Acne Flashcards

(93 cards)

1
Q

What is acne?

A

A skin condition that occurs where there’s a hair follicle
Teenagers are prone to acne but so are adults (there is also neonatal acne)
90-100% of people experience acne at some point in their life

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2
Q

What are the peak ages for acne?

A

14-19 years

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3
Q

Does acne resolve?

A

Most of the time it will resolve before the age of 25 but it can persist

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4
Q

Where do lesions appear?

A

Face, neck, check, back (upper back and upper chest)

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5
Q

What are aggravating factors of acne?

A

Stress/emotions (range of extreme emotions)
Family history
Diet (possibly - low glycemic index, low levels of processed sugar, more protein may lead to less acne)
Medications (occlusive agents)
Environmental factors
Hormones

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6
Q

How does acne affect people?

A

It can have significant psychological morbidity

It’s a visible condition so people are often self-concious about it

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7
Q

Describe the pathology of acne?

A

There are 4 major stages:

  1. Increased follicular keratinization (sticky plug that forms at the top of the follicle and blocks it)
  2. Increased sebum production (due to hormone changes)
  3. Bacterial (Propionibacterium acnes) lipolysis of sebum triglycerides to free fatty acids
  4. Inflammation (redness and swelling)
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8
Q

What are the non-inflammatory lesions?

A
Closed comedones (whitehead)
Open comedones (blackhead)
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9
Q

Describe a blackhead

A

Open comedone - the sebum is exposed to oxygen and light, which turns it dark
The follicle is still open

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10
Q

Describe a whitehead

A

There’s a layer of tissue or epithelial cells cover the trapped sebum underneath

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11
Q

How long does it take before a close comedone appears?

A

5 months

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12
Q

What are the inflammatory lesions?

A

Papules
Pustules
Nodules
Cysts

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13
Q

What is a papule?

A

It involves the epidermis and the dermis
This lesions extends deep within the layers of the skin
It is often a small, pink/reddish bump that is tender to the thouch (they’ve gone nerve deep)
The opening is still closed

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14
Q

What is a pustule?

A

A pus-filled papule

Often red and inflamed at the base

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15
Q

What are the 3 types of acne scars?

A

Depressed (classic icepick, boxed, rolling)
Hypertropic (aka keloidal; it’s a raised scar due to hyperproliferation)
Atrophic
There can also be pigmentary alteration

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16
Q

What are the different types of acne?

A
Drug-induced acne
Neonatal acne
Acne conglobata
Acne fulminans
Contact acne
Endocrine acne
Acne mechanica
Acne excoriee
Acne rosacea
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17
Q

Describe drug-induced acne

A

It can be a side effect (ask patients if they’ve been on any new medications recently)
It often has a very consistent presentation (there isn’t a variety of close and open comedones, there isn’t a variety in size)

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18
Q

Describe neonatal acne

A

Presents usually in the first 2-3 months of life
Affects more boys than girls
Might be due to the transfer of maternal androgens
We do not treat this (self-limiting)
Infants who have neonatal acne may have more severe form of acne when they’re in their teens

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19
Q

Describe acne conglobata

A

A very serious form of acne
Nodulocystic
Can be extremely painful

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20
Q

Describe acne fulminans

A

Very serious form of acne
The nodules and cysts ulcerate
There are often systemic symptoms (joint pain, fever, muscle pains)

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21
Q

Describe contact acne

A

Can occur when you come into contact with an occlusive agent (e.g., oil-based cosmetic, hair bangs, industrial agents such as aerosolized oils)

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22
Q

Describe endocrine acne

A

Related to a syndrome in which there’s androgen production or an off balance of hormone production
Sometimes occurs in females with polycystic ovarian syndrome

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23
Q

Describe acne mechanica

A

Localized acne from physical stress (e.g., bangs, bike helmet, etc.)

