Acne Treatment Flashcards
1
Q
Acne Vulgaris
A
- most common skin disease
- affects 85% population 12-25 w/o regard to gender, race, ethnicity
- inflammatory lesions found on face, neck, back, shoulders
2
Q
Pathophysiology of Acne Vulgaris
A
- increased sebum production (b/c of androgens)
- excess sebum and sloughing of keratinocytes = comedones
- Propionebacterium acnes convert sebum to fatty acid (results in inflammation)
- follicular plugging takes about 4 weeks to evolve into inflammatory lesion
3
Q
Goals of Acne Treatment
A
- eliminate existing lesions
- prevent new lesions from developing
- prevent or minimize scarring
- decrease discomfort
4
Q
Nonpharmacological Treatment
A
- mild, noncomedogenic facial soap bid
- avoid oily skin products
- avoid acne manipulation (no popping!)
5
Q
Pharmacological Treatment Approach (general)
A
- tx of choice depends on severity, lesion types, scarring, previous tx hx, patient tolerance
- may take 6-8 weeks to see improvement
- may see flare initially as existing lesions evolve more rapidly
6
Q
Mild Acne Lesion Type and General Treatment Plan
A
- noninflammatory lesions; open and closed comedones
- TOPICAL RETINOID; may or may not add topical antimicrobials, salicylic acid, or azelaic acid
7
Q
What are 3 topical retinoids?
A
- tretinoin (RetinA)
- adapalene (Differin)
- tazarotene (Avage, Tazorac)
8
Q
Tretinoin Dose
A
-0.01% or 0.025% gel, qhs or qohs
9
Q
Tretinoin Adverse Effects
A
- erythema
- dryness
- burning
- photosensitivity
10
Q
How does tretinoin (and retinoids in general) work?
A
- increases cell turnover in follicular wall
- this leads to resolution of existing comedones and inhibits new comedone formation
- also anti-inflamm effects
11
Q
Adapalene Dose
A
qhs
12
Q
Why might adapalene be used?
A
- anti-inflamm
- better tolerated than tretinoin
13
Q
Tazarotene
A
- new generation retinoid
- anti inflamm effects
- tends to be more irritating than tretinoin
14
Q
Name a topical antimicrobrial used in treating mild acne.
A
benzoyl peroxide (Benzagel)
15
Q
What is the dose of benzoyl peroxide?
A
2.5-5% gel qd or bid
16
Q
Adverse Effects of Benzoyl Peroxide
A
- local irritation
- dryness
17
Q
Special Considerations/Pt Education for Benzoyl Peroxide
A
-bleaches fabric
18
Q
What topical antibiotics can be used for mild acne?
A
-clindamycin or erythromycin qd or bid
19
Q
How do topical antibiotics work and what type of lesions are they affective for treating?
Advantages and disadvantages?
A
- kills bacteria in follicles
- effective on papulopustular lesions
- anti-inflamm properties
- less irritating but more drying than benzoyl peroxide
- bacterial resistance possible after months
20
Q
Azelaic Acid
A
- interferes with bacterial DNA synthesis
- anti-inflamm
- local irritation, pruritus, burning
21
Q
Moderate Acne Lesion Type and General Treatment Plan
A
- inflammatory papules and pustules with some noninflammatory lesions
- topical retinoids and oral antibiotics; may also add benzoyl peroxide; 6-12 weeks for efficacy
22
Q
What are the 5 oral antibiotics for inflammatory, moderate acne?
A
- doxycycline
- minocycline
- tetracycline
- erythromycin
- trimethoprim-sulfamethoxazole (bactrim)
23
Q
Doxycycline Dose
A
- initial 100-200 mg qday
- maintenance 50 mg qday
24
Q
Adverse Reactions of Tetracycline Antibiotics
A
- all 3: photosensitivity, GI upset, pseudotumor cerebri (intracranial HTN)
- minocycline: abnormal pigmentation, vertigo, rarely a severe drug rxn
- tetracycline: take on empty stomach; interacts w/ dairy products, Mg, Zn, Ca, Fe
- drug interactions: antacids, OCs, anticoagulants
25
Adverse Reactions in Erythromycin Oral Antibiotic
- stomach upset
| - cutaneous reactions
26
Why might Bactrim (trimethoprim-sulfamethoxazole) be used?
