Acne Flashcards
What are the exclusions for self care in acne?
Moderate acne defined as many erythematous papules and pustules and prominent scarring.
Severe acne defined as extensive pustules, erythematous papules, and multiple nodules in an inflamed background
Exacerbating factors such as comedogenic drugs, mechanical irritation, etc.
Possible rosacea
What are the 4 levels of diagnosis?
- almost clear, rare NIL with no more than one papule
- mild, some NIL but no more than a few papules/pustules
- moderate, many NIL, some inflammatory lesions, no more than one nodule
- severe, up to many NIL and inflammatory lesions, but no more than a few nodular lesions
What are the goals of treatment for acne
- alleviate symptoms
- reduce number/severity of lesion
- slow the progression
- limit duration and recurrence
- prevent scarring, hyperpigmentation, and psychosocial suffering
- improve pt self-assessment
- adherence to treatment
What are the nonpharm treatments for acne?
- avoid aggravating factors
- dietary avoidance of triggers
- wash face twice daily
- caution when shaving
- avoid oil-based cosmetics and wash makeup off at night
What are the OTC agents for acne?
salicylic acid, benzoyl peroxide, and adapalene
What is the MOA of salicylic acid?
comedolytic, keratolytic, and antibacterial activity
How is salicylic acid applied?
1-3 times daily at concentrations of 0.5-2%
What are the adverse effects of salicylic acid?
skin irritation, peeling, scaling
When is salicylic acid contraindicated?
in diabetic patients with poor circulation
What is the MOA of benzoyl peroxide?
antibacterial effects against anaerobes by releasing free radical oxygen, bactericidal, suppresses sebum production, reduces free fatty acids
How do you use benzoyl peroxide?
apply sparingly once daily, and increase to 2-3 times daily
What is the OTC strength of benzoyl peroxide?
0.5-2%
What is the Rx strength of benzoyl peroxide?
2.5-3% and 5-10%
What are the adverse effects of benzoyl peroxide?
skin irritation, peeling, and scaling
How does benzoyl peroxide interact with dapsone?
It causes skin discoloration
How does benzoyl peroxide interact with isotretinoin?
it diminishes the effect of isotretinoin
What will benzoyl peroxide do to anything it comes in contact with?
It will bleach it
How long will a patient have to titrate up on benzoyl peroxide?
Until they have to leave the product on all night
Can bacteria develop a resistance to benzoyl peroxides?
No
What is the first line topical agent for acne?
adapalene
What are the topical antimicrobials?
Erythromycin and clindamycin
What is the MOA of erythromycin and clindamycin
binds to the 50s subunit of bacterial rRNA and inhibits protein synthesis
How often do you apply erythromycin and clindamycin?
1-2 times daily
What are the adverse effects of erythromycin and clindamycin?
dryness, burning, itching, scaliness, peeling of skin, and erythema
Can resistance to P. acnes occur with erythromycin and clindamycin? And which one is more likely?
Yes, more common with erythromycin
What are the topical retinoids?
tretinoin, adapalene, and tazarotene
What is the MOA of the topical retinoids?
binds to and activates retinoic acid receptors which activate specific gene transcription. They are comedolytic, anti-inflammatory, and normalize keratinocyte differentiation. They also help facilitate absorption of other agents
What are the adverse effects of topical retinoids?
erythema, irritation, dryness, skin peeling, and photosensitivity
How are topical retinoids initially be applied?
every other night for the first 2 weeks
Why should patients wear sunscreen with topical retinoids?
because topical retinoids thin the stratum corneum
What pregnancy category are tretinoin and adapalene?
category C
What pregnancy category is tazarotene?
category X
What systemic antimicrobials can be used for acne?
tetracyclines, erythromycin, and TMP/SMX
What is the MOA of tetracyclines?
inhibits bacterial protein synthesis by binding to the 30s and 50s ribosomal subunit
What is the dose of tetracycline for acne?
250-500 BID on an empty stomach
What is the dose of doxycycline for acne?
50-100 mg BID with food
What is the dose of minocycline for acne?
100-200 mg daily
What are the adverse effects of tetracyclines?
GI upset, photosensitivity
What adverse effects are specific to minocycline?
hyperpigmentation and dizziness
When are tetracyclines contraindicated?
in pregnancy and children ≤ 8 years old
What are the major counseling points with tetracyclines?
Take with a full glass of water and don’t lay down immediately. Separate from dair and antacids.
What is the dose of erythromycin in acne?
250-500 mg q6-12h
What is the dosing of erythromycin ethyl succinate?
400-800 mg q6-12h for better absorption
What are the adverse effects of erythromycin?
upset stomach (take with food)
What is the MOA of TMP/SMX?
it inhibits bacterial folic acid synthesis
What is the dose of TMP/SMX for acne?
800/160 mg BID
What are the adverse effects of TMP/SMX?
GI upset, hypersensitivity reactions, hematologic suppression, and hyperkalemia
When should you suspect bacterial resistance?
after 6-8 weeks of unresponsive therapy
Which drug is the most common for bacterial resistance?
erythromycin
How do you limit bacterial resistance?
Limit use to less than 3 months
What is the MOA of isotretinoin?
inhibits sebaceous gland activity, growth of p. acnes, inflammation, and improves follicular epithelial differentiation
What is the dose of isotretinoin?
0.5-1 mg/kg/day given over a 20 week course (usually 20-40 mg per day in divided doses with an increase to 40-80 mg after 1 month)
What is the cumulative weight-base dosing formula for isotretinoin?
120-150 mg/kg during the entire therapy
Which version of isotretinoin can be taken on an empty stomach?
Absorica
What are the adverse effects of isotretinoin?
Cheilitis, dry nose/nose bleed, dry mouth, dermatitis, pruritus, dry eyes, corneal opacities, decreased night vision, hypertriglyceridemia, increased LFTs, myalgias, HA, depression, psychosis, and suicidal ideation
How often should liver enzymes and lipid panels be monitored?
every month
What are the drug interactions with isotretinoin?
vitamin A, tetracyclines, and alcohol
What pregnancy category is isotretinoin?
category X (not compatible with breastfeeding)
What is iPledge?
A risk management program for isotretinoin
Who must enroll in iPledge?
Males and females who are taking isotretinoin and physicians and pharmacies
What do female patients of childbearing age need for the iPledge program?
- education on fetal harm
- two negative pregnancy tests before initiation at least 19 days apart and then one monthly thereafter
- two forms of contraception started 1 month before therapy continued until one month after therapy
What type of contraceptive is NOT acceptable for iPledge?
progesterone-only pills
What are the three situations in which contraception can be avoided?
- abstinence throughout treatment
- menopause (no menses for 12 months)
- ovaries or uterus removed (confirmed by physician)
When does isotretinoin have to be picked up from the pharmacy?
Within 7 days of visiting your PCP
What is the MOA of hormonal contraceptives for acne patients?
decreases androgen synthesis and binds androgens to decrease free testosterone
Which type of progestin/ethinyl estradiol combination needs to be selected?
3rd, 4th, or 5th generation (drospirenone, norgestimate, or desogestrel)
What is the MOA of spironolactone in acnes?
decreases effects of androgens which have a role in sebum production
What doses of spironolactone have antiandrogenic properties?
50-200 mg
What are the adverse effects of spironolactone in acne?
irregular menses, urinary frequency, dizziness, HA, N/V, breast tenderness and enlargement
Which drugs should be avoided in pregnancy?
topical and oral retinoids, estrogens, and tetracyclines
