Exam 1 Acneiform Disorders Flashcards
general concepts of acne treatment
- There is no cure
- Don’t forget patient expectations (as with all diseases) and discuss preventive measures
things to address with acne
- Discomfort
- Appearance
- Long-term scarring
- Psychological stress
Acne is believed to result from a combination of:
- Sebaceous gland hyperplasia
- Follicular hyperkeratosis
- Propionibacterium acnes colonization
- Inflammation
What is drug therapy aimed at?
1 or more of the mechanisms:
- Sebaceous gland hyperplasia
- Follicular hyperkeratosis
- Propionibacterium acnes colonization
- Inflammation
Non-drug therapy
- Avoid contributing factors when possible
- Counsel pt that acne is NOT poor hygiene
- Simple washing with water/mild cleanser BID is enough
- Advise pt not to squeeze/pick
- Avoid oil-based products
MOA of topical retinoids
- Vitamin A analogs that work by stimulating epidermal cell turnover which unplugs follicles
- Inhibit production of inflammatory mediators
Preferred first-line agents in mild-moderate acne either alone or in combination
topical retinoids
Should be used as part of combo therapy for moderate-severe acne
topical retinoids
First-line to maintain remission
topical retinoids
should use sunscreen because new skin burns easily, use moisturizer in combo
topical retinoids
use topical retinoids at night because drugs are _____
use topical retinoids at night because drugs are photolabile
Original tretinoin should avoid use with ______ _______
Original tretinoin should avoid use with benzoyl peroxide
skin irritation including stinging, redness, dryness
ADRs of topical retinoids
topical retinoid drugs
- Tretinoin (Retin-A)
- Tazarotene (Tazorac)
- Adapalene (Differin)
- Adapalene + benzoyl peroxide (Epiduo Forte Gel)
Possibly more effective but more irritation
tazarotene (Tazorac)
Contraindicated in pregnancy – don’t use in females 10-50
tazarotene (Tazorac)
Less irritation
adapalene (Differin)
July 2016: Approved for OTC 12+ years old
adapalene (Differin)
Come in a variety of dosage forms (gels, lotions, creams, swabs, cleansers, etc.)
topical retinoids
MOA of benzoyl peroxide
Antibacterial (releases oxygen free radicals that damage cell wall) and keratolytic (exfoliates and opens pores) properties
Often in combo with other antibiotics to reduce resistance (bacteria have no way to produce resistance to above mechanism of action)
benzoyl peroxide
Available OTC so often used first-line as monotherapy
benzoyl peroxide
Can cause bleaching of skin
benzoyl peroxide
Avoid overuse (mostly once daily)
benzoyl peroxide
Skin irritation
Dryness and peeling of skin
benzoyl peroxide
topical antibiotics for acne
*Erythromycin
*Clindamycin
Sulfacetamide
Sulfur & Sulfacetamide
Dapsone
other treatment failure of mild acne
topical antibiotics
Moderate acne (usually in combo with other topicals)
topical antibiotics
MOA for Azelaic Acid (Azelex)
- antimicrobial, comedolytic, anti-inflammatory properties
- Normalizes keratinization and suppresses P. acnes
Touted to cause less irritation so you might chose first-line for very sensitive skin
azelaic acid (Azelex)
Downside is that it is usually less effective than other topicals and expensive
azelaic acid (Azelex)
Also indicated for Rosacea (specific product form)
azelaic acid (Azelex)
- Reported cases of hypopigmentation
- $$$
azelaic acid (Azelex)
Local skin irritation
ADR of azelaic acid (Azelex)
MOA of salicylic acid
Produces desquamation of hyperkeratotic epithelium
Salicylic acid is ______ at concentrations of 3% to 6%; it becomes ______ to tissue at concentrations >6%.
Salicylic acid is keratolytic at concentrations of 3% to 6%; it becomes destructive to tissue at concentrations >6%.
what are concentration of salicylic acid at concentrations of 6-60% used for?
- remove corns and warts
- in the treatment of psoriasis and other hyperkeratotic disorders.
- Less effective v. benzoyl peroxide
- May use second-line if other comedolytic agents haven’t worked
- May be in combo with other agents
salicylic acid
local skin irritation
ADR of salicylic acid
what PO antibiotics should you usually start with
minocycline or doxycycline
second-line options for PO antibiotics
- TMP-SMX
- Azithromycin
- Erythromycin
- Clindamycin
usually for moderate-severe acne
PO antibiotics
when do you check patient back for efficacy when using PO antibiotics
6-8 weeks
How long do you try to limit duration of treatment for PO antibiotics?
12 to 18 weeks to limit resistance
Dosed with topical retinoid and/or benzoyl peroxide to improve efficacy and reduce resistance
PO antibiotics
Estrogen is an ____-_______ agent
Estrogen is an anti-androgen agent
for moderate-severe acne
oral contraceptives
Only indicated for severe, recalcitrant, nodular acne
isotretinoin
Option for management of acne that is producing either physical or psychological scarring
isotretinoin
Used in a variety of other skin diseases such as ichthyosis and some cancers
isotretinoin
ORAL ISOTRETINOIN IS A POTENT _________
ORAL ISOTRETINOIN IS A POTENT TERATOGEN
Female patients of ____-_____ potential must only be treated with oral isotretinoin if they are participating in the approved pregnancy prevention and management program (______).
Female patients of child-bearing potential must only be treated with oral isotretinoin if they are participating in the approved pregnancy prevention and management program (iPLEDGE).
Male patients must enroll in ______ as well as some amount of drug is found in ______.
Male patients must enroll in iPLEDGE as well as some amount of drug is found in semen.
Mood disorders, depression, suicidal ideation, and suicides have been reported in patients taking this drug. However, a causal relationship has not been established.
isotretinoin
Chronic, relapsing inflammatory skin disorder with exact cause unknown
rosacea
possible causes of rosacea
- Innate immunology
- Microorganisms (Demodex folliculorum, Bacillus oleronius, etc.)
- UV radiation
- Vascular hyperreactivity
- Genetics
clinical features of rosacea
- Facial erythema
- Telangiectasias
- Inflammatory skin lesions
No cure known so treatment focus is on symptom suppression
rosacea
4 types of rosacea
- Erythematotelangiectatic rosacea – red blood vessles
- Papulopustular rosacea – pus filled papules
- Phymatous rosacea - nose
- Ocular rosacea - eye
non-medical treatment of rosacea: avoid triggers of flushing
- Extremes of temperature
- Sunlight
- Spicy foods
- Alcohol
- Exercise
- Acute psychological stressors
- Medications
- Menopausal hot flashes
non-medical treatment of rosacea: skin care
- Frequent skin moisturization
- Gentle skin cleansing
- Avoidance of irritating topical products
medical treatment for rosacea
- light therapy
- drug therapy - topical or systemic
Especially good for telangiectasias
laser therapy
first line treatment treatment in rosacea
Topical brimonidine (Mirvaso) - Topical alpha2-adrenergic agonist *Causes direct vasoconstriction
second line treatment in rosacea - topical
- usually for mild-moderate disease or failed other therapies
- Metronidazole, azelaic acid, doxycycline
second line treatment in rosacea - systemic
- for more severe/inflammatory lesions or for those where topicals fail
- Doxycycline or minocycline
for refractory cases of rosacea
isotretinoin
if rosacea has ocular involvement…
refer to ophthalmology