-used in patients who cannot tolerate tetracyclines or erythromycin or in cases of resistance to tetracyclines and erythromycin
27
Mechanism of Action for Oral Contraceptives in Acne Tx
- androgen levels correlate with sebum production
| - OCs decrease unbound, biologically active androgens (free testosterone)
28
Why might oral contraceptives be used to tx acne?
-used in moderate acne pts who also want contraception
29
What are potential adverse effects of OCs?
- nausea
- weight gain
- breast tenderness
- increased risk of thromboembolism, MI, stroke, HTN
30
How long does it take for OC tx to make a change with acne?
-up to 2-4 months
31
Severe Acne
-inflammatory lesions and scarring with some noninflammatory lesions
32
What is the most effective tx for inflammatory acne?
isotretinoin/Accutane
33
Indications for Isotretinoin
- severe nodulocystic acne
- inflammatory acne w/ scarring that has not responded to conventional therapy
- chronic relapsing acne
- acne w/ severe psych distress
34
Mechanism of Action of Isotretinoin
- reduces sebaceous gland size
- reduces sebum production
- alters keratinization w/in follicles
- inhibits P. acnes growth and inflammation
35
Efficacy of Isotretinoin
- response rate as high as 90% with 1-2 courses of therapy
| - about 30% of pts required 2nd course (need a drug vacation of 8 wks)
36
Dose of Isotretinoin
0.5-1 mg/kg/day in 2 divided doses for 15-20 weeks
37
Adverse Effects of Isotretinoin
- 80-90% with dry skin, lips, eyes, hair
- alopecia, photosensitivity
- hypertriglyceridemia (25%)
- LFT abnormalities (10%)
- arthralgias and muscle stiffness (15%)
- teratogenicity: pregnancy category X: contraception mandatory for women (iPLEDGE)
- isolated reports of depression, psychosis
38
What 4 things must be monitored for a pt on isotretinoin?
- pregnancy: baseline and every month
- triglyceride levels: baseline and after 4 & 8 weeks of treatment; must D/C use of drug if TG > 700
- liver function tests: baseline and after 4 & 8 weeks
- complete blood count: baseline and after 4 & 8 weeks
39
2 Goals of iPLEDGE
- no woman should begin isotretinoin if pregnant
| - no pregnancies should occur while a woman is taking isotretinoin
40
What are the requirements for a female pt to take isotretinoin (iPLEDGE)?
- use 2 forms of contraception, even if not sexually active
- need 2 negative pregnancy tests before starting Rx
- negative pregnancy test each month of tx before receiving next Rx
- sign patient consent form about birth defects
- pick up rx w/in 7 days of office visit
41
iPLEDGE Prescriber Requirements
- enter pt info: pregnancy test result, 2 forms of contraception, confirmation of pt counseling
- document that pts meet iPLEDGE requirements
- only pts registered by prescribers can receive isotretinoin
42
iPLEDGE Pharmacist Requirements
- only pharmacies registered and activated in iPLEDGE can dispense isotretinoin (1 month supply)
- pharms must access iPLEDGE to receive authorization to fill and dispense every isotretinoin rx
43
iPLEDGE Wholesaler Requirements
- must register annually in iPLEDGE to distribute isotretinoin
- can only ship to pharmacies registered/activated in iPLEDGE
44
Monitoring Acne Tx
monitor after 6 weeks to evaluate improvement in signs and sxs:
-decreased # and severity of lesions, relief of pain and irritation
45
If response to acne tx is inadequate, what should you do?
- switch to a different agent (eg tretinoin to adapalene)
- add another agent from a different category (eg in addition to a topical retinoid, add an oral antibiotic)
- consider adjunctive therapy (oral contraceptive)
46
Monitoring Acne Tx Adverse Effects
- effects vary depending on prescribed therapy
- check as recommended for specific drug and at any follow up appts
- pt should call sooner PRN
