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Imm/Musculoskel/Skin > Acne Vulgaris (2) > Flashcards

Acne Vulgaris (2) Flashcards

1
Q

Acne is more common in which patients?

A

Adolescents (effects 85% of teens)
-tends to occur younger in girls
note - can persist beyond adolescence or have late onset (>25 years old)

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2
Q

Sebum

A

Oily secretion produced by the sebaceous gland
Keeps skin and hair hydrated

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3
Q

Follicle

A

small pore/cavity in skin that surrounds the root of a hair
(where the hair grows)

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4
Q

Comedome

A

Clogged hair follicle - filled with skin, bacteria, and sebum

(note - some therapies are “comedolytic” - meaning they inhibit the formation of comedomes)

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5
Q

Keratinocytes and Hyperkeratinization

A

main skin cells found on the surface of skin (epidermis)
have a fast turnover rate

Hyperkeratinization (overproduction of skin cells) - there is overproduction of the keratinocyte layer, or failure to slough off as a normal - resulting in thickening of the layer
-this is a sign of acne

Keratinolytic agents can be used to remove/lyse keratinocytes

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6
Q

Etiology of acne (4)

A

There are 4 parts that contribute to etiology …

  1. Increased sebum production
  2. Inflammation
  3. Bacterial colonization (with gram positive Cutibacterium acnes)
  4. follicular hyperkeratinozation (overproduction of skin cells, increase clogging)
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7
Q

Types of acne lesions

A

Present differently based on if inflammation is occurring or not…

Non-inflammatory:
First starts as microcomedomes (small clogged hair follicles, not visible at first)

Then forms closed comedomes (white heads)
Which can progress to open comedomes (black heads)

Inflammatory
Development of papules and pustules
-papules don’t have puss, pustules do

And can progress to even more severe… nodules and cysts
-nodules don’t have puss and cysts do
-these are deeper lesions and can cause scarring

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8
Q

Risk factors for acne

A

Biggest one: Hormonal changes
-typical onset is during puberty/pre puberty
-also occur with pregnancy
-hormone altering medications

Genetic factors - first degree relatives

Possibly - diet (this is controversial)
-excessive milk consumption
-high glycemic load

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9
Q

What are some factors that can exacerbate acne?

A

Oil based cosmetics

Scratching, picking, scrubbing (increases lesion exposure to bacteria)

Tight/occlusive clothing, helmets, headbands (local irritation and friction)

Constant exposure to dirt, oil, and chemicals (occupational)

Certain medications
Certain medical conditions (hormone induced acne -pregnancy, premenstrual flares)

Extreme stress or anger

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10
Q

Which medications can induce acne?

A

Corticosteroids
Anabolic steroids
Isoniazid
Lithium
Phenytoin

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11
Q

What are some complications of acne? (3)

A

Depression
Anxiety
Scarring

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12
Q

What are some exclusions to self care?

A
  1. Moderate, severe, or cystic acne
  2. concurrent use of comedogenic medications (e.g. corticosteroids, isoniazid, lithium, phenytoin)
  3. Unavoidable mechanical irritation (such as occupational factors)
  4. Probable that the patient has another form of acne (e.g. rosacea)
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13
Q

Non pharm strategies

A

Eliminate exacerbating factors (environmental, behavioral, and emotional factors)

Proper skin care
-cleanse no more than twice daily (frequent cleansing can cause dry skin and worsening of acne)
-use mild soap or non-soap cleanse (harsh soaps have alkaline pH which can promote C. acne growth)
-avoid abrasive products (e.g. exfoliants, harsh washcloths)
-hydrate skin with moisturizer once daily

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14
Q

Almost all topical acne agents cause what side effect?

