risk of scarring presentation is typical
What are the goals of therapy?
- Alleviate symptoms by decreasing the number and severity of lesions
- Slow progression of signs and symptoms
- Limit duration and reoccurrence
- Prevent long-term disfigurement associated with scarring and hyperpigmentation
- Alleviate psychological distress
- Avoid factors that exacerbate acne
- Minimize treatment failure due to poor compliance
- Educate patients with emphasis on realistic expectations (important due to media claims)
What is some non-pharmacological advice for the treatment of acne?
Wash face with mild soap (Dove soap) or soapless cleanser (cetaphil, spectrogel) no more than twice a day (no more than twice a day)
Avoid vigorous scrubbing
Be careful when shaving
Shampoo hair regularly and keep off face
Don’t pop, pick at, or manipulate lesions
Minimize cosmetic use
Use cosmetic products, moisturizers and sunscreens that are oil-free
Discontinue or avoid aggravating factors
Eat a well balanced diet and drink lots of water
Try to minimize stress
How do the pharmacological treatments work?
They do one or more of the following: Normalization of follicular keratinization Reduce P. acnes growth Reduce sebum production Reduce inflammatory process
What products normalize follicular keratinization?
Topical BPO (available without prescription) Topical SA/sulphur/resorcinol (available without prescription) Topical retinoid Retinoid analogues Oral isotretinoin Oral contraceptives Topical/oral antibiotics Azelaic acid
What products reduce P. acnes growth?
Topical BPO (available without prescription)
Oral isotrenoin
Topical/oral antibiotic
Azelaic acid
What products reduce sebum production?
Oral isotrenoin
Oral contraceptives
Oral anti-androgens
What products reduce inflammatory processes?
Topical BPO (available without prescription) Retinoid analogs Oral isotrenoin Topical/oral antibiotics Azalea acid Oral anti-androgens
What are formulations available for acne treatment?
Gel Lotion Cream Bars and washes Microsphere formulation
Describe gel formulation
Acetone/alcohol or water based
Acetone/alcohol good for very oily skin
Water based gels are better for oily but sensitive skin
Gels have greatest efficacy
Describe lotion formulation
Good for all skin types, especially sensitive
Have lower incidence of side effects as compared to gels
Second best with respect to efficacy
Spreads well over large and hairy areas
Describe cream formulation
Good for dry skin
Less effective than lotions and gels
Describe bars and washes
Can be used by all skin types
Last effective as there is less contact time
Describe microsphere formulations
Microspheres localize in the hair follicle and releases medication over time
They have increased tolerability due to the lower concentration in skin
Good for sensitive skin
What are some non-prescription acne products?
Benzoyl peroxide Salicylic acid Sulfur Resorcinol Glycolic acid Various cleansers
Describe salicylic acid
Mild comedolytic and keratolytic
Indicated for mild acne when BPO is not tolerated (second line)
OTC products contain 0.5-2.0% SA
Applied OD to BID
Generally takes 6-8 weeks of use to see improvement
Maintenance therapy is required
SE: redness, peeling, stinging
Describe sulfur
Comedolytic and keratolytic
Third line agent
Often combined with SA or resorcinol to increase its effects
Maintenance therapy is required
Offensive odor, noticeable colour and comedogenic with continued use
Describe resorcinol
Mild keratolytic
Has little effect on its own
Usually used on combination with salicylic acid and sulfur
SE: dark brown scales on dark-skinned patient
Describe glycolic acid AHA 8%
Used alone or as a base for topical antibiotic preparations (clindamycin)
Available as Reversa or Neostrata
Less skin irritation than SA (but probably not as effective)
Describe benzoyl peroxide
Well absorbed through stratum corner and concentrates in the pilosebaceous unit
3 actions that treat noninflammatory and inflammatory acne:
-primarily works as an antibiotic (slowly releases oxygen), does not lead to resistance
-normalizes follicular keratinization
-decreases inflammation
Good first choice for treatment of non-inflammatory or mild inflammatory (OTC)
Used in combination with topical retinoid and topical AB to treat mild-moderate acne
Used in combination with topical retinoid and oral AB to treat moderate and moderate-severe acne
What are the strengths of BPO available?
Non prescription strengths: 2.5, 4 and 5%
Prescription strengths: 8, 10, 15 and 20%
Start low and work up
What are the side effects of BPO?
Irritant dermatitis, redness, scaling, dryness, itching
May cause photosensitivity, bleaching, door on clothing, bed sheets
OD to BID
In rare cases, it can cause contact dermatitis
What are the self-care treatment approaches?
Start low and go slow
Usually start with 2.5 or 4% BPO water based product
Ineffective after 6-8 weeks: increase to 5% BPO water based products
Ineffective after 6-8 weeks: change to BPO acetone/alcohol gel
Ineffective after 6-8 weeks: refer to doctor
What are key counselling points on topical acne products?
