Acne Vulgaris and Perioral Dermatitis (PHARM)

Question 1

Definition of Acne Vulgaris

Answer 1

Common chronic inflammatory disorder of the sebaceous glands and hair follicles of the skin, occurs usually in teens (8-18 yrs), resolves by 25
-Uncommon to have first outbreaks 20-25 in women

Question 2

Key features of acne vulgaris

Answer 2

-Inflammatory lesions, papules, pustules, cysts
-Non-inflammatory lesions comedones
-Scarring
-Lesion count
-Face, neck, upper back and chest

Question 3

When diagnosing acne vulgaris, what are the two main conditions you need to rule out?

Answer 3

-Acne rosacea
-Perioral dermatitis

Question 4

What is the etiology of acne vulgaris?

Answer 4

-Increase activity of sebaceous glands in the face, upper back and chest
-Sensitivity to androgens
-Acne originates in the pileosebaceous unit

Question 5

What is a pilosebaceous unit?

Answer 5

-Consists of a hair follicle and a sebaceous gland that is connected to the surface of the skin by a duct through which the hair shaft passes

Question 6

What does the sebaceous glands produce?

Answer 6

-Sebum (a fat and wax mixture) to maintain proper hydration of the skin and hair

Question 7

Pathophysiology of acne vulgaris

Answer 7

1. Increase sebum production secondary to androgen
2. Abnormal follicular keratinization that causes a microcomedone (plug)
3. Proliferation of p. acnes
   (propionibacterium acnes gm+) causes free fatty acids leading to inflammation/irritation

Question 8

What happens when P.acne proliferates?

Answer 8

-Liberates lipases that hydrolyze triglycerides of the sebum to irritating free fatty acids and causes inflammation

Question 9

What are the open and closed comedomes?

Answer 9

-Open=black heads-oxidized
-Closed: whiteheads, precursor of inflammatory lesions

Question 10

Three classifications of acne

Answer 10

1. Comedonal: open and closed comedones
2. Inflammatory: papules and pustules
3. Nodulocystic: nodules and cysts, describe the severity and presence of scarring, pain

Question 11

Examples of topical corticosteroids in each potency

Answer 11

-High potency: clobetasol 0.05%
-Medium potency: betamethasone 0.05%
-Low potency: hydrocortisone 0.5% or 1%

Question 12

Example of Calcineurin inhibitor creams

Answer 12

-Tacrolimus 0.03, 0.1% (Protopic)
-Pimecrolimus cream 1% (Elidel)

Question 13

Risk factors for acne vulgaris

Answer 13

-Stress
-Premenstrual flares
-Improper cleansing of hair and skin
-Local friction
-Androgens, barbiturates, corticosteroid, haloperidol, lithium, phenytoin, oral contraceptives (levonorgestrel), bromides, iodines

Question 14

What are the treatment goals in acne vulgaris?

Answer 14

1. Reduce keratinization process
2. Decrease sebum production
3. Reduce microbial flora and decrease enzyme
   -takes 8-12 weeks to see improvement

Question 15

What is perioral dermatitis?

Answer 15

-Papules and pustules around mouth area
-No white or black heads are seen
-Can be caused by steroid or cosmetic cream

Question 16

Treatment for normalization of follicular keratinization

Answer 16

-Benzoyl peroxide
-Topical retinoids
-Oral Isotretinoin
-Hormonal therapy

Question 17

Treatment for antibacterial

Answer 17

-Antibiotics topical and oral
-Benzoyl peroxide

Question 18

Treatment for anti-inflammatory

Answer 18

-Benzoyl peroxide
-Topical retinoids
-Antibiotics
-Oral isotreinoin

Question 19

Treatment for decrease sebum production

Answer 19

-Oral isotretinoin
-Hormonal therapy

Question 20

Benzoyl Peroxide mechanism of action

Answer 20

-Antibacterial
-Reduces free fatty acids
-Prevents new comedones
-Reduces resistance of p.acnes when combined with topical and oral antibiotics

Question 21

Disadvantages of Benzoyl Peroxide

Answer 21

-Dryness and irritation redness for first 1-2 weeks
-Contact dermatitis so do a trial test first
-Apply benzoyl in AM and tretinoin in PM

Question 21

Topical Retinoid, Tretinoin mechanism of action

Answer 21

-Decreases cohesiveness of follicular epithelial cells
-Increases cell turnover results in explosion of existing comedones, unplugs the pore (most effective comedolytic)
-Thins skin
-apply HS
-Category C in pregnancy

Question 22

Disadvantages of Topical Retinoid

Answer 22

-Irritation, redness, peeling 2-10 days post usage
-Need suncreen
-Flare of acne appears 3-6 weeks and clears by 8-12 weeks

Question 23

What is Tazarotene?

