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1

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

2

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

3

Adapalene
Class / MoA / Efficacy 

Retinoid
 (both RX & Only OTC Retinoid - 0.1% gel)

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

4

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

5

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

6

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

7

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

8

Pathophysiology of ACNE

Puberty = Onset of Androgen production

Effect on PiloSEBEACEOUS GLAND
produce MORE SebumKeratinized
--> obstruction of sebaceous gland (micromedone)

Can lead to:
Non-Inflammatory (white+blackheads)
or
Inflammatory Acne 
(from bacteria & pro-inflammatory mediators)

9

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

10

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

11

Treatment Approach for Acne Vulgaris

Mild
Comedonal
White + blackheads

<10 Papules/Pustules

No Scarring

TOPICAL RETINOID

Adapalene
Tretinoin / Tazarotene

12

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?

13

Acne Therapy Pathway Choice

14

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

15

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

16

​Treatment Approach for Acne Vulgaris

Nodular / Conglobate

Multiple Nodules / Cysts

Extensive Scarring

ORAL TRETINOIN

17

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

18

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

19

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

20

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

21

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

22

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)

23

Non-Inflammatory Acne

Whiteheads = CLOSED Comedones

 

Blackheads = OPEN Comedones
 

occur after the obstruction of sebaceous gland

24

Classes of Anti-Acne

RX TREATMENTS

RX Only

ISOTRETINOIN affects ALL CLASSES

 

25

Combination Therapy
for Acne

Commonly Used!

for Different Mechanisms of action
+
Limits ABx Resistance!

Commercially available or given as 2 seperate agents

26

Acne Distribution

Occurs at any site where there are SEBACEOUS GLANDS

FACE

BACK

CHEST

27

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

28

Classes of Anti-Acne Medications

OTC TREATMENTS

BPO Affects 3 of them

NONE AFFECT SEBUM PRODUCTION

29

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

30

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