DERM 02: Acne Flashcards
1
Q
What is acne?
A
chronic inflammatory disorder of sebaceous glands and hair follicles of skin (pilosebaceous unit)
2
Q
What are the key features of acne?
A
- non-inflammatory lesions (comedones)
- inflammatory lesions (papules, pustules, and nodules)
- lesion extensiveness
- presence of scarring (secondary to nodules)
- involves face, neck, upper back, and chest
3
Q
What is the pilosebaceous unit?
A
where acne originates
- consist of hair follicle and sebaceous gland connected to skin’s surface by duct that hair shaft passes through
4
Q
What do sebaceous glands do?
Where are they found?
A
- produce sebum (fat and wax mixture) that maintains proper skin and hair hydration
- most common on face, upper chest, upper back
5
Q
What is the role of androgens?
A
- increased androgen levels during puberty increase size and activity of sebaceous glands
- patients with acne have exquisite end-organ sensitivity to androgens
6
Q
Pathophysiology
What is the normal keratinization process?
A
keratinous lining of follicle is continuously shed and carried to surface by flow of sebum
7
Q
Pathophysiology
Describe the disrupted keratinization process in acne (simplified).
A
- abnormal ↑ follicular keratinization → microcomedone (plug)
- increased sebum production secondary to androgens (testosterone)
- proliferation of cutibacterium acnes → inflammation
- inflammatory cascade
8
Q
Pathophysiology
Describe the disrupted keratinization process in acne (detailed).
A
epithelial cells (keratinocytes) lining follicle are overproduced and become cohesive (sticky), resulting in retention within follicle (microcomedone)
- sebaceous glands produce excessive oil → sebum backs up b/c passage is narrowed in follicle
- accumulation of keratinous and sebaceous debris eventually causes impaction/plug of follicle and forms comedones (open and closed) – non-inflammatory acne or comedonal acne
local (gram-positive) anaerobic diphtheroid bacteria, Cutibacterium acnes (previously propionibacterium acnes), liberate lipases that hydrolyze triglycerides (in sebum) to irritating fatty acids
- promotes colonization and initiates influx of white blood cells (inflammation), and can eventually rupture follicle wall – development of inflammatory lesions
9
Q
When are open comedones (blackheads) formed?
A
when follicle is open and sebum is exposed to air (oxidation), and top blackens due to collection of melanin
10
Q
When are closed comedones (whiteheads) formed?
A
when opening of follicle is closed at skin surface
11
Q
What is the precursor of inflammatory lesions?
A
closed comedones (whitehead)
12
Q
What are the 3 types of inflammatory lesions?
A
- papules: elevated, red, solid, and circumscribed lesions that precede pustules
- pustules: small elevation of skin filled with pus
- nodule: elevated, solid, palpable lesions > 1 cm in diameter, likely heal with atrophic scars
- note: cysts (sac under skin with definite wall around it, contains fluid or semifluid material) are uncommon in acne but may be large nodules
13
Q
What is considered when diagnosis/classifying acne?
A
- no universally accepted grading system – system use may help facilitate decision-making and assessing treatment response
- consider: (1) lesion types, (2) acne severity – including distribution and extent of skin involvement, (3) complications – pigmentation, scarring, psychological distress
14
Q
What are the 3 categories of acne severity?
A
- comedonal
- mild or moderate papulopustular acne
- severe
15
Q
What is comedonal acne?
A
closed and open comedones predominate
16
Q
What is mild or moderate papulopustular acne?
A
superficial inflammatory lesions (papules and pustules) predominate, plus comedones
17
Q
What is severe acne?
A
deep pustules and/or nodules that can be painful, extend over large areas, and can lead to tissue destruction (scars)
18
Q
What is acne fulminans or conglobate?
A
rare and severe forms of acne
19
Q
What is mild acne?
A
< 20 comedones, or < 15 inflammatory lesions, or total lesion count < 30
20
Q
What is moderate acne?
