Acne EXAM III Flashcards
QUEST Process
QU: Ask questions about Symptoms, Onset, History, characteristics, Location, Aggravating and Remitting factors, Medication, Allergies
E: Establish if the patient is a candidate for self-care
S: Suggest appropriate treatment
T: Teach the patient
Where are most of the sebaceous glands found?
Epidermis on hair folicles, oily preventing drying
Around the mouth
Back
What are the causes of acne?
Androgen-stimulated
2. 1. Increases sebum production
2. Follicular hyperkeratinization
3. Colonization of Propionibacterium acnes
4. Release of inflammatory mediators
What is a follicular occlusion within the pilosubecous unit?
Microcomedone
How are non-inflammatory and inflammatory acne classified?
Non-Inflammatory: Comedones
Open (blackhead)
Closed (whitehead)
Inflammatory:
Papules
Pustules
Nodules
Cysts
How is mild acne classified?
Mild: Open (blackhead) and closed (whitehead) Comedones and a few papules and pustules
How is Moderate acne classified?
Comedones, more papules and pustules, minimal scarring
mainly comedonal or mainly inflammatory acne
How is severe acne classified?
Comedones, even more papules and pustules + nodular abscesses - more excessive scarring
What does scarring indicate?
Previous episodes of severe acne
-> may need more aggressive treatment
When to refer a patient?
inflammatory acne (papules, pustules) with a risk of scarring
Meaning of Keratolytic and Comedolytic
Keratolytic: too much keratin -> agents that soften the skin by loosening keratin and helping with exfoliation (removal of dead skin)
Comedolytic: breaks down power blockage by causing skin cells to slough away faster -> addresses RETENTION HYPERKERATOSIS
Non-pharmacological treatment
-Shampoo, balanced diet, hydration, exercise (more blood flow, wash with warm water twice a day)
-not effective alone -> combine with pharmacological treatment
What is the most effective pharmacologic treatment approach for acne?
Benzoyl Peroxide (topical antimicrobial)
-2.5-10% gel
-lotion
-creams
-pads, masks, cleansers
AE: Contact dermatitis, skin irritation, bleaching on clothing
AE often bc not the appropriate dose or formulation -> CHANGE
Available doses for Benzoyl Peroxide
2.5% - 10%
10% (Rx)
AE of Benzoyl Peroxide
AE: Contact dermatitis, skin irritation, bleaching on clothing
AE often bc not the appropriate dose or formulation -> CHANGE
-mild erythema and scaling but should subside in 1-2 weeks
What patients should expect when using Benzoyl Peroxide?
-Frequency depends on mild peeling
-may experience mild erythema and scaling in the first 1-2 weeks
-allergic reaction with Rx: sudden erythema and vesiculation /vesicles filled with fluid)
Direction Benzoyl Peroxide
-Do not apply for 15-20min after washing
-Apply 1-2 times daily at 2.5%
-Leave initial application on for only 15min then wash off and slowly increase
-Once product can be tolerated for 2 hours then can leave on overnight
-After 1-2 weeks can increase to 2-3x/day
Counseling points for Benzoyl Peroxide
-avoid contact with clothes
-use sunscreen SP15
-expect it to work within 8 weeks - sebaceous glands turn over every other month -> so it takes time to unblock
-acne can get worse before it gets better! (pt may stop treatment - so warn them)
-Continue treatment after lesions have
cleared
MOA for Beta-hydroxy acids (salicylic acid)
Keratolytic and comedolytic
-Contraindicated in diabetes and pts with poor circulation
dose: 0.5% to 5%
Signs of toxicity for Beta-hydroxy acids
-N/V, dizziness, diarrhea
-loss of hearing, tinnitus
-lethargy (lack of energy)
-hyperpnea (breathing faster)
-psychic disturbances
-Contraindicated in diabetes and pts with poor circulation
Dose for Beta-hydroxy acids
0.5% to 5%
Indication of Beta-hydroxy acids
Hyperkeratotic skin
Alpha-hydroxy acids
-glycolic, lactic, or citric acid
-not often used
-not enough evidence to support use for acne
-may be useful for scarring
MOA Salicylic Acid
Mild comedolytic and keratolytic
-Unclog pores by causing peeling
-less effective alternative to tretinoin (Rx)
-Wash or cleansing agents used as adjuvant treatment
-dose: 0.5% to 2%
What is the Rx alternative to Salicylic Acid considered to be more effective?
Tretinoin (Rx)
Salicylic Acid
Counseling
-If excessive peeling occurs, limit use to once daily or every other day
-May cause sun sensitivity
Sulfur
-Keratolytic & antibacterial in 3-10%
-Resolution of existing comedones
Counseling Sulfur
-Color and odor should be considered
-dose: Applied in thin film to affected area 1-3x/day
Which drugs can be combined with Sulfur for more efficacy?
-Resorcinol: enhances the effect of sulfur (cell turnover)
(May experience dark brown scale with darker skin)
-Sodium Sulfacetamide – destroys para-aminobenzoic acid (essential for bacterial growth)
Adapalene Gel 0.1%
-Retinoid
-MOA: Modulator of cellular differentiation, keratinization, and anti-inflammatory
-used for mild acne! (moderate acne -> Benzoyl peroxide)
-expect scaling and worsening of acne in the first 2 weeks (let patient KNOW)
AE Adapalene Gel 0.1%
-the sensation of warmth or slight stinging right after application,
-Burning, skin redness, dryness - dry skin (45%),
-itching, scaling, and worsening of acne within the first 2-4 weeks of treatment
Adapalene Gel 0.1%
Counseling points
-Onset of 8 weeks
-how to apply: wash the face and wait to dry –> apply on clean, dry skin at bedtime -> wash off in the next morning
-don’t apply on broken skin, lips, ankle of the nose, eyes
-Avoid other alpha hydroxy or glycolic
acid containing products
-Hypersensitivity and Photosensitivity (use sunscreen)
Drug class of Adapalene
Retinoid
Which formulation is the most effective?
-Gels are most effective (astringent and stay on skin longer) -> but have a drying effect (EXAM!), non-greasy better for oily skin
-Creams and lotions less irritating
– Counteract drying and peeling
– Alternative to gels -> for dry sensitive skin and in warm weather
-AVOID ointments, it is occlusive and makes acne worse
-start from low dose and increase if needed
How is acne treated in people of color?
How does pregnancy contribute to acne?
-high contribution due to hormonal change
-acne medication should be stopped - it should resolve after pregnancy
-the OTC products for acne are Category C (safe) but should be cautious when treating
How to treat acne in neonates?
-in 20% of newborns, caused by mother’s hormones
-males > females
-Begins at 6 weeks and clears at 4-6 months of age
-Clean fingertips or soft washcloth with mild soap and water twice daily
CAM Therapy (alternative medicine)
-Tea tree oil: antibacterial (staph aureus), one trial: as effective as benzoyl peroxide, slower onset
-Oral Zinc: Alternative to tetracyclines, No phototoxicity
Products for mild, moderate, and severe acne
mild: Adapalene (decreases formation of comedones, and inflammatory and noninflammatory acne lesions)
moderate: Adapalene, Benzoyl peroxide
severe: Tretinoin Rx, consider REFERRAL
Products that also need sunscreen use
-Benzoyl peroxide
-Salicylic acid
-Adapalene
Products to expect worsening before improvement
-Benzoyl peroxide
-Adapalene