Apply to the entire affected area, not just to the lesions (do not spot treat)
Must be used regularly
Skin may actually worsen before it improves (this is important for patient education)
Allow 6-8 weeks before assessing improvement; may take 8-12 weeks to see full benefit
What are counselling points for the application of topical acne?
Wash skin with mild soap/soapless cleanser
Pat skin dry (applying to wet skin can irritate skin - can suggest waiting 20-30 minutes to lessen skin irritation)
Apply pea sized amount
Wash hands before and after application
Avoid washing area for 1 hour after application
If using other skin products, do not apply at the same time, wait at least an hour following application
Only use as directed - not more than recommended
Address missed doses even though topical
Avoid applying in and around the eyes, lips, inside the nose, or on sensitive areas on neck
Don’t apply on sunburned or broken skin
Don’t use other acne products or products that will further irritate the skin - alcohol containing, abrasive, etc.
What are prescription products that are available?
BPO Azalea acid Topical retinoids and retinoid analogues Topical antibiotics Oral antibiotics Hormone replacement therapy Isotretinoin
Describe Azelaic acid
Available as 15% gel in Canada and 20% cream in US
Useful in treatment of mild to moderate acne in patients wh don’t tolerate BPO or tretinoin
Useful in treating post-inflammatory hyperpigmentation
Applied BID
SE: burning, pruritis, stinging and tingling
What are the indications for topical retinoids and retinoid analogues
First line treatment for comedian only acne and mild to moderate inflammatory acne
Use by itself to treat comedonal only mild acne
Use in combination with topical AB with or without BPO to treat mild to moderate inflammatory acne
Use in combination with oral AB with or without BPO to treat moderate to moderate-severe acne
Essential part of maintenance therapy
Describe topical retinoids and retinoid analogues
Directions: all applied OD
SE: itching, stinging, redness, peeling, photosensitivity, skin discolouration
Makes skin more susceptible to dryness and cold temperature
Best to avoid in pregnancy
Don’t use with isotretinoin (important)
What are some antibiotics used for the treatment of acne?
Clindamycin 1% (solution, gel) - apply BID
Erythromycin 3%/BPO 5% (gel) - apply BID
Clindamycin 1%/BPO 5% (gel) - apply OD HS
Erythromycin 2% with sunscreen (gel) - apply BID
Describe the use of topical antibiotics for acne
Used to treat mild to moderate inflammatory acne in combination with topical retinoid with or without BPO
Avoid the use of these agents alone
Combination with oral antibiotic is not recommended
Most products are applied BID
SE: erythema, dryness, peeling of the skin and stinging
Avoid if allergic to oral antibiotic from same class
Patients with colitis should avoid clindamycin
Describe topical clindamycin
Lincosamide antibiotic
Has a potent action, lack of significant systemic absorption
Monotherapy should be avoided due to the development o resistance
Adverse effects: dryness, burning, itching, scaliness or peeling of skin (lotion solution); erythema (foam, lotion, solution); oiliness (gel, lotion)
Clindamycin has been reported to cause pseudomembranous colitis (rare)
Use with caution with atopic individuals
What are contraindications for topical clindamycin?
Allergy to clindamycin, lincomysin
Previous C. difficile-associated diarrhea
Inflammatory bowel disease (enteritis, ulcerative colitis)
When dispensing topical antibiotics, what should be watched out for?
Compounding instructions prior to dispensing to patient Storage instructions (at pharmacy and for patient) Expiration date
What are available oral antibiotics for the treatment of acne?
Tetracyclin (capsule) Minocycline (capsule) Doxycycline (tablet and capsule) Erythromycin (tablet and capsule) Sulfamethoxazole/trimethoprim (tablet)
What are the indications for oral antibiotics?
Treatment-resistant forms of mild-moderate inflammatory acne
First line treatment for moderate-severe acne in combination with topical retinoid with or without BPO
Used for scarring acne if patient won’t take isotretinoin
What are the guidelines for oral antibiotics?
Avoid monotherapy
Combine with topical retinoid
Add BPO to reduce resistance
Use the same antibiotic if additional courses are required
If antibiotic treatment ineffective, try a different antibiotic
What is the duration of use and side effects of oral antibiotics?
Duration of use: no longer than 3-6 months
SE: GI upset, nausea/vomiting, diarrhea, headache
Tetracyclines: photosensitivity, esophagitis (rare)
Minocycline: dizziness, drowsiness, ataxia, discolouration of mucous membranes and drug-induced lupus (rare)
Doxycycline and erythromycin: GI SE
Sulfamethoxazole/trimethoprim: Steven-Johnson syndrome (rare)
What is important to watch for with tetracyclines?
Avoid during pregnancy/lactation
Avoid in children under 8 years of age
Watch for drug-drug and drug-food interactions
What is important to watch for with oral antibiotics?
Resistance is common especially with erythromycin
SMX/TMP is useful if acne is resistant to other antibiotics
What are agents available for hormone therapy?
