Ch. 37 Acne Flashcards
1
Q
Acne Vulgaris (AV)
A
- Common inflammatory disease
- Mostly face, also neck, chest, upper back, and shoulders can be affected
- Affects 81-95% of teen boys and 79-82% of teen girls
- Rising disease in adults, especially women 25+ y.o.
- Unknown cause
- Mean age AV treatment: 24 y.o.
- Spontaneous remission or continuous into adulthood can occur
- Physical and psychological scarring can occur
- Non-Rx drugs increasing while Rx drugs decreasing in sales for acne
2
Q
AV Pathophysiology
A
- From several pathological processes in the pilosebaceous unit in dermis (hair follicle and sebaceous gland)
- Sebum: normally protected skin from light, retains moisture, has antibacterial and anti-inflammatory properties
- CRH increases sebum production by increasing sebum gland function which can also cause stress acne
- Multifactorial: pathophysiology, genetics, gender
- Pathological factors: androgenic hormone triggers, excess sebum production, keratinization altering, proliferation of Propionibacterium acnes, and inflammatory processes
- Low linoleic acid concentrations and interleukin-1 release may increase acne
- Hyperproliferation causes cell adhesion which can plug and block the follicular orifice
- Behind plug, P. acnes is ideal lining causing inflammation, irritation, and local tissue destruction
- Stimulated cytokines/inflammation via TLR-2
- Diets, especially western diet, increase acne by increasing glycemia load, dietary milk, high fat/meat consumption which increases androgens and acne
3
Q
Closed Comedo
A
- White head
- Just beneath cell surface
4
Q
Opened Comeda
A
- Black head
- Protrudes from pore
- Blackens from melanin and oxidation
5
Q
AV Clinical Presentation
A
- Noninflammatory or inflammatory
- Noninflammatory - opened or closed comedones, usually presents on forehead first with puberty and then moves below neck with age
- Inflammatory - papules, pustules, or nodules
- Severity based on number and types of lesions
- Acne Assessment System provided, grade 0-4
- If acne lasts past 20 y.o. or starts in the mid-20s, ay be rosacea and requires a differential diagnosis
- Complications: scarring, negative psychological and social impacts, acute: erythema or hyperpigmentation
6
Q
AV Treatment
A
- Usually self-limiting and controllable
- Therapy adherence decreases symptoms and minimizes scarring
- Treatment must be long term, continuous, and consistent
7
Q
AV Treatment Goals
A
Once classification and exacerbating factors are identified recommend treatment initiation and adherence
8
Q
AV General Treatment
A
- Usually 1+ treatments, topicals or topical + systemic
- Mild-moderate: self treat with non-Rx
- Severe: oral antibiotics and Rx-medications, don’t use additional non-Rx products unless recommended
9
Q
AV Nonpharmacologic
A
- Eliminate exacerbating factors
- Cleanse skin with mild soap or nonsoap cleanser twice a day
- Don’t use abrasive products/excessive cleaning
- Stay well hydrated
- Diet changes: decease glycemia load
10
Q
AV Physical Treatments
A
- Increasing in popularity
- Extracting comedones with acrylate glue-based strips
- Better than “picking” at acne which leads to scarring
- Light-based therapy that targets P. acnes and disruption of sebaceous gland function may be used as an adjunct to traditional pharmacologic therapy, but not a lot of data supporting its efficacy
11
Q
AV Pharmacologic
A
- Topicals are the standard of treatment
- Be familiar with these
12
Q
Benzoyl Peroxide (BP)
A
- Most common antiacne product
- Keratolytic, comedolytic, and antibacterial properties
- Introduces oxygen which kills P. acnes
- FDA recognizes it as safe and effective, especially 2.5-10%
- Prevents/eliminates treatment resistance by P. acnes
- BP + antibiotics recommend to minimize resistance, topical or oral increasing its efficacy
- Strengths >10% increase irritation with no additional benefits
- No contact with skin/hair since it can cause bleaching
- Avoid excessive sun exposure and use sunscreen