A
20-100 comedones, or 15-50 inflammatory lesions, or total lesion count 30-125
21
Q
What is severe acne?
A
> 5 nodules, or total inflammatory count > 50, or total lesion count > 125 (has active scarring)
22
Q
Investigator’s Global Assessment (IGA)
Clear (0)
A
normal clear skin
23
Q
Investigator’s Global Assessment (IGA)
Almost Clear (1)
A
rare non-inflammatory lesions, with rare non-inflamed papules
24
Q
Investigator’s Global Assessment (IGA)
Mild (2)
A
some non-inflammatory lesions, with few inflammatory lesions (papules and pustules only)
25
Investigator’s Global Assessment (IGA)
Moderate (3)
multiple non-inflammatory lesions and inflammatory lesions are evident – several to many comedones and papules/pustules, may or may not be one small nodulocystic lesion
26
Investigator’s Global Assessment (IGA)
Severe (4)
inflammatory lesions are more apparent, many comedones and papules/pustules, may or may not be few nodulocystic lesions
27
What are the 2 types of acne scars?
- hypertrophic (excess skin)
- atrophic – ice pick scars, rolling scars, boxcar scars
28
What are the investigations required for acne diagnosis?
usually none required – clinical diagnosis
29
What are the 5 differential diagnoses of acne?
- folliculitis
- keratosis pilaris ('chicken skin')
- seborrheic dermatitis
- perioral/periorificial dermatitis
- rosacea
30
What is folliculitis?
- inflamed hair follicles
- inflammatory monomorphous lesions, no comedones
31
What is keratosis pilaris ('chicken skin')?
- excessive keratin causing plugged hair follicles
- appears as bumps
- typically on arms, but may resemble acne if on cheeks
32
What is seborrheic dermatitis?
- red, scaly, greasy plaques/patches
- affects sebaceous, gland-rich regions of scalp, face (creases behind nose, behind ears, eyebrows), and trunk
33
What is perioral/periorificial dermatitis?
- papules and pustules around mouth area
- association with steroid use
- affects women and children
- no comedones
34
What is rosacea?
- vasodilation, telangiectasia, papules, and pustules involving central face
- starts at older age (30-60)
- no comedones
35
What are the 3 types of acneiform eruptions?
- drug-induced acne
- acne mechanica
- acne cosmetica
36
What drugs can induce acne?
- androgens/anabolic steroids (ie. testosterone, DHT)
- barbiturates (ie. butalbital, phenobarbital)
- corticosteroids
- haloperidol
- lithium
- phenytoin
- tetracycline
- progesterone
- vitamins B1, B2, B6, B12
37
What is acne mechanica caused by?
caused by local friction and irritation
- masks, bra-straps, turtlenecks, shoulder pads, sports helmets, headbands
38
What is acne cosmetica caused by?
caused by irritating cosmetics
- products have become less comedogenic over time
- heavy, oil-based products (ie. pomade) still used
39
What are the red flags and referral signs for minor ailment prescribing? (3)
- unclear diagnosis
- moderate to severe acne vulgaris
- appropriate care involves further investigation and/or systemic therapy
40
What is considered an unclear diagnosis for acne? (4)
- atypical age for new onset (< 12 years old, > 30 years old)
- signs of acne-like variant (monomorphic pattern, abrupt onset, and/or absence of comedones)
- signs of hyperandrogenism (ie. hirsutism, infertility, infrequent menses, insulin-resistant diabetes, middle-age onset in female sex)
- atypical systemic signs and symptoms (ie. arthralgia, fever, etc.)