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24
Q

Describe acne excoriee

A

The patient will pick at the comedones that it actually ends up in chronic erosions

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25
Describe acne rosacea
Generally appears later in life (over 30 years) Redness, inflammation Capillaries are close to the surface (spider veins) Sometimes the patient also has eye symptoms (red, gritty eyes) Certain things can cause a flare (sun, extreme temperatures, spicy foods, alcohol) It is important that the patient seeks treatment for the condition because there's a potential for negative side effects (the tissue can become so inflamed that the patient's nose will enlarge and appear red; it's very difficult to return it back to normal)
26
What is perioral dermatitis?
Treated very similarly to acne More of an inflammatory condition Specifically around the chin and nose area
27
What is gram negative folliculitis?
Lesions have a sudden onset Often mistaken for flares of acne Treated slightly different
28
How is acne classified?
Mild Moderate Severe
29
Describe mild acne
Many comedones Few to several papules and pustules No noodles or scarring Under 50% of affected area is involved
30
Describe moderate acne
Numerous comedones, papules and pustules Few nodules may be present Scarring possible or may be present Over 50% of the affected area is involved
31
Describe severe acne
``` Numerous comedones Numerous and extensive papules and pustules Nodules and cysts are extensive Scarring is probable or present Entire area is involved ```
32
What are red flags of acne?
Evidence of scarring Moderate to severe acne Signs and symptoms of infection Acne is drug-induced Symptoms consistent with endocrinopathy (e.g. POS) Atypical presentations (e.g., rosacea) Patients who are non-responsive to non-prescription therapy
33
What kind of acne is self-treatable?
``` Mild-moderate acne vulgaris, contact ance and acne mechanica Only if: onset age is between 12-25 no scarring or risk of scarring presentation is typical ```
34
What are the goals of therapy?
1. Alleviate symptoms by decreasing the number and severity of lesions 2. Slow progression of signs and symptoms 3. Limit duration and reoccurrence 4. Prevent long-term disfigurement associated with scarring and hyperpigmentation 5. Alleviate psychological distress 6. Avoid factors that exacerbate acne 7. Minimize treatment failure due to poor compliance 8. Educate patients with emphasis on realistic expectations (important due to media claims)
35
What is some non-pharmacological advice for the treatment of acne?
Wash face with mild soap (Dove soap) or soapless cleanser (cetaphil, spectrogel) no more than twice a day (no more than twice a day) Avoid vigorous scrubbing Be careful when shaving Shampoo hair regularly and keep off face Don't pop, pick at, or manipulate lesions Minimize cosmetic use Use cosmetic products, moisturizers and sunscreens that are oil-free Discontinue or avoid aggravating factors Eat a well balanced diet and drink lots of water Try to minimize stress
36
How do the pharmacological treatments work?
``` They do one or more of the following: Normalization of follicular keratinization Reduce P. acnes growth Reduce sebum production Reduce inflammatory process ```
37
What products normalize follicular keratinization?
``` Topical BPO (available without prescription) Topical SA/sulphur/resorcinol (available without prescription) Topical retinoid Retinoid analogues Oral isotretinoin Oral contraceptives Topical/oral antibiotics Azelaic acid ```
38
What products reduce P. acnes growth?
Topical BPO (available without prescription) Oral isotrenoin Topical/oral antibiotic Azelaic acid
39
What products reduce sebum production?
Oral isotrenoin Oral contraceptives Oral anti-androgens
40
What products reduce inflammatory processes?
``` Topical BPO (available without prescription) Retinoid analogs Oral isotrenoin Topical/oral antibiotics Azalea acid Oral anti-androgens ```
41
What are formulations available for acne treatment?
``` Gel Lotion Cream Bars and washes Microsphere formulation ```
42
Describe gel formulation
Acetone/alcohol or water based Acetone/alcohol good for very oily skin Water based gels are better for oily but sensitive skin Gels have greatest efficacy
43
Describe lotion formulation
Good for all skin types, especially sensitive Have lower incidence of side effects as compared to gels Second best with respect to efficacy Spreads well over large and hairy areas