A

Xeroderma - dry skin
(at least when initiating therapy, can resolve with time)

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15
Q

Benzoyl Peroxide MOA

A

Exhibits bactericidal effects against C. acne

Once it is absorbed by the skin, it is metabolized to benzoic acid
Benzoic acid is then metabolized by cysteine in the skin, releasing free-radical oxygen species resulting in oxidation of bacterial proteins

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16
Q

Benzoyl peroxide counseling points

A

-Available OTC

-Use lowest strength once daily to small affected areas for the first 3 days to test tolerance, then slowly increase to 3 times a day
-decrease frequency if irritation and skin peeling occurs (note mild erythema and scaling usually subsides after 1-2 weeks of use)

-avoid contact with hair and clothes (can bleach)

-use sunscreen and avoid sun exposure to decrease risk of photosensitivity

-visible improvements may occur from 5 days to 3 weeks, but full effect may take 8-12 weeks and adherence is important for this to occur

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17
Q

Retinoid MOA

A

These are derived from vitamin A
When topically applied, they remain in the epidermis (minimal systemic absorption)

They bind specific receptors in cells - retinoic acid receptors (RARs) and retinoid X receptors (RXRs)
-these receptors are involved in regulating gene expression and cell differentiation
(so their MOA is kind of like steroids - bind to nuclear receptors which then move to nucleus and alter gene transcription)

They decrease cohesion between epidermal cells and increase epidermal cell turnover causing the expulsion of open comedomes and the conversion of closed into open ones

(Animal studies suggest that this may be tumorigenic)

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18
Q

What are the available topical retinoid products (3)

A

Adapalene (Differin) - available OTIC
Tretinoin (Retin-A, Tretin-X) - prescription only
Tazarotene (Tazorac) - prescription only

Note - there is no evidence to suggest that one works better than the other

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19
Q

Topical retinoids counseling points

A

Apply thin layer to affected skin once daily at bedtime

Can cause dry skin, scaling, erythema, skin irritation during the first few weeks of use (decrease frequency if side effects aren’t tolerable)
-peeling and dryness is expected, this is how these drugs work to open microcomedones
-note acne may look like its worsening at first (since opening of microcomedones occurs)

Can cause photosensitivity (use sunscreen, avoid exposure)

Do NOT use in pregnancy (due to risk of systemic absorption)

May take 8-12 weeks to see full therapeutic effect

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20
Q

Avoid applying tretinoin at the same time as __________

A

Benzoyl peroxide
-tretinoin can be oxidized and inactivated by benzoyl peroxide (this does not apply to the other retinoids)

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21
Q

Alpha Hydroxy Acids (AHA) considerations/use

A

E.g. lactic, glycolic, and citric acids

These are available OTC, are referred to as “chemical peels”

Not as effective as other available agents, not in the guidelines

May quicken the process of non-inflammatory comedone resolution, but the improvement is usually mild and temporary

Should only be used sparingly (every 2 weeks)

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22
Q

Salicylic acid MOA

A

This is a lipophilic acid
It works by dissolving intercellular cement (the substance that causes skin cells to stick together) - preventing pores from clogging up
Makes it easier to shed skin cells
Also has some anti-inflammatory properties

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23
Q

Sulfur MOA

A

keratolytic, antiseptic, antiparasitic, and antiseborrheic

Exerts keratolytic effect by reacting with cysteine within keratinocytes - producing cystine and hydrogen sulfide (H2S)

H2S breaks down keratin

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24
Q

BHA (salicylic acid) counseling points

A

Available OTC

Should be applied 1-3 times daily only to the affected area
-application to large areas can cause systemic toxicity
-so, should only be used as spot therapy or as wash off formulations

Can cause skin peeling/dryness (decrease frequency if cannot tolerate)

Do NOT use in patients with aspirin allergy

Not preferred option - less effective than benzoyl peroxide

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25
Q

Azelaic Acid MOA

A

Naturally occurring dicarboxylic acid

AZA is metabolized via beta oxidation pathway to form malonyl-CoA or acetyl CoA

Has antibacterial, comedolytic and peeling action

Exact mechanism is unknown but inhibits the synthesis of cellular proteins in anaerobic and aerobic bacteria

Also has anti-inflammatory properties

26
Q

What are the 2 azelaic acid products available

A

Azelex (cream)
Finacea (gel/foam)

Prescription only for both

27
Q

Azelaic acid counseling points

A

Apply twice daily (morning and evening)

Mostly localized ADRs - burning, tingling, stinging of skin (decrease frequency if not tolerated)

Can cause hypopigmentation in darker skinned people

Do not use occlusive dressing/wrapping after application to avoid systemic absorption

28
Q

What are 3 topical antibiotics that can be used for acne vulgaris?

