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Fall 2014 - Pharm Intro Unit > Acne Treatment > Flashcards

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
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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
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3
Q

Goals of Acne Treatment

A
  • eliminate existing lesions
  • prevent new lesions from developing
  • prevent or minimize scarring
  • decrease discomfort
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4
Q

Nonpharmacological Treatment

A
  • mild, noncomedogenic facial soap bid
  • avoid oily skin products
  • avoid acne manipulation (no popping!)
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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
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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

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7
Q

What are 3 topical retinoids?

A
  • tretinoin (RetinA)
  • adapalene (Differin)
  • tazarotene (Avage, Tazorac)
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8
Q

Tretinoin Dose

A

-0.01% or 0.025% gel, qhs or qohs

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9
Q

Tretinoin Adverse Effects

A
  • erythema
  • dryness
  • burning
  • photosensitivity
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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
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11
Q

Adapalene Dose

A

qhs

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12
Q

Why might adapalene be used?

A
  • anti-inflamm

- better tolerated than tretinoin

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13
Q

Tazarotene

A
  • new generation retinoid
  • anti inflamm effects
  • tends to be more irritating than tretinoin
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14
Q

Name a topical antimicrobrial used in treating mild acne.

A

benzoyl peroxide (Benzagel)

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15
Q

What is the dose of benzoyl peroxide?

A

2.5-5% gel qd or bid

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16
Q

Adverse Effects of Benzoyl Peroxide

A
  • local irritation

- dryness

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17
Q

Special Considerations/Pt Education for Benzoyl Peroxide

A

-bleaches fabric

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18
Q

What topical antibiotics can be used for mild acne?

A

-clindamycin or erythromycin qd or bid

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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
Q

Adverse Reactions in Erythromycin Oral Antibiotic

A
  • stomach upset

- cutaneous reactions

26
Q

Why might Bactrim (trimethoprim-sulfamethoxazole) be used?

A

-used in patients who cannot tolerate tetracyclines or erythromycin or in cases of resistance to tetracyclines and erythromycin

27
Q

Mechanism of Action for Oral Contraceptives in Acne Tx

A
  • androgen levels correlate with sebum production

- OCs decrease unbound, biologically active androgens (free testosterone)

28
Q

Why might oral contraceptives be used to tx acne?

A

-used in moderate acne pts who also want contraception

29
Q

What are potential adverse effects of OCs?

A
  • nausea
  • weight gain
  • breast tenderness
  • increased risk of thromboembolism, MI, stroke, HTN
30
Q

How long does it take for OC tx to make a change with acne?

A

-up to 2-4 months

31
Q

Severe Acne

A

-inflammatory lesions and scarring with some noninflammatory lesions

32
Q

What is the most effective tx for inflammatory acne?

A

isotretinoin/Accutane

33
Q

Indications for Isotretinoin

A
  • severe nodulocystic acne
  • inflammatory acne w/ scarring that has not responded to conventional therapy
  • chronic relapsing acne
  • acne w/ severe psych distress
34
Q

Mechanism of Action of Isotretinoin

A
  • reduces sebaceous gland size
  • reduces sebum production
  • alters keratinization w/in follicles
  • inhibits P. acnes growth and inflammation
35
Q

Efficacy of Isotretinoin

A
  • 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
Q

Dose of Isotretinoin

A

0.5-1 mg/kg/day in 2 divided doses for 15-20 weeks

37
Q

Adverse Effects of Isotretinoin

A
  • 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
Q

What 4 things must be monitored for a pt on isotretinoin?

A
  • 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
Q

2 Goals of iPLEDGE

A
  • no woman should begin isotretinoin if pregnant

- no pregnancies should occur while a woman is taking isotretinoin

40
Q

What are the requirements for a female pt to take isotretinoin (iPLEDGE)?

A
  • 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
Q

iPLEDGE Prescriber Requirements

A
  • 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
Q

iPLEDGE Pharmacist Requirements

A
  • 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
Q

iPLEDGE Wholesaler Requirements

A
  • must register annually in iPLEDGE to distribute isotretinoin
  • can only ship to pharmacies registered/activated in iPLEDGE
44
Q

Monitoring Acne Tx

A

monitor after 6 weeks to evaluate improvement in signs and sxs:
-decreased # and severity of lesions, relief of pain and irritation

45
Q

If response to acne tx is inadequate, what should you do?

A
  • 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
Q

Monitoring Acne Tx Adverse Effects

A
  • effects vary depending on prescribed therapy
  • check as recommended for specific drug and at any follow up appts
  • pt should call sooner PRN

Fall 2014 - Pharm Intro Unit (5 decks)

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