41
When does acne require further investigation and/or systemic treatment? (4)
- family history or presence of scarring acne
- presence of disfiguring dyspigmentation
- presence of signs or symptoms indicating significant psychological morbidity (ie. low self-esteem, shame, anxiety or depression)
- failure of topical treatment trial x 2
42
What are risk factors/triggers for acne? (4)
- stress
- pre/perimenstrual flares
- skin trauma – picking/scratching/squeezing/improper cleansing
- diet – controversial, no evidence that acne is worsened by chocolate/nuts/candy/pop, high glycemic index diet may exacerbate acne, dairy ingestion (particularly skim milk) may be associated with acne
43
What are the goals of treatment for acne? (3)
- prevent new lesions from forming, heal existing lesions, and minimize permanent scarring by: reducing keratinization process, decreasing sebum production, reducing microbial flora, therefore decreasing enzymes and inflammation
- reduce dyspigmentation
- prevent psychological distress
44
How long must topical treatment be used to see improvement?
at least 2-3 months
45
What is recommended to optimize acne treatment?
combining multiple MOAs – optimizes treatment and reduces risk of resistance
46
Comedonal Acne (Mild)
What is the recommended treatment?
topical therapy
- topical retinoids (tretinoin, adapalene, tazarotene, trifarotene)
- benzoyl peroxide (BPO)
- azelaic acid
- commercially available combinations of: BPO, topical retinoid, topical antibiotic (clindamycin)
(treatment choice is determined by factors such as type of vehicle, ease of use, and cost)
47
Benzoyl Peroxide (BPO)
MOA
antibacterial
- converted to benzoic acid on skin, which releases free oxygen radicals that oxidize bacterial proteins (↓ FFA by 50% and C. acnes by 98%)
- not subject to bacterial resistance
- mild keratolytic/comdeolytic
48
Benzoyl Peroxide (BPO)
Use
- mild or moderate acne (alone)
- adjunct for all types of acne
- can be used with oral or topical antibiotics to increase effectiveness and reduce resistance
- reduces resistance of C. acnes when combined with topical antibiotics
49
Benzoyl Peroxide (BPO)
Products and Administration
Proactiv, Benzagel
- available as creams, lotions, gels, cleansers, and washes – relatively inexpensive
- 2.5%, 4%, and 5% (OTC), 10% (Rx) – higher concentrations are not more effective, but may be more irritating
- typically used once daily, but can be BID
50
Benzoyl Peroxide (BPO)
Safety
- dryness, irritation, burning, stinging, erythema, and peeling are common
- titrate frequency (alternate day) or duration of application time
- may cause contact dermatitis (do patch test)
51
What are retinoids?
vitamin A derivatives
- synthetic and natural compounds that have biologic activity similar to vitamin A and alter gene expression by activating retinoid receptors
52
Retinoids
MOA
- bind to two nuclear receptors (members of steroid receptor superfamily)
- retinoic acid receptors (RARs) – RAR-α, β, γ
- retinoid X receptors (RXRs) – RXR-α, β, γ
- receptors form heterodimers (RAR-RXR) that bind specific DNA sequences called retinoic acid-responsive elements (RAREs) that activate gene transcription → pharmacologic effects
- retinoids that target RAR → cellular differentiation and proliferation – used in acne, psoriasis
- retinoids that target RXR → induce apoptosis (programmed cell death) – used in malignancies
- skin has RAR-α, γ (alpha and gamma) receptors
53
How do topical retinoids work?
- decrease cohesiveness of follicular epithelial cells
- increase cell turnover in follicular wall results in expulsion of existing comedones
- decrease number of cell layers in stratum corneum (very effective comedolytic)
54
How do oral retinoids work?
