Acne Vulgaris Therapy Flashcards
Grade I (mild) acne
Mainly comedones
Occasional papules
No nodules, no scarring
Mostly non-inflammatory
Grade II (moderate) acne
Comedones
more papules and pustules(mainly facial)
Mild scarring
Inflammatory lesions
Grade III (Moderate) acne
Numerous and extensive comedomes, papules, pustules, and nodules
(facial with spread to back, chest, shoulders)
Occasional cyst or nodule
Moderate scarring
Grade IV (Severe) acne
Numerous large cysts or nodules on the face, neck and upper trunk
Severe scarring
Persistant pustulocystic
Recalcitrant cystic
Assessment of severity
Garde 1, II, III, and IV
Guides whether or not patient can be a candidate for self treatment and what treatment strategies will be necessary or work best for them.
Approach to acne treatment
- Identify/limit exposure to exacerbating factors
- Alleviate discomfort
- Control lesions
- Prevent pitting/scarring
- Prevent new lesions
- Minimize adverse drug reactions
- Address as many pathogenic factors for acne development as possible by:
- Reducing sebum production
- Suppress P. acnes
- Reducing inflammatory process to prevent scarring
Non-pharmacologic therapy for acne
- Eliminate exacerbating factors
- Counsel patient on importance of adherence
- Cleanse skin with mild soap or non-soap cleanser twice a day
- Avoid using abrasive products and excessive cleansing
- Stay well hydrated
- Do not pop, squeeze or pick acne
Non-prescription topical products
Benzoyl Peroxide: Bacetricidial Slightly Keratolytic Comes in wash, liquid, cream, and gel Adverse: bleach hair & clothes, drying, photosensitivity
Salicylic Acid: Keratolytic Comedolytic (lyses comedones) Comes in pads, cream, gel Adverse: Potent keratolytic at high concentration, drying, photosensitivity
Sulfur: Bactericidal Keratolytic Comedolytic Comes in cream & lotion Adverse: color, malodorous, drying
Topical product selection for oily to normal skin
Gels, solutions, and lotions
Topical product selection for normal skin
Gels, solutions, lotions, and creams
Topical product selection for normal to dry skin “sensitive skin”
Lotions and creams
Ointments and bars
not usually recommended for any skin type
Benzoyl Peroxide
Most common topical OTC product for acne
Recognized by FDA as safe and effective
Used alone or in combination with oral/topical antibiotics
Prevents development of P. acnes resistance
Benzoyl Peroxide OTC Formulations
2.5% to 10% concentration
Prescription strength up to 20%
Benzoyl Peroxide Side Effects
Most common: skin irritation (more likely in higher strengths)
Side effects will stabilize within 1-2 weeks
Photosensitivity
Bleached hair/clothing
Allergic reaction
Salicylic Acid
FDA-approved topical product available OTC
Comedolytic and keratolytic
Efficacious in treatment of acne, though less than benzoyl peroxide
Salicylic Acid Formulations
Non-prescription strengths: 0.5 to 2%
Prescription strengths up to 30%
Salicylic Acid Side Effects
Potent keratolytic
Drying
Photosensitivity
Sulfur
FDA-approved for OTC treatment of acne
Keratolytic and antibacterial
Useful for existing comedones but may promote comedone development with long-term use
Sulfur Formulation
Can be combined with resorcinol
- Enhances sulfur effect
- Can produce a reversible, dark brown pigment in darker-skinned patients
Sulfur Side Effects
Dry skin, noticeable odor
Complementary Therapy for Acne
Tea Tree Oil: Essential oil May have antiseptic properties Has been shown to reduce lesions but slower onset of action May be irritating if applied directly Add to a moisturizing or gel vehicle
Alpha Hydroxy Acids
- Glycolic acid; Lactic acid; Citric acid
- Exfoliates
- In high concentrations, can be used as a chemical peel to reduce acne scarring
- Need to use sunscreen due to increased photosensitivity
Prescription Products for Acne
Topical Retinoids Topical Antibiotics Topical Antimicrobials Oral Antibiotics Oral Antiandrogen Oral retinoid Other Topicals
Topical Retinoid examples
Tretinoin
Adapalene
Tazarotene
Topical Antibiotic examples
Clindamycin
Erythromycin
Topical Antimicrobial examples
Erythromycin
Clindamycin
Oral Antibiotic Examples
Tetracycline Minocycline Erythromycin Doxycycline Clindamycin
Oral Antiandrogen Examples
Spironolactone
Drospirenone
Flutamide
Oral contraceptives
Oral retinoid examples
Isotretinoin
Other topical examples
Benzoyl Peroxide
Azelaic Acid
Salicylic Acid
Corticosteroids
Topical retionds
Vitamin A derivatives Tretinoin (Retin-A ®) Adapalene (Differin ®) Tazarotene (Tazorac® or Fabior ® foam) Most powerful peeling agents available
