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Pharmacotherapy > Acne > Flashcards

Acne Flashcards

1
Q

What is the proper name for acne, what are some common names?

A

acne vulgaris, common names are pimples, spots, zits

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2
Q

Where does acne grow?

A

Acne most often affects the face, but it may spread to

involve the neck, chest and back, and sometimes even more extensively over the body.

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3
Q

What is the incidence (% of people with acne)? Is it chronic?

A

80% of people between 11-30 years old,
20-30% of 20-40 years old
Earlier onset and more persistent in females, severe in males 15%
50% of cases (especially females) persist into adult years.
It is usually considered self-limiting since it subsides in the mid-late 20s but may evolve into a chronic condition

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4
Q

Describe treatment effectiveness and adherence?

A

Treat it like other chronic conditions, proper treatment can control disease and morbidity. Treatment is effective but adherence poor (30-65% of patients do not adhere to treatment, and 50% do not achieve full benefit due to poor adherence)

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5
Q

How to improve adherence?

A

Choose treatment based on symptoms, skin type and skin sensitivity, risk of adverse effects and patient’s preference
Improved treatment satisfaction is likely to adherence

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6
Q

What is the general pathophysiology?

A
  • Increased sebum production (androgens may play a
    role) and Increased follicular keratinization
  • Proliferation of bacteria which results in lipolysis of
    sebum triglycerides to free fatty acids (bacteria
    feast on the triglycerides)
  • Inflammation
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7
Q

How is a comedo formed?

A
  • increased androgen production -> increased sebaceous gland size and activity -> increased sebum production
  • increased keratinization of the epithelial cells cause obstruction of the follicle forming a dense plug
  • Sebum becomes trapped and accumulates forming a comedo
  • Comedo contains oily sebum, keratinized cells, bacteria
  • Sebum continues to be produced -> comedo continues to grow
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8
Q

How do Cutibacterium acne (C. acnes) grow?

A

feeds off sebum
- C. acnes hydrolyzes the sebum triglycerides into free fatty acids
- Fatty acids increase keratinization feeding into the cycle of more
microcomedones
-> Increase of C. acnes leading to T cell response and inflammation
polymorphonucleocytes move to follicle and bacteria release chemokines - formation of pus

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9
Q

What are the terms to describe acne and its different presentations?

A

Papule, pustule, nodule, cyst

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10
Q

Describe papule

A

Solid, elevated lesion <5mm

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11
Q

Describe pustule

A

Vesical filled with purulent liquid <5mm

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12
Q

Describe nodule

A

Deep lesion. Warm, tender, firm >5mm diameter. May result in scarring

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13
Q

Describe cyst

A

A nodule containing liquid, may result in scarring

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14
Q

What does increase in C. acnes lead to?

A

T-cell response leads to inflammation. Polymorphonucleocytes move to the follicle, bacteria releasing chemokines -> pus formation

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15
Q

Non-inflammatory comedones, white heads vs black heads?

A 
White head
• Closed comedone
• First clinically visible
lesion of acne
• Completely obstructed
Black head
• Open comedone
• Dark color due to
contents of the
comedone being
oxidized (lipid and
melanin)
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16
Q

What are contributing factors of acne (6 main ones and 1 controversial theoretical one).

A
  1. Genetic predisposition
  2. Emotional stress
  3. Hormones - Pregnancy, oral contraceptive pills
  4. Occlusion (greasy products on the skin, clothing, sweating) - Coal tar, oily products, Physical occlusion from hats, helmets, headbands
  5. Picking at lesions
  6. Bacteriostatic soaps (e.g. hexachlorophene) are acnegenic
    ? Dietary factors (controversial theory)
     Correlation with Western diet
     ? Milk
     High glycemic index foods (e.g. white rice, white bread)
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17
Q

What are some drugs that induce acne? (12)

A 
 Anabolic steroids
 Corticosteroids
 Testosterone
 Progesterone
 Phenytoin
 Lithium
 Phenobarbital
 Azathioprine
 Cyclosporine
 Isoniazid
 Disulfiram
 Quinidine
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18
Q

How to go about assessment? ie what things to look for? (8)

A

Symptons, characteristics, history, onset, location, aggravating factors, remitting factors, explanatory model.

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19
Q

What to ask about symptons?

A

Itch? Pain? Any systemic symptoms? Psychological symptoms?

Excessive hair growth (PCOS)? Weight gain?

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20
Q

What to ask about characteristics?

A

Number and type of lesions present? Distribution of lesions?

Scarring? Hypo- or hyperpigmentation? Inflammation? Signs and symptoms of infection?

21
Q

What to ask about history?

A

How long? Does it come and go? Have you experienced this before? What have you tried?

22
Q

What to ask about onset?

A

When did it start? What were you doing? Anything change in your life at that point?

23
Q

What to ask about location?

A

Where is it?