- decreases sebum production by 70%
- normalizes keratinization
55
Topical Retinoids
Use
- powerful comedolytic
- minor differences in terms of effectiveness
- tazarotene = adapalene > tretinoin
56
Topical Retinoids
Administration/Counselling
- ‘flare of acne’ appears after 3-6 weeks and clears by 8-12 weeks
- comedones take longest to respond
- once daily HS (limits photosensitization)
57
Topical Retinoids
Safety
- tazarotene is most irritating
- adapalene is least irritating
- irritation, erythema, peeling are common
begin after 2-10 days usage. persist until adaptation occurs in 10-14 days
- start with low strength and/or titrate frequency or duration of application time
- photosensitivity – need sunscreen SPF30+, tretinoin is most photosensitizing
58
Tretinoin
MOA
binds to α, β, γ retinoic acid receptors (non-selective)
59
Tretinoin
Products
- Retin-A
- Stieva-A
- Vitamin A Acid
- available as cream or gel
- combination products: Biacna (tretinoin 0.025%, clindamycin 1.2%) gel
- cost-effective
60
Tretinoin
Safety
- BPO oxidizes tretinoin – apply BPO in AM and tretinoin in PM
- products that have microspheres and polymerized products are more stable
61
Adapalene
MOA
synthetic naphthoic acid derivative with retinoid activity (more receptor selective for β and γ receptors)
62
Adapalene
Products
- 0.1% cream or gel, 0.3% gel
- Differin 0.1% gel – available OTC in USA
- combination products: Adapalene (0.1%) + BPO (2.5%) Gel (Tactupump or generics)
- expensive
63
Adapalene
Safety
- least irritating of retinoids
- preferred by patients
64
Tazarotene
MOA
- once absorbed in skin, immediately converted to active metabolite tazarotenic acid
- synthetic retinoid (more receptor selective for β and γ receptors)
65
Tazarotene
Products
- Tazorac 0.05% and 0.1% creams and gels
- most potent topical retinoid
66
Tazarotene
Safety
- most irritating topical retinoid
67
Trifarotene
MOA
selective retinoic acid receptor (RAR)-γ agonist
68
Trifarotene
Products
Aklief 50 mcg/g
- expensive (> $125)
- newest
- postulated to more effective and less irritating (clinical evidence is lacking)
69
What products should be used for dry or sensitive skin?
water-based creams or lotions
70
What products should be used for oily skin?
less greasy gel
71
What products should be used if a large area is affected?
solution
72
What are the general principles for topical treatment?
- initiate with lowest strengths in water-based products or apply every 2nd/3rd night for adaptation
- apply to entire area affected by acne
- if using two different therapies, apply one in morning and one in evening
- acne may initially worsen for first few weeks
- optimal effect is delayed up to 12 weeks (3 months)
73
Exfoliants (OTC)
(limited evidence for effectiveness)
- sulfur 3-12% (antibacterial as well)
- resorcinol 1-3% (not used alone)
- hydroxy acids
74
Hydroxy Acids
chemical peels (high concentrations), spot treatment, gel, lotion, creams, washes
- salicylic acid (beta-hydroxy acid) 0.5-6% – can be useful in young patients with recent onset/comedonal acne, 1-2% is better tolerated than other OTC options
- glycolic acid (alpha-hydroxy acid) 4-30%
concentration dependent – limited evidence for effectiveness
75
Localized Papulopustular Acne
What is the therapy for mild localized papulopustular acne?
topical therapy
- topical retinoids
- BPO – faster onset than retinoids for inflammatory lesions
- azelaic acid
- commercially available combinations of: BPO, topical retinoid, topical antibiotic (clindamycin)
- treatment choice is determined by factors such as type of vehicle, ease of use, and cost
76
Localized Papulopustular Acne
What is the therapy for moderate localized papulopustular acne?
topical + oral/systemic therapy (but topical alone might be reasonable)
- topical therapy combined with systemic therapy (antibiotics or combined oral contraceptives)
- topical: clindamycin, erythromycin
- COC:
77
Topical Antibiotics (Clindamycin and Erythromycin)
MOA
- eliminates or reduces C. acnes from follicle, decreasing free fatty acid production and subsequent inflammation
- concentrates medication in affected area and reduces risk of systemic antibiotic side effects
78
Topical Antibiotics (Clindamycin and Erythromycin)
Uses
- mild to moderate acne (inflammatory lesions)
- avoid monotherapy (combine with BPO)
- C. acnes resistance with prolonged use (limit to 3-6 months)
79
Clindamycin
Use
- equal efficacy to topical erythromycin
- less resistance than topical erythromycin (preferred topical antibiotic)
80
Clindamycin
Safety
rare cases of pseudomembranous colitis
81
Clindamycin
Products
- Dalacin-T 1% solution BID
combination products (note storage, stability):
- Clindoxyl, Clindoxyl ADV, BenzaClin – clindamycin 1% + BPO 3/5%
- Biacna – clindamycin 1.2% + tretinoin 0.025% Gel
- Cabtreo – clindamycin 1.2%, adapalene 0.15%, BPO 3.1% fixed-dose topical gel (expensive, > 12)
82
Erythromycin
Use
- safest in pregnancy
- greatest resistance risk of C. acnes and Staphylococci aureus (second-line choice)
83
Erythromycin
Products
- combination products: Benzamycin – erythromycin 3% + BPO 5%
84
Localized Papulopustular Acne
What are the miscellaneous agents?