44
Describe cream formulation
Good for dry skin | Less effective than lotions and gels
45
Describe bars and washes
Can be used by all skin types | Last effective as there is less contact time
46
Describe microsphere formulations
Microspheres localize in the hair follicle and releases medication over time They have increased tolerability due to the lower concentration in skin Good for sensitive skin
47
What are some non-prescription acne products?
``` Benzoyl peroxide Salicylic acid Sulfur Resorcinol Glycolic acid Various cleansers ```
48
Describe salicylic acid
Mild comedolytic and keratolytic Indicated for mild acne when BPO is not tolerated (second line) OTC products contain 0.5-2.0% SA Applied OD to BID Generally takes 6-8 weeks of use to see improvement Maintenance therapy is required SE: redness, peeling, stinging
49
Describe sulfur
Comedolytic and keratolytic Third line agent Often combined with SA or resorcinol to increase its effects Maintenance therapy is required Offensive odor, noticeable colour and comedogenic with continued use
50
Describe resorcinol
Mild keratolytic Has little effect on its own Usually used on combination with salicylic acid and sulfur SE: dark brown scales on dark-skinned patient
51
Describe glycolic acid AHA 8%
Used alone or as a base for topical antibiotic preparations (clindamycin) Available as Reversa or Neostrata Less skin irritation than SA (but probably not as effective)
52
Describe benzoyl peroxide
Well absorbed through stratum corner and concentrates in the pilosebaceous unit 3 actions that treat noninflammatory and inflammatory acne: -primarily works as an antibiotic (slowly releases oxygen), does not lead to resistance -normalizes follicular keratinization -decreases inflammation Good first choice for treatment of non-inflammatory or mild inflammatory (OTC) Used in combination with topical retinoid and topical AB to treat mild-moderate acne Used in combination with topical retinoid and oral AB to treat moderate and moderate-severe acne
53
What are the strengths of BPO available?
Non prescription strengths: 2.5, 4 and 5% Prescription strengths: 8, 10, 15 and 20% Start low and work up
54
What are the side effects of BPO?
Irritant dermatitis, redness, scaling, dryness, itching May cause photosensitivity, bleaching, door on clothing, bed sheets OD to BID In rare cases, it can cause contact dermatitis
55
What are the self-care treatment approaches?
Start low and go slow Usually start with 2.5 or 4% BPO water based product Ineffective after 6-8 weeks: increase to 5% BPO water based products Ineffective after 6-8 weeks: change to BPO acetone/alcohol gel Ineffective after 6-8 weeks: refer to doctor
56
What are key counselling points on topical acne products?
Apply to the entire affected area, not just to the lesions (do not spot treat) Must be used regularly Skin may actually worsen before it improves (this is important for patient education) Allow 6-8 weeks before assessing improvement; may take 8-12 weeks to see full benefit
57
What are counselling points for the application of topical acne?
Wash skin with mild soap/soapless cleanser Pat skin dry (applying to wet skin can irritate skin - can suggest waiting 20-30 minutes to lessen skin irritation) Apply pea sized amount Wash hands before and after application Avoid washing area for 1 hour after application If using other skin products, do not apply at the same time, wait at least an hour following application Only use as directed - not more than recommended Address missed doses even though topical Avoid applying in and around the eyes, lips, inside the nose, or on sensitive areas on neck Don't apply on sunburned or broken skin Don't use other acne products or products that will further irritate the skin - alcohol containing, abrasive, etc.
58
What are prescription products that are available?
``` BPO Azalea acid Topical retinoids and retinoid analogues Topical antibiotics Oral antibiotics Hormone replacement therapy Isotretinoin ```
59
Describe Azelaic acid
Available as 15% gel in Canada and 20% cream in US Useful in treatment of mild to moderate acne in patients wh don't tolerate BPO or tretinoin Useful in treating post-inflammatory hyperpigmentation Applied BID SE: burning, pruritis, stinging and tingling
60
What are the indications for topical retinoids and retinoid analogues