Drospirenone/ethinyl estradiol Cyproterone acetate/ethinyl estradiol Norgestimate/ethinyl estradiol Levonorgestrel/ethinyl estradiol Spironolactone These are all available as tablets. These are all oral contraceptives (except spironolactone)
What are the indications for oral contraceptives for the treatment of acne?
Mild or moderate acne in combination with topical therapies in females who desire contraception, or have irregular menses
Adult onset acne in females that has been treated unsuccessfully with other agents
Severe acne for females on isotrentinoin
What are the side effects and considerations for the use of oral contraceptives to treat acne?
SE: nausea/vomiting, weight gain, breakthrough bleeding, breast tenderness and headache
Advise patients about the risks of smoking while on OC
To be used in females only
Don’t use if pregnant/lactating
What are the indications for androgen-receptor blockers? What are the side effects?
Indicated in females who have adult onset acne that has been treated unsuccessfully with other agents
Women who suffer from acne due to an excess of androgen hormones
Agents include cyproterone acetate, finasteride, flutamide and spironolactone
Only use in females
Avoid in pregnancy
SE: dizziness, drowsiness, nausea, vomiting, diarrhea, headache, menstrual irregularities
Hyperkalemia with spironolactone
What are the benefits of isotretinoin?
It induces a prolonged remission
In 85% of cases, it will result in a clinical cure of acne because it addresses all 4 factors of the pathophysiology
What are the indications for isotretinoin?
Severe nodulocystic acne Treatment failures Scarring Frequently relapsing acne Cases where psychological distress is sever
Describe the use of isotretinoin
Duration of treatment: 12-16 weeks
Can take 2-3 months for optimal effects
Patients may experience an acute exacerbation in the first 7 to 10 days of treatment
Can produce long-term drug-free remission
Used as a single drug therapy except for females where an oral contraceptive is strongly recommended
What are the side effects of isotretinoin?
SE are dose related
Common SE: cheilitis (inflammation and cracking around the lips), facial redness, dry skin/itching, dry mouth, nose, eyes, photosensitivity
Other SE: depression, decreased night vision, joint/muscle pain, severe headaches, hair thinning
What are contraindications for isotretenoin?
Relative CI: hyperlipidemia, diabetes mellitus, severe osteoporosis
Absolute CI: breastfeeding, pregnancy (teratogenic), previous allergic reaction, hepatic and renal insufficiency
Patients should be screened for depression and before starting treatment and monitored throughout
What tests are required before the initiation of treatment with isotretinoin?
Lipid and blood glucose levels Liver function tests Complete blood count and differential Pregnancy (requires 2 negative tests) Signs of depression
What should be avoided when being treated with isotretinoin?
Avoid giving blood transfusions Avoid alcohol (relieve the stress on the liver) Avoid vitamin A or beta-carotene supplements Avoid tetracyclines (in rare cases, can cause intercranial hypertension) Avoid in patients under 12 years of age Avoid other topical acne products, hair waxing, laser treatment and dermabrasion
What should be prescribed for the treatment of mild acne (comedonal)?
Topical retinoid
What should be prescribed for the treatment of mild-moderate acne (papular)?
Topical retinoid + topical AB +/- BPO
What should be prescribe for the treatment of moderate acne (papular/pustular)?
Topical retinoid + oral AB +/- BPO
Discontinue AB when inflammatory lesions resolve (usually no more than 6 months)
Use topical retinoid to maintain remission post AB
What should be prescribed for the treatment of severe acne (nodulocystic)?
Oral isotretinoin
What should be prescribed for maintenance of mild to mild-moderate acne?
Topical retinoid
What should be prescribe for maintenance of moderate to moderate-sever acne?
Topical retinoid +/- BPO
What is the treatment approach in pregnant patients?
Non-pharmacological treatment is first line
If pharmacological treatment is deemed appropriate by physicina:
-topical BPO, eythromycine and clindamycin considered safe
-no agents have been studied in pregnancy therefore weigh the risks vs benefits
-erythromycin is the safest oral antibiotic
What are the short term monitoring parameters?
Lesion count: decreased by 10-25% within 4-8 weeks or over 50% within 2-4 months
Comedones: resolve by 3-4 months
Inflammatory lesions: resolve within a few weeks
Anxiety or depression: control or improvement within 2-4 months
What are long term monitoring parameters?
Progression of severity: no progression of severity
Recurrent episodes: lengthening of acne free periods
Scarring and pigmentation: no further scarring or pigmentation
What is the role of a pharmacist in the treatment of acne?
Dispel myths related to acne
Educate patients about what causes acne
Counsel patients on proper skin care
Inform patients about treatment options and expected outcomes
Educate patients on products including proper use, benefits and side effects
Identify at risk of scarring and refer
Identify patients who have been unresponsive to therapy and refer
Monitor therapy particularly oral antibiotic use in order to prevent resistance
Encourage patients to persist with therapy long enough to see benefit