- finacea (azelaic acid)
- winlevi (clascoterone)
- dapsone 5% gel (aczone)
85
Finacea (Azelaic Acid)
MOA
- mild anti-bacterial, anti-inflammatory, and comedolytic activity
- can help lighten skin
86
Finacea (Azelaic Acid)
Use
- reasonable choice for mild comedonal acne, mild to moderate inflammatory acne, or in combination with systemic antibiotics for severe acne
- does not promote resistant organisms
87
Finacea (Azelaic Acid)
Products
- Finacea – azelaic acid 15% gel
- apply BID
88
Finacea (Azelaic Acid)
Safety
- well-tolerated (compared to some topical retinoids and BPO)
- mildly irritating
- can cause hypopigmentation
89
Winlevi (Clascoterone)
MOA
topical antiandrogen – androgen receptor inhibitor that may help reduce sebum production and inflammation
90
Winlevi (Clascoterone)
Use
- first hormonal option indicated for both male and female patients ≥ age 12
- for inflammatory or non-inflammatory acne – consider in patients unresponsive to initial topical therapy (data lacking for combination with other topicals)
91
Winlevi (Clascoterone)
Products
- Winlevi – clascoterone 1% cream
- refrigerate before dispensing – store at room temperature after dispense, discard one month after opening
- apply BID (morning and evening)
- very expensive
92
Winlevi (Clascoterone)
Safety
- local irritation (redness, dryness, itching, edema, stinging, burning)
- some cases of HPA axis suppression
93
Dapsone 5% Gel (Aczone)
MOA
anti-inflammatory and antimicrobial properties
94
Dapsone 5% Gel (Aczone)
Use
- topical sulfone (structurally distinct from sulfonamides)
- used in place of topical antibiotic in combos for mild to severe acne
- low response rate, limited evidence, expensive
95
Dapsone 5% Gel (Aczone)
Safety
- adverse effects: dryness, rash, sunburn, burning, erythema, yellow-orange discolouration of skin and hair when used with BPO
96
What is the treatment for extensive moderate papulopustular acne?
systemic antibiotics + topical BPO (to prevent antibiotic resistant bacteria)
- doxycycline
- minocycline – caution rare ADR
- tetracycline
- reserved antibiotics (concerns with development of bacterial resistance): erythromycin (greatest risk for resistance, useful in pregnancy), TMP/SMX, TMP
combined oral contraceptives (COC) or spironolactone for women
97
What are the general principles for systemic antibiotics?
