Week 5: Agents Used to Treat Acne Flashcards
First-line therapy for acne vulgaris with closed comedones includes:
a) oral antibiotics
b) isotretinoin
c) benzoyl peroxide
d) hydrocortisone cream
C - Benzoyl peroxide - can be used as monotherapy
Benzoyl peroxide mechanism of action
- antibacterial against P Acne
- releases active or free radical O2 to oxidize bacteria
- drying effect, removes extra sebum
- causes mild desquamation
Benzoyl peroxide ADRs
- dryness, peeling, irritation
- photosensitivity
- can bleach clothes, sheets, towels
Benzoyl peroxide Precautions/Contraindications
- safe for use in pregnancy
- BP applied AM, retinoid applied PM
Erythromycin topical mechanism of action
- topical antibiotic
- a bacteriostatic macrolide antibiotic which interrupt protein synthesis at the 50S ribosomal subunit
- combo with BP = reduce bacterial resistance
Erythromycin topical Precautions/Contraindications
- safe in pregnancy
- better tolerated than Clindamycin
- don’t use with clindamycin
Clindamycin topical (topical antibiotic) ADR
- burning and irritation
- diarrhea / colitis (rare) monitor !
Azelaic acid (topical antibiotic) ADRs
- skin hypopigmentation may occur
- avoid in people with color
Azelaic acid Precautions/Contrainindictions
- Pregnancy Category B
- absorbed systemically even when applied in small amounts so may be excreted in breast milk
- caution in lactating women
TRUE or FALSE
It is not appropriate to use Benzoyl Peroxide and either Clindamycin or Erythromycin on the same patient
FALSE - it is appropriate to be used on the same patient simultaneously - but the two products should be used at a different time of day (one medication in the morning and the other medication in the evening)
Isotretinoin (Accutane) Mechanism of Action
- systemic retinoid
- used for severe nodular cystic acne
- reduces sebaceous gland size & sebum
- normalizes follicular keratinization
- reduces P Acne
Isotretinoin (Accutane) Precautions/Contraindications
- pregnancy category X
- must verify the patient is not pregnant or trying to get pregnant before giving
- should not be used in patients at risk for osteoporosis
- NO ALCOHOL
Isotretinoin (Accutane) ADRs
- cheilitis (drying, peeling skin)
- photosensitivity
- lethargy/fatigue
- arthralgias/myalgias
- hypertriglycerdemia (LFTs)
- mood changes
- SI, mood swings, depression
Tretinoin (Retin-A) [topical retinoid] - mechanism of action
- decreases the cohesion between the epithelial cells and follicular cells of the hair
- expulsion of comedomes and prevent new ones
- NO antibiotic properties, but can enhance the penetration of other topical agents such as benzoyl peroxide
When prescribing tretinoin (Retin-A), the nurse practitioner (NP) advises the patient to:
a) use it with benzoyl peroxide to minimize irritating effects
b) use a sunscreen because the drug is photosensitzing
c) add a sulfa-based cream to enhance anti-acne effects
d) expect a significant improvement in acne lesions after approximately 1 week of use
B - use a sunscreen because the drug is photosensitizing
- can also cause hypopigmentation
Tretinoin (Retin-A) cautions
- pregnancy category C -
- thin layer is all that is needed
- caution in lactation, sensitive skin pts, eczema, skin abrasions, sunburn
What are some important things to educate your patient on when using topical medications for acne?
- Your acne may get worse before it gets better. Benefits may take 6-8 weeks to appear.
- Use sunscreen.
- Topical retinoids should not be used at the same time of day as topical antibiotics.
All topical retinoids should be avoided in what patient conditions?
- eczema, sunburn, or skin abrasions at the site of application
You prescribe a topical medication and want it to have maximum absorption, so you choose the following vehicle:
a) gel
b) lotion
c) cream
d) ointment
D - ointments - more occlusive, so more potent
creams are less occlusive, so less potent and lotions are the lease potent
You write a prescription for a topical agent and anticipate the greatest rate of absorption when it is applied to the:
a) palms of the hands
b) soles of the feet
c) face
d) abdomen
C - face
One of the mechanisms of action of a topical corticosteroid preparation is as:
a) an antimitotic
b) an exfoliant
c) a vasoconstrictor
d) humectant
C - a vasoconstrictor
To enhance the potency of a topical corticosteroid, the prescriber recommends that the patient apply the preparation:
a) to dry skin by gentle rubbing
b) and cover with an occlusive dressing
c) before bathing
d) with an emollient
B - and cover with an occlusive dressing
Which of the following is the least potent topical corticosteroid?