First line treatment for comedian only acne and mild to moderate inflammatory acne Use by itself to treat comedonal only mild acne Use in combination with topical AB with or without BPO to treat mild to moderate inflammatory acne Use in combination with oral AB with or without BPO to treat moderate to moderate-severe acne Essential part of maintenance therapy
61
Describe topical retinoids and retinoid analogues
Directions: all applied OD SE: itching, stinging, redness, peeling, photosensitivity, skin discolouration Makes skin more susceptible to dryness and cold temperature Best to avoid in pregnancy Don't use with isotretinoin (important)
62
What are some antibiotics used for the treatment of acne?
Clindamycin 1% (solution, gel) - apply BID Erythromycin 3%/BPO 5% (gel) - apply BID Clindamycin 1%/BPO 5% (gel) - apply OD HS Erythromycin 2% with sunscreen (gel) - apply BID
63
Describe the use of topical antibiotics for acne
Used to treat mild to moderate inflammatory acne in combination with topical retinoid with or without BPO Avoid the use of these agents alone Combination with oral antibiotic is not recommended Most products are applied BID SE: erythema, dryness, peeling of the skin and stinging Avoid if allergic to oral antibiotic from same class Patients with colitis should avoid clindamycin
64
Describe topical clindamycin
Lincosamide antibiotic Has a potent action, lack of significant systemic absorption Monotherapy should be avoided due to the development o resistance Adverse effects: dryness, burning, itching, scaliness or peeling of skin (lotion solution); erythema (foam, lotion, solution); oiliness (gel, lotion) Clindamycin has been reported to cause pseudomembranous colitis (rare) Use with caution with atopic individuals
65
What are contraindications for topical clindamycin?
Allergy to clindamycin, lincomysin Previous C. difficile-associated diarrhea Inflammatory bowel disease (enteritis, ulcerative colitis)
66
When dispensing topical antibiotics, what should be watched out for?
``` Compounding instructions prior to dispensing to patient Storage instructions (at pharmacy and for patient) Expiration date ```
67
What are available oral antibiotics for the treatment of acne?
``` Tetracyclin (capsule) Minocycline (capsule) Doxycycline (tablet and capsule) Erythromycin (tablet and capsule) Sulfamethoxazole/trimethoprim (tablet) ```
68
What are the indications for oral antibiotics?
Treatment-resistant forms of mild-moderate inflammatory acne First line treatment for moderate-severe acne in combination with topical retinoid with or without BPO Used for scarring acne if patient won't take isotretinoin
69
What are the guidelines for oral antibiotics?
Avoid monotherapy Combine with topical retinoid Add BPO to reduce resistance Use the same antibiotic if additional courses are required If antibiotic treatment ineffective, try a different antibiotic
70
What is the duration of use and side effects of oral antibiotics?
Duration of use: no longer than 3-6 months SE: GI upset, nausea/vomiting, diarrhea, headache Tetracyclines: photosensitivity, esophagitis (rare) Minocycline: dizziness, drowsiness, ataxia, discolouration of mucous membranes and drug-induced lupus (rare) Doxycycline and erythromycin: GI SE Sulfamethoxazole/trimethoprim: Steven-Johnson syndrome (rare)
71
What is important to watch for with tetracyclines?
Avoid during pregnancy/lactation Avoid in children under 8 years of age Watch for drug-drug and drug-food interactions
72
What is important to watch for with oral antibiotics?
Resistance is common especially with erythromycin | SMX/TMP is useful if acne is resistant to other antibiotics
73
What are agents available for hormone therapy?
``` Drospirenone/ethinyl estradiol Cyproterone acetate/ethinyl estradiol Norgestimate/ethinyl estradiol Levonorgestrel/ethinyl estradiol Spironolactone These are all available as tablets. These are all oral contraceptives (except spironolactone) ```
74
What are the indications for oral contraceptives for the treatment of acne?
Mild or moderate acne in combination with topical therapies in females who desire contraception, or have irregular menses Adult onset acne in females that has been treated unsuccessfully with other agents Severe acne for females on isotrentinoin
75
What are the side effects and considerations for the use of oral contraceptives to treat acne?
SE: nausea/vomiting, weight gain, breakthrough bleeding, breast tenderness and headache Advise patients about the risks of smoking while on OC To be used in females only Don't use if pregnant/lactating
76
What are the indications for androgen-receptor blockers? What are the side effects?
