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DEENT Exam 4 > Acne Vulgaris Therapy > Flashcards

Acne Vulgaris Therapy Flashcards

1
Q

Grade I (mild) acne

A

Mainly comedones
Occasional papules
No nodules, no scarring
Mostly non-inflammatory

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2
Q

Grade II (moderate) acne

A

Comedones
more papules and pustules(mainly facial)
Mild scarring
Inflammatory lesions

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3
Q

Grade III (Moderate) acne

A

Numerous and extensive comedomes, papules, pustules, and nodules
(facial with spread to back, chest, shoulders)
Occasional cyst or nodule
Moderate scarring

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4
Q

Grade IV (Severe) acne

A

Numerous large cysts or nodules on the face, neck and upper trunk
Severe scarring
Persistant pustulocystic
Recalcitrant cystic

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5
Q

Assessment of severity

A

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.

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6
Q

Approach to acne treatment

A
  • 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
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7
Q

Non-pharmacologic therapy for acne

A
  • 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
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8
Q

Non-prescription topical products

A 
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
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9
Q

Topical product selection for oily to normal skin

A

Gels, solutions, and lotions

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10
Q

Topical product selection for normal skin

A

Gels, solutions, lotions, and creams

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11
Q

Topical product selection for normal to dry skin “sensitive skin”

A

Lotions and creams

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12
Q

Ointments and bars

A

not usually recommended for any skin type

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13
Q

Benzoyl Peroxide

A

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

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14
Q

Benzoyl Peroxide OTC Formulations

A

2.5% to 10% concentration

Prescription strength up to 20%

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15
Q

Benzoyl Peroxide Side Effects

A

Most common: skin irritation (more likely in higher strengths)
Side effects will stabilize within 1-2 weeks

Photosensitivity

Bleached hair/clothing

Allergic reaction

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16
Q

Salicylic Acid

A

FDA-approved topical product available OTC

Comedolytic and keratolytic

Efficacious in treatment of acne, though less than benzoyl peroxide

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17
Q

Salicylic Acid Formulations

A

Non-prescription strengths: 0.5 to 2%

Prescription strengths up to 30%

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18
Q

Salicylic Acid Side Effects

A

Potent keratolytic
Drying
Photosensitivity

19
Q

Sulfur

A

FDA-approved for OTC treatment of acne

Keratolytic and antibacterial

Useful for existing comedones but may promote comedone development with long-term use

20
Q

Sulfur Formulation

A

Can be combined with resorcinol

  • Enhances sulfur effect
  • Can produce a reversible, dark brown pigment in darker-skinned patients
21
Q

Sulfur Side Effects

A

Dry skin, noticeable odor

22
Q

Complementary Therapy for Acne

A 
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
23
Q

Alpha Hydroxy Acids

A
  • 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
24
Q

Prescription Products for Acne

A 
Topical Retinoids
Topical Antibiotics
Topical Antimicrobials
Oral Antibiotics
Oral Antiandrogen
Oral retinoid
Other Topicals
25
Q

Topical Retinoid examples

A

Tretinoin
Adapalene
Tazarotene

26
Q

Topical Antibiotic examples

A

Clindamycin

Erythromycin

27
Q

Topical Antimicrobial examples

A

Erythromycin

Clindamycin

28
Q

Oral Antibiotic Examples

A 
Tetracycline
Minocycline
Erythromycin
Doxycycline
Clindamycin
29
Q

Oral Antiandrogen Examples

A

Spironolactone
Drospirenone
Flutamide
Oral contraceptives

30
Q

Oral retinoid examples

A

Isotretinoin

31
Q

Other topical examples

A

Benzoyl Peroxide
Azelaic Acid
Salicylic Acid
Corticosteroids

32
Q

Topical retionds

A 
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

33
Q

Topical antibiotics

A

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

34
Q

Systemic Retinoids

A

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

35
Q

Systemic Antibiotics

A

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

36
Q

Hormonal Agents

A

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

37
Q

Treatment Strategies:

Pediatric mild treatment

A 
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

38
Q

Pediatric Moderate Treatment

A 
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

39
Q

Pediatric Severe Treatment

A

Initial:
Combo therapy
Oral antibiotic +/- topical antibiotic+BP+topical retinoid

Inadequate:

Change oral antibiotic+consider oral isotretinoin

Female:consider hormone therapy

40
Q

Acne Patient Conseling

A

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

41
Q

Case 1: 16 year old girl acne on face, no inflammatory lesions; wearing heavy makeup

A

Classify her acne – mild
First line of medications to suggest – Benzoyl peroxide
Non-pharm advice – hydration

42
Q

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.

A

Classify his acne – moderate mixed

Topical preparation type – gel

Add to current regimen – topical retinoid

43
Q

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.

A

Next treatment step: oral contraceptives

Oral contraceptives do not work, wants to start oral retinoids, what counseling points? iPledge, teratogenic, side effects – mood

44
Q

Suggesting Regimen

A

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

DEENT Exam 4 (6 decks)

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