- do NOT use topical and oral antibiotics at same time
- always combine with BPO (or retinoid/azelaic acid)
- if no response in 6 weeks, switch antibiotics – individuals respond differently to different antibiotics
- takes 1-2 months to see benefit
- use antibiotics judiciously for inflammatory acne – limit to < 3 months treatment to reduce risk of resistance
- 6 months may be done in practice
- consider discontinuing once acne has improved, and giving maintenance with topical
98
Tetracyclines – Tetracyline, Doxycycline, Minocycline
MOA
reduces C. acnes from follicle and has anti-inflammatory action
99
Tetracyclines – Tetracyline, Doxycycline, Minocycline
Use
- first-line for moderate or severe inflammatory acne, extensive acne (back, shoulders, chest), failed topicals after 2-3 months
100
Tetracyclines – Tetracyline, Doxycycline, Minocycline
Products
- Tetracycline BID-QID on empty stomach
- Doxycycline 100 mg (max 200 mg) once daily (with or without food due to improved absorption)
101
Tetracyclines – Tetracyline, Doxycycline, Minocycline
Administration
- do not take at bedtime
- take with large glass of water while standing/sitting up
102
Tetracyclines – Tetracyline, Doxycycline, Minocycline
Safety
- minocycline: associated with ↑ risk of ADRs
- CI: children < 8 years old, pregnancy, patients with myasthenia gravis (doxycycline only)
- ADR: GI upset, vaginal candidiasis, gram-negative folliculitis (proteus, klebsiella), photosensitivity reacti`ons, pseudotumor cerebri, esophageal ulcerations
- DI: absorption ↓ by aluminum, iron, calcium, magnesium and bismuth (separate by 2 hrs)
103
Minocycline
Use
- considered highly effective due to its high lipid solubility and ability to penetrate follicle – but evidence shows equal efficacy to doxycycline
104
Minocycline
Dose
50 mg BID or 100 mg once daily (max 200 mg daily)
105
Minocycline
Adverse Effects
- dizziness (vestibular irritation in 30% patients)
- blue-black color changes in acne scar (rarely)
- drug-induced lupus reported (reversible in 16 weeks)
- autoimmune hepatitis
- hypersensitivity/ reactions involving liver and skin (DRESS – drug reaction with eosinophilia and systemic symptoms)
106
What is minocycline hyperpigmentation?
- pigmentation appears after months to years in small percentage of patients
- first noticeable on mucous membranes of mouth
- skin deposition can be brown or blue-grey – blue-grey pigmentation may occur in scars
- skin pigmentation may not fade after discontinuation
107
What is the treatment for severe acne?
- isotretinoin
- if unwilling, unable, or intolerant: systemic antibiotics + topical BPO (+/- topical retinoids), combined oral contraceptive (COC) or spironolactone
108
Isotretinoin
MOA
- oral vitamin A derivative
- ↓ sebum production by 70% and normalizes keratinization
- ↓ C. acnes and inflammation
109
Isotretinoin
Use
- for severe papulopustular or moderate to severe nodulocystic acne
- most effective anti-acne agent with most patients achieving clearing and remission (even in severe cases)
- 20% patients relapse within 2 years
- can give second course after 2-4 months
- acne exacerbation can occur during first 2 months of therapy
- caution soybean allergy
110
Isotretinoin
Warnings
- associations – no noted increases in population based studies
- mood disorder/depression
- inflammatory bowel disease
111
Isotretinoin
Pregnancy
- teratogenic (use 2 methods of contraception one month before, during, and one month after therapy)
112
Isotretinoin
Products
- traditional dose: 0.5-1 mg/kg/day
- low dose: < 0.5 mg/kg/day
- different formulations, NOT interchangeable
- original/conventional/standard (ie. Accutane Roche) – better bioavailability when taken with high fat meal
- lidose isotretinoin (ie. Epuris) – lipid encapsulation, less affected by food intake
- micronized isotretinoin (ie. Absorica LD) – not in Canada
113
Isotretinoin
Adverse Reactions
- dryness of skin and mucous membranes (ie. dry lips (cheilitis), desquamation of face)
- worse in first 2 months
- use lip balm, eye lubricants, nasal moisturizer
- 25% ↑ TG and cholesterol
- elevated liver enzymes
- photosensitivity (use sunscreen with SPF 30+)
- CNS: ↑ intracranial pressure (pseudotumor cerebri)
- eyes: corneal opacities, irritation (conjunctivitis), decreased night vision
- MSK pain (treat with acetaminophen, NSAIDs)
114
Isotretinoin
Monitoring
- LFT, lipids (baseline, 4 and 8 weeks), pregnancy (before, during, after), +/- CBC
115
Combined Oral Contraceptives
What do estrogens do?
decrease amount of circulating androgens and increase sex hormone binding globulin → reduce androgen action on sebum production
116
Combined Oral Contraceptives
What do progestins do?
