_Dermatologic_ Dry skin / mucus membrane + photosensitivity _Ophthalmogic_ Dry eyes / conjuctivitis _Musculoskeletal_ Joint + Muscle Pains --\> monitor ESR & Creatinine Kinase _CNS_ HA / Fatigue / Mood _TERATOGENIC_

11 - Acne Flashcards by Karlo Sison

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

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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

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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)

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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

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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

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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

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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

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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)

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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

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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

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Treatment Approach for Acne Vulgaris

Mild
Comedonal
White + blackheads

<10 Papules/Pustules

No Scarring

TOPICAL RETINOID

Adapalene
Tretinoin / Tazarotene

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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?

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Acne Therapy Pathway Choice

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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

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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

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Treatment Approach for Acne Vulgaris

Nodular / Conglobate

Multiple Nodules / Cysts

Extensive Scarring

ORAL TRETINOIN

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Topical Antibiotics
RX Agents for Acne

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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

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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

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ORAL ANTIBIOTIC

BPO

TOPICAL RETINOID

same as moderate treatment

ADAPALENE
Acne Treatment

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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

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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

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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

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Whiteheads = CLOSED Comedones

Blackheads = OPEN Comedones

occur after the obstruction of sebaceous gland

Classes of Anti-Acne

RX TREATMENTS

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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** ## Footnote **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** ## Footnote ***_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*

11 - Acne Flashcards

(41 cards)