Indicated in females who have adult onset acne that has been treated unsuccessfully with other agents Women who suffer from acne due to an excess of androgen hormones Agents include cyproterone acetate, finasteride, flutamide and spironolactone Only use in females Avoid in pregnancy SE: dizziness, drowsiness, nausea, vomiting, diarrhea, headache, menstrual irregularities Hyperkalemia with spironolactone
77
What are the benefits of isotretinoin?
It induces a prolonged remission | In 85% of cases, it will result in a clinical cure of acne because it addresses all 4 factors of the pathophysiology
78
What are the indications for isotretinoin?
``` Severe nodulocystic acne Treatment failures Scarring Frequently relapsing acne Cases where psychological distress is sever ```
79
Describe the use of isotretinoin
Duration of treatment: 12-16 weeks Can take 2-3 months for optimal effects Patients may experience an acute exacerbation in the first 7 to 10 days of treatment Can produce long-term drug-free remission Used as a single drug therapy except for females where an oral contraceptive is strongly recommended
80
What are the side effects of isotretinoin?
SE are dose related Common SE: cheilitis (inflammation and cracking around the lips), facial redness, dry skin/itching, dry mouth, nose, eyes, photosensitivity Other SE: depression, decreased night vision, joint/muscle pain, severe headaches, hair thinning
81
What are contraindications for isotretenoin?
Relative CI: hyperlipidemia, diabetes mellitus, severe osteoporosis Absolute CI: breastfeeding, pregnancy (teratogenic), previous allergic reaction, hepatic and renal insufficiency Patients should be screened for depression and before starting treatment and monitored throughout
82
What tests are required before the initiation of treatment with isotretinoin?
``` Lipid and blood glucose levels Liver function tests Complete blood count and differential Pregnancy (requires 2 negative tests) Signs of depression ```
83
What should be avoided when being treated with isotretinoin?
``` Avoid giving blood transfusions Avoid alcohol (relieve the stress on the liver) Avoid vitamin A or beta-carotene supplements Avoid tetracyclines (in rare cases, can cause intercranial hypertension) Avoid in patients under 12 years of age Avoid other topical acne products, hair waxing, laser treatment and dermabrasion ```
84
What should be prescribed for the treatment of mild acne (comedonal)?
Topical retinoid
85
What should be prescribed for the treatment of mild-moderate acne (papular)?
Topical retinoid + topical AB +/- BPO
86
What should be prescribe for the treatment of moderate acne (papular/pustular)?
Topical retinoid + oral AB +/- BPO Discontinue AB when inflammatory lesions resolve (usually no more than 6 months) Use topical retinoid to maintain remission post AB
87
What should be prescribed for the treatment of severe acne (nodulocystic)?
Oral isotretinoin
88
What should be prescribed for maintenance of mild to mild-moderate acne?
Topical retinoid
89
What should be prescribe for maintenance of moderate to moderate-sever acne?
Topical retinoid +/- BPO
90
What is the treatment approach in pregnant patients?
Non-pharmacological treatment is first line If pharmacological treatment is deemed appropriate by physicina: -topical BPO, eythromycine and clindamycin considered safe -no agents have been studied in pregnancy therefore weigh the risks vs benefits -erythromycin is the safest oral antibiotic
91
What are the short term monitoring parameters?
Lesion count: decreased by 10-25% within 4-8 weeks or over 50% within 2-4 months Comedones: resolve by 3-4 months Inflammatory lesions: resolve within a few weeks Anxiety or depression: control or improvement within 2-4 months
92
What are long term monitoring parameters?
Progression of severity: no progression of severity Recurrent episodes: lengthening of acne free periods Scarring and pigmentation: no further scarring or pigmentation
93
What is the role of a pharmacist in the treatment of acne?
Dispel myths related to acne Educate patients about what causes acne Counsel patients on proper skin care Inform patients about treatment options and expected outcomes Educate patients on products including proper use, benefits and side effects Identify at risk of scarring and refer Identify patients who have been unresponsive to therapy and refer Monitor therapy particularly oral antibiotic use in order to prevent resistance Encourage patients to persist with therapy long enough to see benefit