Acne EXAM III

Question 1

QUEST Process

Answer 1

QU: Ask questions about Symptoms, Onset, History, characteristics, Location, Aggravating and Remitting factors, Medication, Allergies

E: Establish if the patient is a candidate for self-care
S: Suggest appropriate treatment
T: Teach the patient

Question 2

Where are most of the sebaceous glands found?

Answer 2

Epidermis on hair folicles, oily preventing drying
Around the mouth
Back

Question 3

What are the causes of acne?

Answer 3

Androgen-stimulated
2. 1. Increases sebum production
2. Follicular hyperkeratinization
3. Colonization of Propionibacterium acnes
4. Release of inflammatory mediators

Question 4

What is a follicular occlusion within the pilosubecous unit?

Answer 4

Microcomedone

Question 5

How are non-inflammatory and inflammatory acne classified?

Answer 5

Non-Inflammatory: Comedones
Open (blackhead)
Closed (whitehead)

Inflammatory:
Papules
Pustules
Nodules
Cysts

Question 6

How is mild acne classified?

Answer 6

Mild: Open (blackhead) and closed (whitehead) Comedones and a few papules and pustules

Question 7

How is Moderate acne classified?

Answer 7

Comedones, more papules and pustules, minimal scarring
mainly comedonal or mainly inflammatory acne

Question 8

How is severe acne classified?

Answer 8

Comedones, even more papules and pustules + nodular abscesses - more excessive scarring

Question 9

What does scarring indicate?

Answer 9

Previous episodes of severe acne
-> may need more aggressive treatment

Question 10

When to refer a patient?

Answer 10

inflammatory acne (papules, pustules) with a risk of scarring

Question 11

Meaning of Keratolytic and Comedolytic

Answer 11

Keratolytic: too much keratin -> agents that soften the skin by loosening keratin and helping with exfoliation (removal of dead skin)

Comedolytic: breaks down power blockage by causing skin cells to slough away faster -> addresses RETENTION HYPERKERATOSIS

Question 12

Non-pharmacological treatment

Answer 12

-Shampoo, balanced diet, hydration, exercise (more blood flow, wash with warm water twice a day)

-not effective alone -> combine with pharmacological treatment

Question 13

What is the most effective pharmacologic treatment approach for acne?

Answer 13

Benzoyl Peroxide (topical antimicrobial)
-2.5-10% gel
-lotion
-creams
-pads, masks, cleansers

AE: Contact dermatitis, skin irritation, bleaching on clothing
AE often bc not the appropriate dose or formulation -> CHANGE

Question 14

Available doses for Benzoyl Peroxide

Answer 14

2.5% - 10%
10% (Rx)

Question 15

AE of Benzoyl Peroxide

Answer 15

AE: Contact dermatitis, skin irritation, bleaching on clothing
AE often bc not the appropriate dose or formulation -> CHANGE
-mild erythema and scaling but should subside in 1-2 weeks

Question 16

What patients should expect when using Benzoyl Peroxide?

Answer 16

-Frequency depends on mild peeling
-may experience mild erythema and scaling in the first 1-2 weeks
-allergic reaction with Rx: sudden erythema and vesiculation /vesicles filled with fluid)

Question 17

Direction Benzoyl Peroxide

Answer 17

-Do not apply for 15-20min after washing
-Apply 1-2 times daily at 2.5%
-Leave initial application on for only 15min then wash off and slowly increase
-Once product can be tolerated for 2 hours then can leave on overnight

-After 1-2 weeks can increase to 2-3x/day

Question 18

Counseling points for Benzoyl Peroxide

Answer 18

-avoid contact with clothes
-use sunscreen SP15
-expect it to work within 8 weeks - sebaceous glands turn over every other month -> so it takes time to unblock
-acne can get worse before it gets better! (pt may stop treatment - so warn them)
-Continue treatment after lesions have
cleared

Question 19

MOA for Beta-hydroxy acids (salicylic acid)

Answer 19

Keratolytic and comedolytic

-Contraindicated in diabetes and pts with poor circulation

dose: 0.5% to 5%

Question 20

Signs of toxicity for Beta-hydroxy acids

Answer 20

-N/V, dizziness, diarrhea
-loss of hearing, tinnitus
-lethargy (lack of energy)
-hyperpnea (breathing faster)
-psychic disturbances