a) betamethasone dipropionate 0.1% (Diprosone)
b) clobetasol propionate 0.05% (Cormax)
c) hydrocortisone 2.5%
d) fluocinonide 0.05% (Lidex)
C - hydrocortisone 2.5%
Topical corticosteroid MOA & Classes
- anti-inflammatory, antipruritic, and vasoconstriction properties
- used for dermatitis, psoriasis, eczema
Class I - very high strength
Class II and III - high strength
Class IV and V - intermediate strength
Class VI and VII - low strength
Topical corticosteroid Cautions/Contraindications
- do not use high-potency agents on face, palms, feet, groin, axilla
- caution in pregnant patients; only use if benefits outweigh the risks
- children are often more susceptible to the effects and require the lowest effective strength to be used
Topical corticosteroid ADRs
- local skin irritation
- increase in the risk for secondary infections - tolerance may occur with prolonged used
- adrenal function should be monitored
- do not stop drug abruptly (rebound effect)
Topical calcineurin inhibitors “limus” (Pimecrolimus/Elidel and Tacrolimus/Protopic) Indications and MOA
- atopic dermatitis/eczema
- much more potent anti-immunologic and immunosuppressive - these are NOT STEROIDS
- suppresses cellular immunity through inhibiting T-cell activation by binding to intracellular proteins, including calcineurin-dependent proteins. This results in inhibition of inflammatory cytokines and mediators from mast cells
Topical calcineurin inhibitor cautions and contraindications
- black box warning for long-term safety concern because of rare cases of malignancy - skin cancer
- do not use occlusive dressing over this drug (do not use in the diaper area)
- NO in children <2 yrs old, immunosuppressed, preg/lactation
Situations when to use of topical calcineurin inhibitors
- atopic dermatitis that is resistant to steroids
- suitable for sensitive areas like face, skin folds
pimecrolimus (Elidel) - approved for mild to moderate disease
tacrolimus (Protopic) - approved for moderate to severe disease
Topical calcineurin inhibitor ADRs
- local reaction at site of application
- burning, pruritus and tingling
- H/A, fever, flu-sx’s, folliculitis
In the treatment of acne vulgaris, which lesions respond best to topical antibiotic therapy?
a) open comedones
b) cysts
c) inflammatory lesions
d) superficial lesions
C - inflammatory lesions
You have initiated therapy for an 18-year-old man with acne vulgaris and have prescribed doxycycline. He returns in 3 weeks, complaining that his skin is “no better.” Your next action is to:
a) counsel him that 6 to 8 weeks of treatment is often needed before significant improvement is achieved
b) discontinue the doxycycline and initiate minocycline therapy
c) advise him that antibiotics are likely not an effective treatment for him and should not be continued
d) add a second antimicrobial agent such as trimethoprim-sulfamethoxazole
A - counsel him that 6 to 8 weeks of treatment is often needed before significant improvement is achieved
Who is the best candidate for isotretinoin (Accutane) therapy?
a) a 17-year-old patient with pustular lesions and poor response to benzoyl peroxide
b) a 20-year-old patient with cystic lesions who has tried various therapies with minimal effect
c) a 14-year-old patient with open and closed comedones and family history of “ice pick” scars
d) an 18-year-old patient with inflammatory lesions and improvement with tretinoin (Retin-A)
B - a 20-year-old patient with cystic lesions who has tried various therapies with minimal effect
In a 22-year-old woman using isotretinoin (Accutane) therapy, the NP ensures follow-up to monitor for all the following tests except:
a) hepatic enzymes
b) triglyceride measurements
c) pregnancy
d) platelet count
D - platelet count
Leonard is an 18-year-old man who has been taking isotretinoin (Accutane) for the treatment of acne for the past 2 months. Which of the following is the most important question for the clinician to ask at his follow up office visit?
a) “Are you having any problems remembering to take your medication?”
b) “Have you noticed any dry skin around your mouth since you started using Accutane?”
c) “Do you notice any improvement in your skin?”
d) “Have you noticed any recent changes in your mood?”
D - “Have you noticed any recent changes in your mood?”
In a 13-year-old female patient with mild acne and who experiences an inadequate response to benzoyl peroxide treatment, an appropriate treatment option would be to:
a) add a topical retinoid
b) add an oral antibiotic
c) consider isotretinoin
d) consider hormonal therapy
B - add an oral antibiotic
Isotretinoin (Accutane) monitor what
LFTs, HCG pregnancy test (need iPledge), lipid panel, mental status
Clindamycin contraindications
- hx of Crohn’s disease
- ulcerative colitis
- antiboitic associated colitis
Salicyclic acid works as…
exfoliant to clear comedomes and has anti-inflammatory effects
- mild acne
Do not use topical retinoids at the same time with…
topical antibiotics
Adapalene (Differin) MOA
- potent comedolytic
- decreases microcomedome formation
Adapalene (Differin) cautions
- preg C
- caution in sensitive skin, ezcema, skin abrasions, sunburn
- avoid harsh soaps, cleansers, alcohol products
- ok in > 12 yrs
Tazarotene (topical retinoid) MOA
- normalize epidermal differentiation & reduce influx of inflammatory cells into skin
Tazarotene cautions
NOT SAFE IN PREGNANCY