A
  1. Dapsone gel
  2. Clindamycin gel
  3. Erythromycin gel

Clindamycin is preferred
(erythromycin is not as effective compared to clindamycin due to resistance)

Note - clindamycin and erythromycin also come as combination products with benzoyl peroxide

29
Q

Dapsone MOA

A

interfered with folate synthesis

30
Q

Dapsone clinical considerations

A

Has anti-inflammatory effect (other topical antibiotics do not)

If more effective in females than males

Can cause orange skin discoloration if used with benzoyl peroxide

31
Q

Clindamycin and erythromycin MOA

A

Clindamycin is a lincosamide
Erythromycin is a macrolide

Both inhibit bacterial protein synthesis by binding to the 50S subunit of the ribosome

32
Q

Which oral antibiotics can be used for acne vulgaris? Which are preferred?

A

Tetracyclines
-Doxycycline
-tetracycline
-minocycline

Macrolides
-erythromycin
-azithromycin

Tetracyclines are preferred over macrolides for acne
And doxycycline is the preferred out of the tetracyclines

Macrolides are used off label if tetracyclines can not be used and patient needs systemic antibiotic

33
Q

When should oral antibiotics be used for acne?

A

Reserved for moderate/severe cases of acne vulgaris

And they should NEVER be used as monotherapy for acne (combine with benzoyl peroxide and retinoid) - to reduce antibiotic resistance

34
Q

Tetracycline should not be used in which patients? (2)

A

Children under 8
Pregnant women

35
Q

Tetracycline counseling points

A

Common ADRs: stomach upset, nausea, photosensitivity, headache, diarrhea

To avoid stomach upset take with food and water

Tetracycline chelate cations … consider DDIs - separate from calcium, aluminum, magnesium, and iron

36
Q

Tetracyclines should be avoided with concomitant use of which 3 medications

A

Oral retinoids
Methotrexate
Acitretin

37
Q

Macrolide counseling points

A

Main ADRs: GI upset (n/v/d), headache

They are strong CYP3A4 inhibitors
-more interactions with erythromycin than azithromycin
-erythromycin is contraindicated with lovastatin and simvastatin

Chelate ions … separate administration from antacids or calcium, magnesium, aluminum containing medications

38
Q

Isotretinoin MOA

A

Synthetic retinoid
Exact mechanism is unknown - appears to act by inhibiting sebaceous gland size and functioning

39
Q

When isotretinoin used

A

Reserved last line for severe, refractory, cystic acne
-because of many side effects

40
Q

Available isotretinoin products

A

Brands: Acutane, Clavaris, Asorbica, Amnesteem
(10-40 mg capsules)

41
Q

Isotretinoin dosing

A

Weight based dosing, start low to minimize reactions…

start at 0.5 mg/kg/day and divide into 2 daily doses
-do this for 1 month

Then increase to full dose - 1 mg/kg/day (as tolerated)

42
Q

How long should isotretinoin be used for?

A

15-20 weeks or until full clearance of acne cysts

43
Q

Isotretinoin counseling points

A

Take with food for better absorption

Teratogenic - BBW for birth defects
-requires REMS program - iPLEDGE to prevent fetal exposure

44
Q

Common side effects of isotretinoin and management of them (3)

A

-Dry skin, lips, nose, eyes, and mouth
^use moisturizer, lip balm regularly

-Photosensitivity
^avoid sun exposure, use sunscreen (SPF >15) daily

-Back/muscle pain
^monitor MSK pain tolerability

45
Q

Rare but serious side effects of isotretinoin and management of them

A

-Depression, suicidal ideation, psychosis
^monitor and discontinue if psychiatric symptoms occur

