Benzoyl Peroxide
MoA / Efficacy
- *ANTIMICROBIAL**
- MILD* keratolytic / Comedolytic effects
Efficacy:
- *2.5%** is just as effective as 5% / 10%
- LOWER CONC are BETTER TOLERATED*
VEHICLE = determines the efficacy
Gels = MOST EFFECTIVE, BUT Most Drying
lotions / creams = intermediate
washes / cleaners = related to the contact time w/ skin
10-15 minutes
Inflammatory Acne
Papules
red bumps
Pustules
contains pus
Cysts /Nodules
deeper
after the obstruction of sebaceous gland
Increased proliferation of propionibacterium acnes
(NORMAL FLORA, body is responding to the oils)
producing chemotactic factors + proinflammatory mediators
Adapalene
Class / MoA / Efficacy
Retinoid
- *Strong Keratolytic / Comedoltic** effects
- MILD* anti-inflammatory effect
Highly Effective - non-inflammatory acne
still good for inflammatory acne - in combo w/ oral/topical anti-microbial
(both RX & Only OTC Retinoid - 0.1% gel)
NON-Pharmacologic TX
of ACNE
HYGIENE
Wash BID
Mildly drying soap / GENTLE abrasive washcloth
no evidence that frequency is more beneficial
unless in dirty environment
Shampoo DAILY if hair is oily
Limit TOUCHing Face
DO NOT POP/PICK lesions
ORAL Antibiotics
RX Agents for Acne
Doxycycline / Tetracycline / MinoCycline / Erythromycin
Moderate to SEVERE Inflammatory/Nodulocysitic Acne
or for EXTENSIVE acne –> on the back / hard to reach
- *Antimicrobial + Anti-Inflammatory**
- DECREASE* Free Fatty Acids on skin
Concern = ABx Resistance
use in a _limited time_ in combination w/ BPO or topical retinoids
ADR = Yeast infections in women
do NOT combine with ORAL & TOPICAL Abx
ISOTRETINOIN
iPLEDGE Program
TERATOGENIC = Preg CAT X
ALL Isotretinoin patients MUST ENROLL
Males + Females
Prescriber = document patient consent / education / monitoring
Pharmacy = Verify online eligibility/dispensing requirements
NOT Refilable
Do NOT share medication / DO NOT DONATE BLOOD
2 types of Contraception + MONTHLY Pregnancy test
Hormones + Hormone Modifiers
for Acne
- DECREASE*
- *Androgen-Induced Sebum** preduction
Combination Oral Contraceptives
Estrogens = IMPROVE
progestins = worsen
generally OCP’s IMPROVE, but MAY exacerbate acne
Spironolactone
Anti-Adrogenic: blocks androgen receptor
commonly used in WOMEN
Pathophysiology of ACNE
Puberty = Onset of Androgen production
Effect on PiloSEBEACEOUS GLAND
produce MORE Sebum + Keratinized
–> obstruction of sebaceous gland (micromedone)
Can lead to:
Non-Inflammatory (white+blackheads)
or
Inflammatory Acne
(from bacteria & pro-inflammatory mediators)
Benzoyl Peroxide = BPO
Considered the MOST effective OTC agent for:
INFLAMMATORY ACNE
some products are RX only, chosen by manufacturer
2.5% - 10%
NOT approved for those < 12 y/o
often used with antimicrobials because it limits ABx Resistance
Topical Retinoids / Prodrugs / Retinoid-Like-Drugs
RX Agents for Acne
Tretinoin / Adapalene RX / Tazarotene / Azelaic Acid
Mild-Moderate Inflammatory Acne & Non-Inflammatory
Comedolytic + Antiinflammatory
SLOW onset of efficacy –> can be WORSE first
ADR:
skin irritation / DRYING / erythema
Photosensitivity = use Sunscreen
choice of VEHICLE matters
Treatment Approach for Acne Vulgaris
Mild
Comedonal
White + blackheads
<10 Papules/Pustules
No Scarring
TOPICAL RETINOID
Adapalene
Tretinoin / Tazarotene
Patient Assessment QUESTIONS
for ACNE
How old are you?
