Acne Flashcards
acne
o Chronic inflammatory disease of the pilosebaceous unit (hair, hair follicle, sebaceous gland, arrector pili muscle)
o Face, chest, back, upper arms – where sebaceuos glands are large and numerous
o Most severe forms occur in males – more persistent in females
o In western cultures, acne affects up to 95% of adolescents
o Persists into middle age in 12% of women and 3% of men
o It is an inherited disease and begins in predisposed individuals when sebum production increases
o Typically begins at ages 8-12, peaks at 15-18 and resolves by age 25
o If both parents have acne, their children have a 75% chance to develop acne
o Severity of acne is not necessarily related to the severity of their parents acne
o Typically lasts for 5-10 years
o Disease may be minor, with only a few comedones, or can be highly inflammatory with diffuse scarring
o 20% of affected individuals will develop severe acne resulting in scarring
postadolescent acne in women
o Low grade, persistent acne is common o Many women have their first acne flare after age 25 o Pre-menstrual flare ups are common o Lesion distribution – Chin, neck o Can last until menopause
four factors are involved in the formation of acne
o Increase in sebum production (influenced by androgens)
o Keratin and sebum plug the hair follicle and accumulate leading to hyperkeratosis (comedone formation)
o P. acnes (bacteria) proliferates in the sebaceous follicle (releases enzymes and stimulates release of pro-inflammatory cytokines)
o Inflammatory response
what is P. acnes?
o Propionbacterium acnes – anaerobic diptheroid
o Normal resident and the principal component of the microbic flora of the pilosebaceous follicle
o P. acnes generates components that create inflammation
o Lipases eat sebum and form fatty acids – which are comedogenic and primary irritants
o What is a BioFilm?
o Inflammatory mediators in response to P. acnes weaken the follicle wall à red papule à wall ruptures à foreign body reaction à pustule/cyst
non-inflammatory acne
o Comedonal Open (blackheads) Closed (whiteheads) o Earliest type of acne o Pre-teen or early teenage years o No Inflammatory lesions
acne vulgaris - approach to treatment
o History: Patients are often embarrassed to ask for help. Must not show apathy or indifference or you will lose them
Take a thorough history as this will reassure the patient that you are taking their condition seriously
o Document all previous medical and OTC products – types of cleansers, lubricants, oral medications
o Acne products are irritating: the potential for irritation can be determined by their response to drying therapy with previous BPO use
o Inquire about any family hx of acne
o Females – any hx of menstrual flare-ups?
o Ask about any psychosocial issues: watch for depression, anxiety and social withdrawal
diet and acne
o Chocolate does not cause acne………but a high glycemic diet will
Elevated blood glucose levels lead to increased insulin production
This affects other hormones that causes excess sebum (IGF-1)
o Acne risk is reduced in patients with a lower BMI
o Stop all whey protein supplements – causes acne
o NO non-fat milk– contains whey protein
o Limit skim milk, whole milk ok to drink in moderation
o Consumption of fish is associated with a protective effect
PA-patient relationship
o Many acne patients expect to be disappointed with tx
o Adolescence is characterized by the challenge of parental rules and this can be transferred to the provider relationship
o Noncompliance can be decreased by carefully explaining the goals and techniques of tx and leaving the choice of implementation to the adolescent
o Parental “Hovering” of acne therapy leads to LESS compliance
o Explain to both the parent and the patient that mom and dad should allow them to be in charge of their acne therapy = more compliance
acne treatment starters
o Cleanse with Dove bar soap, Cetaphil or CeraVe cleanser
o No Astringents or Toners = these equal irritation
o Moisturize with Cetaphil or CeraVe cream
o When possible, regimen should be simplified, utilizing the fewest medications as possible
o Use water based or mineral based cosmetics only
acne treatment - mild
o Mild Comedonal Acne – 1st line are topical retinoids
Can add topical BPO or combo BPO/Clindamycin later
o Mild with Papules and Pustules – Topical retinoid plus topical antimicrobial, such as BPO, at initial visit
OR BPO/clindamycin if can’t tolerate topical retinoid
May add oral ABX at 3 month visit if lackluster response especially if inflammatory component
o TOPICAL RETINOIDS = 1sr LINE MILD COMEDONAL ACNE
acne treatment - moderate to severe
o Moderate Papular/pustular – Topical retinoid/BPO combination product
Start tx with oral Doxycycline or Minocycline
o Moderate à Severe Papular/pustular with nodules – If no or minimal scarring à Topical retinoid/BPO combo + oral tetracycline derivative
o If scarring, long hx of acne or psychological effects – Start Isotretinoin as initial therapy
o Doxy no more than 3 months
hormonal acne
o How do you know if a patient has hormonal acne?
o Acne can be the presenting sign of the overproduction of androgens. PCOS, Cushing’s diseases and androgen secreting tumors cause acne and hirsutism
o 2 systemic option for hormonal acne:
Oral contraceptives
Spironolactone
o Most likely to respond to hormonal treatment with:
Increased facial oiliness, premenstrual flare-ups, inflammatory acne on the mandibular line and neck
o Most women with acne have normal serum androgen concentrations and do not require serum evaluation. Women presenting with rapid onset of acne, hirsutism, androgenetic alopecia or
o signs of virulization (low voice, increased muscle mass, increased libido, or clitoromegaly) require screening to rule out a tumor. Total testosterone levels of greater than 200ng/dl suggest a possible tumor, usually ovarian in origin.
hormonal acne treatment
o Mild inflammatory – Start with topicals
Retinoid +/- BPO/Clindamycin +/- Oral ABX
o Once patient has failed oral ABX –> hormonal therapy
o Moderate inflammatory acne – OCP’s or Spironolactone
o OCP’s FDA approved for Acne – Estrostep, Ortho Tri-cyclen, Yaz
o Spironolactone – 50mg BID or 100mg QD – the most effective tx for female hormonal acne
o Spironolactone – currently data suggests initial and monthly potassium levels are not necessary. Can test if needed at baseline and q month
o Must ask about any kidney conditions before initiating spironolactone tx.
o SPL acts as an antiandrogen peripherally by competitively blocking receptors for dihydrotestosterone in the sebaceous glands.
acne brand products
o EpiDuo Forte – BPO/Adapalene 0.3%
o Retin-A, Retin-A micro
o Aczone (dapsone)
o Onexton, Duac
o BenzeFoam + Clindamycin solution (back, trunk)
o Panoxyl Foam for chest and back acne (OTC)
o Veltin/Ziana (Clindamycin 1.2%+ tretinoin 0.025%) – works very well when adding Panoxyl foam
isotretinoin (Accutane)
o Oral retinoid – reduces sebum excretion, follicular hyperkeratinization, and ductal and surface P. acnes counts
o Treatment – 30mg qd x 1 month, 40mg qd x 1 month, 60mg qd x 1 month, 80mg qd x 2 months à stop isotretinoin therapy
o These effects are often persistent after therapy discontinuation
o Isotretinoin is a potent TERATOGEN
o iPLEDGE – designed to eliminate fetal exposure to the drug
2 forms of birth control, monthly pregnancy tests
o Labs – CBC, LFT’s, Triglycerides measured each month or Rx not filled
o AE’s – Dry chapped lips (95% of patients), dry skin, itching, dry mouth
o Must ask about history of depression, suicide attempts or ideation, or IBD – ask about a family hx of IBD in 1st degree relatives. Isotretinoin can incite IBD in a genetically susceptible patient (although this is rare)