Reduce inflammation, normalize keratinocyte differentiation, and increase keratinocyte proliferation/migration
Apply to clean, dry skin (avoid eyes, mucous membranes, abrasions)
Photosensitivity/photoirritants
Topical antibiotics
Antibiotic and anti-inflammatory effects
Erythromycin
Clindamycin
Foam: apply daily; use gloves to apply and wash hands thoroughly afterward
Apply to dry, clean skin BID
Wait 30 minutes to shave area or apply makeup
Adding benzoyl peroxide or topical retinoids can prevent/overcome bacterial resistance
Systemic Retinoids
Isoretinoin (Accutane®)–Oral
Treatment for:
Severe recalcitrant acne
Treatment resistant acne
Acne causing significant physiological/psychological scarring
Weigh benefits of use against risk of adverse effects:
Dry nose, eyes, mouth, inflammation of the lips
Musculoskeletal, ophthalmic effects, headache, CNS effects
Mood disorders, depression, suicidal ideation
Lab monitoring: triglycerides, cholesterol, LFTs, and CBC
Potent teratogen—iPledge program for child-bearing aged female patients
Systemic Antibiotics
Moderate to severe acne
Minocycline
Doxycycline
Erythromycin (bacterial resistance)
Trimethoprim-sulfamethoxazole
Bacterial resistance for antibiotics increasing problem
If using tetracycline, separate from dairy products by 1-2 hours and use sunscreen to avoid toxicity
Hormonal Agents
Estrogen containing oral contraceptives for some women
Oral anti-androgenic agents—spironolactone and cyproterone acetate
Side effect of spironolactone—hyperkalemia
Oral corticosteroids—limited data
May be beneficial for patients with highly inflammatory disease
Treatment Strategies:
Pediatric mild treatment
Initial: benzoyl Peroxide or topical retinoid OR Combination Therapy BP+antibiotic, BP+retinoid BP+retinoid+antibiotic
Inadequate Response:
-Add BP or Retinoid (if not already prescribed).
-Change Retinoid Concentration, Type, and/or formulation
OR
-Change topical combination therapy
Pediatric Moderate Treatment
Initial: Topical Combo BP+ Retinoid OR Retinoid+(BP+antibiotic) OR (Retinoid+Antibiotic)+BP
OR
Oral antibiotic+topical retinoid+BP
OR
Topical Retinoid+Antibiotic+Bp
Inadequate:
-Change Retinoid Concentration, Type, and/or formulation
OR
-Change topical combination therapy
AND/OR
Change oral antibiotic
Female:consider hormone therapy
OR
Consider oral isotretinoin
Pediatric Severe Treatment
Initial:
Combo therapy
Oral antibiotic +/- topical antibiotic+BP+topical retinoid
Inadequate:
Change oral antibiotic+consider oral isotretinoin
Female:consider hormone therapy
Acne Patient Conseling
It may take 8 weeks or more to see visible benefits of treatment
Acne is a condition that will get worse before it gets better
Peeling of the skin when first using topical agents may occur
Case 1: 16 year old girl acne on face, no inflammatory lesions; wearing heavy makeup
Classify her acne – mild
First line of medications to suggest – Benzoyl peroxide
Non-pharm advice – hydration
Case 2: 18 year old boy; acne is on his forehead and cheeks, and that he also gets lesions and papules on his shoulders. There is some mild scarring. He does not take any medications on a regular basis, though he admits to trying topical benzoyl peroxide 10% twice a day for the past few weeks. He just moved away from home to go to college and reveals his diet consists of primarily sugary drinks and fast food. He complains that his skin on his face is oily.
Classify his acne – moderate mixed
Topical preparation type – gel
Add to current regimen – topical retinoid
Case 3: A 27 year old women with moderate acne is complaining of acne despite being prescribed oral doxycycline, topical retinoids and benzoyl peroxide for 8 months She takes loratidine 10 mg daily for allergic rhinitis and has no drug allergies She has comedones on her forehead, nose and chin, as well as papules on her nose and two cysts below her chin. She states that she also has some cystic lesions on her upper back and shoulders She is also complaining of irregular periods. She is not sexually active nor planning a pregnancy in the near future.
Next treatment step: oral contraceptives
Oral contraceptives do not work, wants to start oral retinoids, what counseling points? iPledge, teratogenic, side effects – mood
Suggesting Regimen
Determine outcomes for that patient
Use non-pharmacologic, first
Then, add lowest strength medications –
Topical then oral
Monitor response over 6 weeks or more
Reduce therapies, when possible
Add or change therapies, as indicated
Remember to check on drug interactions, side effects – sunscreen, moisturizer, etc