-Contraindicated in diabetes and pts with poor circulation

Question 21

Dose for Beta-hydroxy acids

Answer 21

0.5% to 5%

Question 22

Indication of Beta-hydroxy acids

Answer 22

Hyperkeratotic skin

Question 23

Alpha-hydroxy acids

Answer 23

-glycolic, lactic, or citric acid
-not often used
-not enough evidence to support use for acne
-may be useful for scarring

Question 24

MOA Salicylic Acid

Answer 24

Mild comedolytic and keratolytic
-Unclog pores by causing peeling
-less effective alternative to tretinoin (Rx)
-Wash or cleansing agents used as adjuvant treatment
-dose: 0.5% to 2%

Question 25

What is the Rx alternative to Salicylic Acid considered to be more effective?

Answer 25

Tretinoin (Rx)

Question 26

Salicylic Acid Counseling

Answer 26

-If excessive peeling occurs, limit use to once daily or every other day -May cause sun sensitivity

Question 27

Sulfur

Answer 27

-Keratolytic & antibacterial in 3-10% -Resolution of existing comedones

Question 28

Counseling Sulfur

Answer 28

-Color and odor should be considered -dose: Applied in thin film to affected area 1-3x/day

Question 29

Which drugs can be combined with Sulfur for more efficacy?

Answer 29

-Resorcinol: enhances the effect of sulfur (cell turnover) (May experience dark brown scale with darker skin) -Sodium Sulfacetamide – destroys para-aminobenzoic acid (essential for bacterial growth)

Question 30

Adapalene Gel 0.1%

Answer 30

-Retinoid -MOA: Modulator of cellular differentiation, keratinization, and anti-inflammatory -used for mild acne! (moderate acne -> Benzoyl peroxide) -expect scaling and worsening of acne in the first 2 weeks (let patient KNOW)

Question 31

AE Adapalene Gel 0.1%

Answer 31

-the sensation of warmth or slight stinging right after application, -Burning, skin redness, dryness - dry skin (45%), -itching, scaling, and worsening of acne within the first 2-4 weeks of treatment

Question 32

Adapalene Gel 0.1% Counseling points

Answer 32

-Onset of 8 weeks -how to apply: wash the face and wait to dry --> apply on clean, dry skin at bedtime -> wash off in the next morning -don't apply on broken skin, lips, ankle of the nose, eyes -Avoid other alpha hydroxy or glycolic acid containing products -Hypersensitivity and Photosensitivity (use sunscreen)

Question 33

Drug class of Adapalene

Answer 33

Retinoid

Question 34

Which formulation is the most effective?

Answer 34

-Gels are most effective (astringent and stay on skin longer) -> but have a drying effect (EXAM!), non-greasy better for oily skin -Creams and lotions less irritating – Counteract drying and peeling – Alternative to gels -> for dry sensitive skin and in warm weather -AVOID ointments, it is occlusive and makes acne worse -start from low dose and increase if needed

Question 35

How is acne treated in people of color?

Question 36

How does pregnancy contribute to acne?

Answer 36

-high contribution due to hormonal change -acne medication should be stopped - it should resolve after pregnancy -the OTC products for acne are Category C (safe) but should be cautious when treating

Question 37

How to treat acne in neonates?

Answer 37

-in 20% of newborns, caused by mother's hormones -males > females -Begins at 6 weeks and clears at 4-6 months of age -Clean fingertips or soft washcloth with mild soap and water twice daily

Question 38

CAM Therapy (alternative medicine)

Answer 38

-Tea tree oil: antibacterial (staph aureus), one trial: as effective as benzoyl peroxide, slower onset -Oral Zinc: Alternative to tetracyclines, No phototoxicity

Question 39

Products for mild, moderate, and severe acne

Answer 39

mild: Adapalene (decreases formation of comedones, and inflammatory and noninflammatory acne lesions) moderate: Adapalene, Benzoyl peroxide severe: Tretinoin Rx, consider REFERRAL

Question 40

Products that also need sunscreen use

Answer 40

-Benzoyl peroxide -Salicylic acid -Adapalene

Question 41

Products to expect worsening before improvement

Answer 41

-Benzoyl peroxide -Adapalene