24
Q

What to ask about aggravating factors?

A

What make it worse? Probe with specific examples. Diet probing, occlusion due to helmets, masks, etc

25
Q

What to ask about remitting factors?

A

What makes it better? Probe with specific examples.

26
Q

What to ask about explanatory model?

A

How does this symptom or condition affect you?

27
Q

How does acne affect people?

A 
1. Physical symptoms
 Soreness
 Itching
 Painful
2. Psychosocial symptoms (studies show 50% of patients have symptoms of mild to moderate depression and anxiety)
 Low confidence
 Low self-esteem
 Withdrawing from society
 Depressive symptoms
28
Q

What global scales are used to access the impact of acne?

A

DLQI - dermatology life quality index, introduced in PMCO 4

Acne Quality of Life Scales

29
Q

What are some red flags with acne? (7)

A
  • Acne is drug-induced or due to a known
    endocrinopathy (e.g., polycystic ovarian syndrome
    as it may be suspected with hirsutism, weight gain)
  • Systemic symptoms are present (fever, malaise)
  • Psychological assessment is required
  • Acne at a very young age (may need endocrinology
    consult)
  • Moderate to severe acne requiring prescription
    therapy (asses your competency to manage acne)
  • Acne that is nonresponsive to initial therapy
  • Presence of scarring, especially if moderate to
    severe
30
Q

What are 2 differential diagnosis to acne?

A
  1. Perioral dermatitis
    - excessive steroid use
    - erythema, scaling, papulopustular lesions around nasiolabial folds, mouth and chin
    - topical steroids on face - refer
  2. Rosacea
     Chronic, relapsing condition involving blood vessels
     Flushing (redness or erythema), followed by development of inflammatory lesions
     Refer to dermatologist
31
Q

Describe perioral dermatitis

A 
 Due to excessive use of steroids
on the face
 Erythema, scaling and
papulopustular lesions clustered
around the nasolabial folds,
mouth and chin.
 D/c use of topical steroids on
face and refer to dermatologist
for management
32
Q

Describe rosacea

A 
 Chronic, relapsing condition
involving blood vessels
 Flushing (redness or erythema),
followed by development of
inflammatory lesions
 Refer to dermatologist
33
Q

What are 2 variants of acne?

A

Neonatal acne

Acne conglobata

34
Q

Describe neonatal acne

A 
 One in 5 infants ≤3 months of age
may develop papules, pustules,
closed or open comedones on face
 Due to placental transfer of maternal
androgens (neonatal acne)
 Usually resolves on its own but topical
agents under the advice of a
paediatrician may be used.
35
Q

Describe acne conglobata

A 
 When acne cysts and nodules fuse
together deep in the skin.
 A form of nodulocystic acne (rare
but serious inflammatory skin
condition)
 Face, back, and chest
 Refer! Requires aggressive
management with systemic therapy
and cosmetic approaches (lasers).
36
Q

What are the 4 goals of therapy for acne?

A
  1. Clear existing lesions
  2. Prevent new lesions
  3. Treat early to minimize scarring, hypo/hyperpigmentation
  4. Minimize psychological impact
37
Q

Treatment -> Non-pharm

A
  1. Address contributing factors and introduce lifestyle/self-care measures
  2. Do not pick and touch lesions
  3. Cleansing
     No more than twice daily
     Suggest cleansers that are mild and unscented
     Do not scrub skin
  4. Cosmetics
     Use oil-free make-up, try to avoid multiple layers
     Wash off at night!
     Hairspray can clog pores, discontinue if possible or wear a headband over exposed skin.
  5. Educate on stress management
  6. Encourage a well balanced diet
  7. Cationic (C) bond strips
     Activated by water, dirt/oil is anionic, strip adheres to this molecules and removes it when strip peeled off
     Temporary improvement in appearance of skin but limited permanent change
  8. Comedone Extraction
     Efficacy may be enhanced if pretreated with a peeler (i.e. glycolic acid, salicylic acid)
38
Q

Treatment - Pharm

A
  • Thousands of non-prescription acne products available
  • Different brands, products within the same brand contain varying concentrations of the same medicinal ingredients
     Benzoyl peroxide
     Salicylic acid
     Glycolic acid
  • Instead of memorizing product names, always look at the active ingredient list on the product label.
39
Q

Topical Benzoyl Peroxide details

when to use
strength
MOA
Vehicles
Administration
Response time
AE
A

When to use: First line for mild-moderate acne as monotherapy, combination

Strength:

  • 2.5-5% most common
  • BPO > 5% no more effective and more irritating
  • Unscheduled: strength <5%
  • Schedule I: >5%, combination product with a topical antibiotic or retinoid

Mechanism of action: Antibacterial: oxidation of bacterial proteins. Eliminates C. acnes on the surface of the skin and sebaceous follicle. Effective in the prevention of bacterial resistance.
- Mildly comedolytic