How long have you had acne? What areas are affected?
What treatments/medications have you tried? Have you seen a physician about your acne?
Are you on any medications? What kind of work do you do?
What is your daily hygiene routine?
Do you use cosmetics?
Acne Therapy Pathway Choice
Salicylic Acid
Acne Treatment
OTC Agent = 0.5 - 2%
Stridex / PROPApH / FOSTEX
for Mild non-inflammatory acne & patients with intolerance
- *Keratolytic + possibly Antimicrobial**
- LESS effective than Adapalene*
Once Daily Dosing
local irriaation / systemic absorption
Isotretinoin ADR’s
- *Dermatologic**
- *Dry skin** / mucus membrane + photosensitivity
- *Ophthalmogic**
- *Dry eyes** / conjuctivitis
- *Musculoskeletal**
- *Joint + Muscle** Pains –> monitor ESR & Creatinine Kinase
- *CNS**
- *HA / Fatigue / Mood**
TERATOGENIC
Treatment Approach for Acne Vulgaris
Nodular / Conglobate
Multiple Nodules / Cysts
Extensive Scarring
ORAL TRETINOIN
Topical Antibiotics
RX Agents for Acne
Erythromycin / Clindamycin / Dapsone
use in COMBO with non-ABx to limit RESISTANCE
BPO
Mild - Moderate Inflammatory Acne
Antimicrobial + possible antiinflammatory
very effective, all similar efficacy
- only local skin irritation*
- do NOT combine with ORAL & TOPICAL Abx*
Resorcinol 2%/3%
acne products
Can ONLY be in combination with SULFUR
Clearasil / acnomel / rezamin
Use for mild / non-inflammatory acne
May cause:
Brown Scale on treated areas
Treatment Approach for Acne Vulgaris
- *Mild-Severe**
- *Nodular = Small nodules** <0.5cm
Few-Moderate Nodules + Cysts
Moderate Scarring
ORAL ANTIBIOTIC
BPO
TOPICAL RETINOID
same as moderate treatment
ADAPALENE
Acne Treatment
Retinoid - Both OTC & RX
1st Line Treatment for NON-INFLAMMATORY ACNE
NOT for use in _children < 12 y/o_
0.1% Gel = OTC now
0.1% cream/soluton/lotion or 0.3% gel or combo with BPO
= RX only
Acne Patient Education
Drugs Prevent & Treat
do NOT CURE acne
Onset of benefit in 4-12 weeks
continued therapy needed for continued benefit
Drugs will NOT resolve existing scars
but are effective in preventing new scars
If patient has a good response –> TAPER therapy
Isotretinoin
LAB ABNORMALITIES
Monitor @
baseline/after initiation/dose increases
LIPIDS
INCREASED TG’s
LIVER
INCREASED LFTs
- *CBC**
- *Anemia / Thrombocytopenia / leukopenia**
- if* significant muscle / joint pain
- *ESR** (Elevated sedimentation rate) + Creatinine Kinase (CK)
Non-Inflammatory Acne
Whiteheads = CLOSED Comedones
Blackheads = OPEN Comedones
occur after the obstruction of sebaceous gland
Classes of Anti-Acne
RX TREATMENTS
RX Only
ISOTRETINOIN affects ALL CLASSES
Combination Therapy
for Acne
Commonly Used!
for Different Mechanisms of action
+
Limits ABx Resistance!