(ie. drospirenone, cyproterone, dienogest)
anti-androgenic properties
- although some progestins can be androgenic (ie. levonorgestrel), estrogen component results in net anti-androgenicity overall
117
Combined Oral Contraceptives
Efficacy
consider all oral contraceptives to have equal efficacy in acne (conflicting evidence)
118
Combined Oral Contraceptives
Use
- commonly used in women (after menarche) with moderate to severe acne
- used in women with acne and other signs of hyperandrogenism (infrequent menses, hirsutism, androgenic alopecia, etc.)
- may also be used in mild acne in women who require contraception
119
Combined Oral Contraceptives
Products
- Yasmin or Yaz (drospirenone + EE)
- Tricyclen (norgestimate + EE)
- Alesse, Alysena, Aviane (levonorgestrel + EE)
- Diane-35, Cyestra-35 (cyproterone acetate + EE)
- maximum effectiveness seen at 4-6 months
120
Combined Oral Contraceptives
Safety
- risk of VTE, arterial thrombosis, breast cancer → screen for CI and risk factors
121
Spironolactone
MOA
androgen receptor blocker
122
Spironolactone
Use
- may be used when contraception is not required/wanted/contraindicated
- response 2-3 months
- avoid in pregnancy – feminization of male fetus
123
Spironolactone
Dose
50 mg daily to 100 mg twice daily
124
Spironolactone
Adverse Effects
- diuresis, hyperkalemia, irregular menstrual periods
125
What is the treatment for acne in pregnancy?-
select erythromycin (topical or oral) with topical BPO
126
What are the drug contraindications in pregnancy?
- oral retinoids (isotretinoin) → teratogenic
- must stop 1 month before getting pregnant
- avoid topical retinoids → insufficient - documentation for safety
avoid tetracyclines → dental staining and enamel hypoplasia, temporary inhibition of fetal bone development
- avoid SMX/TMP → teratogenic
- avoid anti-androgens (spironolactone) and hormones → contraindicated
127
Summary:
What is mild acne?
What are the treatment options?
comedones with few inflammatory lesions
- topical agents (BPO or retinoid) alone or in combinations
- topical retinoids are most effective for comedones
- add BPO/topical antibiotics if inflammatory lesions present
- assess at 2-3 months
128
Summary:
What is moderate acne?
What are the treatment options?
comedones with marked number of inflammatory lesions, may involve areas other than face
- topical agents as in mild acne OR topical agents and oral antibiotics for inflammatory lesions
- limit to 3 months of treatment if possible
129
Summary:
What is severe acne?
What are the treatment options?
extensive inflammatory lesions with diffuse scarring
- isotretinoin
- hormonal therapy for women
130
What are some tips for acne treatment?
- dispel myths – acne is not caused by inadequate facial cleansing (routine skin care should be gentle, patient-specific, and no more than twice daily), diet has little effect on acne
- avoid picking, vigorous scrubbing, and drying (scrubbing may rupture follicle)
- topical treatment should be applied to entire area (use regularly) – if irritation occurs, reduce duration and/or frequency of application
- antibiotic therapy should be combined with benzoyl peroxide to prevent C. acnes resistance
- noticeable improvement may take 8-12 weeks – may get worse before it gets better
- use non-comedogenic oil-free cosmetics and moisturizers
131
Summary:
What is the morphology of acne?
- characterized by open and closed comedones, papules, pustules, and nodules
- severity and presence of scarring must be included with describing acne
132
Summary:
What is the pathophysiology of acne?
related to presence of androgens, follicular hyperkeratinisation, excess sebum production, activity of C. acnes, and inflammation
133
Summary:
What are the main classes of drugs for acne treatment?
- topical retinoids, benzoyl peroxide, antibiotics
- systemic antibiotics, retinoids, hormones (COCs)
(untreated acne can result in permanent scars)