Vehicles: Gel, cream, solution, lotion, wash, soap
• Avoid recommending washes, soaps -> little contact time with the face = least effective

Administration: Apply topically to entire affected area
To minimize irritation, start with applying for 15 mins 1st night, 30 mins 2nd night, increase to over night eventually

Response time: • Rapid bactericidal effects may start seeing a decrease in inflamed lesions ~5 days. See optimal improvement 8-12 weeks

Adverse effects • Dryness, peeling, erythema, burning, bleaches clothing, smell that lingers (body odor)

Other counseling • Decrease irritation at initiation by decreasing frequency (eg. apply every 2-3 days, various regimens)
• Sunscreen during the day, BP at night
• Can bleach hair/ clothing
• PRACTICAL TIP: use at night to avoid staining of clothes

Examples: Non-prescription
• Neutrogena On-the-Spot (2.5% benzoyl peroxide)
Prescription
• BenzaClin gel (benzoyl peroxide 5% clindamycin 1%) - Rx

40
Q 
Salicylic acid details
when to use
strength
MOA
Vehicles
Administration
Response time
AE
A

Schedule U: in topical preparations in concentrations <40%

Mechanism of action: Mildly comedolytic Keratolytic, mildly antibacterial, mildly antiinflammatory

Available strengths: 0.5-3.5% daily-BID
Vehicles: Gels, toners, cleansers, washes, pads

Adverse effects: Drying, burning, stinging, erythema, pruritus, peeling

Other 
• Well tolerated
• Less potent than equal
strength benzoyl peroxide
• 8-12 weeks time to effect
41
Q

Glycolic acid details

schedule
strength
MOA
Vehicles
Administration
Response time
AE
A

Schedule: U

Mechanism of action: Mildly comedolytic, causes desquamation

Available strength: 2-15% (40% used as a peel)

Vehicles:
• solution, gel, lotion, cream;
• apply once to BID

Adverse effect:
Burning, stinging, erythema, dryness, pruritus

Other:
• At higher concentrations used for chemical peels
• 6-7 weeks time to effect

42
Q

zinc acetate or zinc gluconate details

schedule
strength
MOA
Vehicles
Administration
Response time
AE
A 
Schedule: U 
Mechanism of action: Absorb excess sebum
Available strengths: n/a 
Vehicles: cleansers 
Adverse effects: burning, stinging 
Other:
• Well tolerated
• Time to effect? Assess for improvement @ 4-8 weeks
43
Q

Resorcinol details

A

Schedule: U
Mechanism of action: Keratolyltic (mild) and
bactericidal and fungicidal
Available strengths: 1-2% (+ sulfur, salicylic acid)
Vehicles: Variety of formulations
Adverse effects:
• Burning, stinging (Do not apply to large areas of skin or broken skin)
• Can pigment skin in darker individuals

Other: • Needs protective packaging because reactive to light and O2.
• Time to effect? Assess @ 4-8 weeks

44
Q

ProActiv

A

 Very expensive “acne system”

 Contains mostly benzoyl peroxide 2.5% and sulphur

45
Q

Mask-ne

A

Due to occlusion of the skin around the perioral region and jawline:
- Hormonally dependent area (more so in
females)
Development of blackheads and white heads along the mask line

Management:
- Non Pharm:
 Wash mask frequently
 Choose a cotton mask
 Follow general care measures as discussed
- Pharm:
 OTC Benzoyl Peroxide
 OTC Salicylic Acid
 Prescription: Topical Retinoid, Topical Dapsone,
BP + Topical Antibiotics
46
Q

Patient education (6) things to tell them to be aware of

A
  1. Therapy needs to be used for an extended period of time with a switch to maintenance therapy once control established (recall the cascade of acne development).
  2. Frame patient’s expectations. Empathy from and encouragement from clinician enhances adherence.
  3. Those with darker skin tones are more susceptible to
    hyperpigmentation.
    - Need early and aggressive treatment
    - Therapy duration is longer in these individuals
  4. Encourage sunscreen use
    - Avoid sunscreens with acnegenic benzophenones
  5. Assess adherence and implement strategies to enhance adherence
  6. Maintain a balanced, low-glycemic-load diet
47
Q

Monitoring for patient

A

Encourage patient to record their treatment response in a diary

  • Timeframe 4-8 weeks for monitoring
  • Lesion count and type (blackheads, white heads, pustules)
  • Inflammatory lesions (weeks?)
  • Anxiety/depressive symptoms
  • The amount and time frame of acne free periods
  • Scarring or pigmentation
48
Q

Follow up for patient

A

may take several months (2-4 months or longer) to see
results. However, it may be beneficial to check in with the patient within a few days of initiating therapy to see how the patient is tolerating therapy. Future follow-up periods can be extended as applicable and based on parameters that patient monitors.

Pharmacotherapy (14 decks)

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