Commercially available or given as 2 seperate agents
Acne Distribution
Occurs at any site where there are SEBACEOUS GLANDS
FACE
BACK
CHEST
Adapalene
Dosing / Adverse Effects
ONCE DAILY
ADR:
Skin irritation - drying / erythema
slow onset = can take WEEKS
photosensitivity = use sunscreen
Appears to be better tolerated vs other retinoids
Classes of Anti-Acne Medications
OTC TREATMENTS
BPO Affects 3 of them
NONE AFFECT SEBUM PRODUCTION
What is the FIRST LINE TREATMENT for
NON-INFLAMMATORY ACNE
ADAPALENE
only OTC Retinoid = 0.1% gel
Strong keratolyic/comedolytic
not for <12 y/o
Treatment Approach for Acne Vulgaris
Mild-Moderate
Mixed & Papular/Pustular
10-25 P/P
On face & trunk
minimal - no scarring
Topical Retinoid
Adapalene
+
Topical Antimicrobial
Erythromycin / Clindamycin
dapsone
Treatment Approach for Acne Vulgaris
Key notes for
OTC Acne Agents
Initial Therapy for Mild / Non-inflammatory Acne
ADAPALENE > Salicylic Acid
Initial therapy for Mild INFLAMMATORY Acne
BPO
use of BPO w/ topical antimicrobials LIMITS resistance
May use in combination w/ RX products
for moderate -> severe acne
4 Classes of ANTI-ACNE Medications
Reduction in Sebum production
Reduction in Abnormal Desquamation
- *Keratolytics / Comedolytics**
- decrease cohesiveness of folicular lining
- formation of NEW comedones** + LOOSEN formed ones
- *Anti-Microbial**
- decrease concentration of* P.Acnes
Anti-Inflammatory
Treatment Approach for Acne Vulgaris
- *Moderate**
- *Mixed + P/P**
>25 P/P
on face / trunk
Moderate Scarring
ORAL ANTIBIOTIC
Doxycycling / tetra cycline / minocycline
WITH OR W/O
BPO
important to prevent resistance of oral antibiotic
+
Topical Retinoid
Adapalene
Benzoyl Peroxide = BPO
Dosing
Start with 2.5% low dose
FIRST: Test on 1-2 small areas for several days = DAILY
possibility for ADVERSE REACTION
if single agent –> increase frequency to BID as Tolerated
if BID 2.5% is tolerated, but ineffective:
–> 5% strength, generally dont go to 10%
AAA –> 15-30 minutes AFTER cleansing
to allow skin to completely dry, to minimize local irritation
BPO
ADR’s
2 Types of Skin Reactions
Allergic Contact Dermatitis = 1-3%
this is why we do a TEST/SPOT dose
Redness / itching / hives even with low doses
possible systemic symptoms, DISCONTINUE = Sensitivity
Irritation / Erythema
DOSE RELATED = Can adjust dose
Avoid excessive SUNLIGHT / Use Sunscreen
may BLEACH CLOTHING
Isotretinoin = Oral Retinoids
RX Agents for ACNE
Targets ALL 4 SITES of Acne Treatment
indicated for:
Severe nodular/cystic acne = FIRST LINE
Mild-Moderate inflammatory acne URESPONSIVE to std treatment = third line
Efficacy: 70% –> prolonged remission may occur
but MANY ADR
Acne Pathogenesis
Microcomodome
forms from more keratin + excess sebum
- *Later Comodome**
- *whitehead** = shedded corneocytes / subum –> PLUG
- *blackhead** = forms an open comedo
- *Papule / Pustule**
- *propinobacterium acnes** proliferiate
- -> initiating a immune response
Cyst / Nodule
marked inflammatory response & rupture of the follicular wall
–> scarring
Sulfur
Acne Treatment
OTC Agent - Sulfur 3% - 10%
use for mild / non-inflammatory acne
typically not recommended
- *KERATOLYTIC**
- *1-3 times a day**
color / odor
possible comedogenic w/ prolonged use
Drugs that can cause ACNE
Can induce a inflammatory acne:
CORTICOSTEROIDS
systemic > topical > inhaled
Androgens / Anabolic Steroids / Progestin
contraceptives
- *CNS Active Drugs**
- *lithium / risperidone / sertraline**
AntiEpilepticDrugs
carbemazepine / phenytoin / topiramate / gabapentin
Cyclosporin
Acne TIME COURSE
Starts @ Puberty
may RELAPSE during pregnancy / menopause
NEW onset of acne in 20+ y/o
needs MEDICAL EVALUATION:
might be due to secondary cause / non-vulgaris acne (rosacea)
Acne in newborns
related to maternal hormones
DO NOT TREAT WITH MEDS = will SELF-RESOLVE