-Conjunctivitis or eyelid inflammation
^monitor for vision changes

-Acute pancreatitis
^avoid alcohol, monitor for increased triglycerides

-Inflammatory bowel disease
^monitor and discontinue if severe diarrhea, abdominal pain, or rectal bleeding occurs

-Hepatitis
^monitor for increased liver enzyme tests

-Neutropenia
^monitor for decreased WBC count

46
Q

Oral and topical antibiotics for acne should never be used as _________________

A

Monotherapy!
They should be used with topical products to avoid antibiotic resistance

47
Q

Comparison of topical vehicle formulations

A

Bars and liquids - less effective because washed off, but better tolerated because not absorbed

Gels and solutions - work as astringents (drying effect) - most effective for acne

Creams and lotions - add hydration to skin, good for dry skin but can clog pores

Ointments - clogs pores not good for acne

48
Q

Oral and topical antibiotics should only be used for how long?

A

8-12 weeks (3-4 months)

49
Q

Sarecycline

A

(Seysara)
This is new tetracycline that has only been approved for the treatment of moderate/severe acne

It has weight based dosing
Can be taken with or without food (with food to help stomach upset)
But should be taken with a full glass of water - to prevent esophageal irritation and ulceration

(same contraindications/drug interactions as other tetracyclines)

50
Q

Mild acne treatment algorithm

A

For mild non-inflammatory acne (comedones only)
-First line - monotherapy topical retinoid
-Alternative: BP or azelaic acid

For mild inflammatory acne (papules/pustules)
-First line - topical retinoid + benzoyl peroxide
-alternative: TR or BP or azelaic acid

Note - alternatives can be used if inadequate response to first line or if unable to use first line
-can switch or add agents…
If partial response after 12 weeks add another topical agent
If no response after 12 weeks switch to another topical agent

51
Q

Moderate acne treatment algorithm

A

For inflammatory papules/pustules
-First line: topical retinoid + benzoyl peroxide
Alternative: consider addition of topical antibiotic

If inflammatory + nodules are present:
-First line: topical retinoid + benzoyl peroxide + oral antibiotic
-Aternative: consider addition of COC or spironolactone

52
Q

Severe acne treatment algorithm

A

If inflammatory + nodules:
First line: topical retinoid + benzoyl peroxide + oral antibiotic
Alternative: consider addition of COC, spironolactone, can consider isotretinoin

If inflammatory + cysts
First line: oral isotretinoin
Alternative: consider addition of COC, spironolactone, and oral antibiotic + BP

53
Q

How long should acne therapy be used for?

A

Typically 12 weeks - after that we start to taper down to monotherapy if possible

54
Q

At which point can we consider efficacy monitoring?

A

No sooner than 8 weeks - much longer for some things/full efficacy
-just know and counsel patients that it will take a while to see improvement and adherence is important to get to that point

55
Q

What are 3 alternative agents that can be used for acne treatment

A
  1. Combined oral contraceptives (COC)
  2. Spironolactone
  3. Clascoterone
56
Q

Combined oral contraceptives for acne

A

Work be decreasing androgen production and binding free circulating testosterone

Can only be used in women who also want contraceptive therapy

Can only be used in females
Cannot be used in pregnancy

Takes 6 cycles of COC therapy (6 months) for full effect
More adverse effects and discontinuation as a result

57
Q

COCs should NOT be used in which cases?

A

-Pregnancy or breastfeeding
-35 or older and heavy smoker
-Uncontrolled hypertension
-History of blood clots or stroke
-History of migraine
-Current breast cancer
-Current liver disease or liver tumor

58
Q

Spironolactone for acne

A

Works by decreasing testosterones production

Not FDA approved for acne
Can only be used in females

Should NOT be used in pregnancy

ADRs: gynecomastia, hyperkalemia, hypotension, diuresis

59
Q

Clascoterone

A

Androgen receptor inhibitor

Topical application

Can be used for males or females - can be used if failed initial topical therapy or in a combination regimen

ADRs - xeroderma, peeling

60
Q

Oral corticosteroids for acne

A

Not generally recommended or used
May be used in severe exacerbations to quickly decrease inflammation

Imm/Musculoskel/Skin (16 decks)

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