- Mild erythema or scaling can occur in first few days which usually subsides in 1-2 weeks, allergic reactions are rare but can be severe
13
Q
Hydroxy Acids
A
- Keratolytic agents: AHA and BHA (alpha and beta)
- Less potent and used when can’t tolerate other products
- AHA: natural exfoliators (lactic, citric, etc. acid) can’t penetrate pilosebaceous unit to cause comedolytic effect
- 4-10% OTC, higher via Rx, BP is better for acne but AHA may be better for scarring/hyperpigmentation
- Polyhydroxyl acids = new AHA with less irritation and stinging; moisturizes, humectant properties, and less photoaging
- BHA - salicylic acid, comedolytic agent, concentration dependent, 0.5-2% OTC
- Milder effect than Rx agents
- Higher concentrations used for chemical/Rx peels
- Adjunct treatment in cleansers
- Helps protect from sunburn, specifically UVB, but should still wear sunscreen
- CI (BHA) - diabetes, poor circulation
- Toxicity (BHA) - N/V, dizzy, hearing loss, tinnitus, lethargy, diarrhea, psyche disturbances, allergies
14
Q
Sulfur
A
- Precipitated or colloidal, keratolytic and antibacterial
- 3-10% as OTC
- Promotes comedone resolution but can have comedonic effect with prolonged use
- Alternate forms like zinc and sodium thiosulfate are not safe or effective
- SE (rare): odor, dry skin
- Usually prescribed with things like resorcinol
15
Q
Sulfur/Resorcinol
A
- 3-8% sulfur + 2% resorcinol/3% resorcinol monoacetate
- Increases sulfur’s effect, primarily keratolytic
- Resorcinol isn’t effective alone but has antibacterial, antifungal, and keratolytic effects when used with sulfur
- Produces reversibly dark brown scale on darker skin individuals
16
Q
AV Product Selection Guidelines
A
- Various vehicles/strengths
- Medicated cleansers not effective (leave little residue)
- Gels: most effective form since they’re astringents
- Gels/solutions can cause drying and contact dermatitis but are also non-greasy and may be best for oily skin
- Creams/lotions are less irritating and counteract drying and peeling, could be best for dry/sensitive skin or in winter
- Don’t use ointments since they are occlusive and can worsen acne
- Start at lowest percent and increase as needed while minimizing irritation
- Get diagnosis for grading/type of acne and proper product recommendation
17
Q
AV Special Populations
A
- Preggo - could be hormone imbalance
- D/C antiacne products once pregnant and see doctor for recommendation since products may be teratogenic
- Pediatric - differential diagnosis
18
Q
AV Complementary Therapies
A
- Tea tree oil - antibacterial, antifungal, anti-inflammatory
- Zinc - alternative to tetracyclinens orally, bacteriostatic v.s. P. acnes and may be effective in severe acne, especially good in summer since it has no phototoxicity
- Zinc has poor adherence due to ASE: N/V, diarrhea
- Vitamin A, retinol, theoretically should work against acne but it isn’t validated
- Vitamin A ASE: xerosis, chelitis
- Nicotinamide - oral or topical, anti-inflammatory, improves skin texture and decreases sebum production, research is limited in its use
19
Q
AV Assessment
A
- Physical assessment to observe the affected area
- Try to determine between AV and other skin conditions
- Also determine severity to see if its okay to self-treat
- Go over medication use first in case already on an antiacne or acne-inducing medication
20
Q
AV Counseling
A
- Educate on causations, correct misconceptions, explain rationale
- Patients need to buy into therapy to increase adherence and increase successful outcomes
- Evaluate patient’s maturity and wiliness to stick to therapy
- Refer patient to reliable internet sources if needed or wanted
21
Q
AV Evaluation
A
- Don’t expect complete resolution
- Decrease in number and severity of lesions is more realistic
- No improvement after 6 weeks of self treatment or 6 months of diet change - ensure they are adherent
- If adherent, medical referral and encourage adherence
- If some improvement occurs, let it go another month and then adjust regimen if needed