Answer 23

-Synthetic retinoid, once metabolized it converts to tazarotenic acid
-Most irritating and potent
-Use sunscreen
-Don’t use with peroxide
-Use HS
-Category X in pregnancy

Question 24

What is topical Adapalene ?

Answer 24

-Synthetic naphthoic acid derivative with retinoid activity
-Inhibits arachidonic acid metabolism, less inflammatory
-Less irritating than retinoids
-More effective than retinoid
-Differin 0.1% at bedtime
-Category C in pregnancy

Question 25

Topical antibiotics mechanism of action

Answer 25

-Elimination of P.acnes from follicle
-Decrease fatty acids production
-Decrease inflammation by suppressing leukocyte chemotaxis
-Avoid using it as the only treatment to prevent bacterial resistance

Question 26

What are examples of topical antibiotics?

Answer 26

-Topical clindamycin (Rare case of pseudomembranous colitis)
-Topical erythromycin (safest in pregnancy, greatest resistance risk)

Question 27

Dapsone 5% gel

Answer 27

-sulfone
-may use in patients with sulphonamide allergy
-Anti-inflammatory effect
-Remote risk of hemolysis if positive for G6PD deficient
-Used in combination with benzoyl peroxide can lead to yellow orange discolouration of skin and hair
-can be used if cannot tolerate other treatments
-$$$

Question 28

What is the mechanism of action of oral antibiotics in acne?

Answer 28

-Eliminate P.acnes from follicle
-Tetracyline inhibit chemotaxis so anti-inflammatory
-Best for moderate to severe inflammatory acne
-Pair with Benzoyl peroxide and retinoid acid
-Switch antibiotics if no response in 6 weeks
-Max 3 months of use oral antibiotics
-Discontinue once acne improves

Question 29

What are the examples of oral antibiotics for acne?

Answer 29

-First choice: tetracycline, contraindicated in pregnancy

-First line: doxycycline, lipid soluble, lower dose to act as anti-inflammatory

-Used in patients unresponsive to tetracycline: minocycline

-Second line: erythromycin, used in pregnancy

-Occasional use: Trimethoprim-sulfamethoxazole, can result in Stevens Johnsons syndrome, to treat gram negative folliculitis

Question 30

What are the specific side effects of minocycline?

Answer 30

-Blue black color changes in scars (check inside the mouth)
-Drug induce lupus reversible in 16 wks
-Liver reactions

Question 31

Which drugs erythromycin interact with?

Answer 31

-By p450 inhibition: anticoagulants, digoxin, carbamazepine, statin, theophylline

Question 32

Mechanism of action for Isotretinoin ?

Answer 32

-Decrease sebum production this decrease p.acne and inflammation
-Normalize keratinization
-Helps in nodulocystic acne

Question 33

Side effects of Isotretinoin?

Answer 33

-Chapped lips+++
-Increase in cholesterol
-Abnormal liver function
-Increase intracranial pressure
-Corneal opacities, conjunctivitis
-Musculoskeletal pain
-Skeletal hyperostosis (excessive bone growth)
-DO NOT start if suicidal ideation
-Teratogenic (NEED two methods of contraception one month before, during and one month after therapy)

Question 34

What blood works are you monitoring for Isotretinoin?

Answer 34

-CBC
-LFT
-Lipids (baseline, 4, 8 weeks)
-Pregnancy negative before during after

Question 35

Hormonal therapy mechanism of action in acne ?

Answer 35

-Estrogen decrease the amount of circulating androgens
-Increase serum binding hormone globulin (so less testosterone)

-If hormone therapy not use, can use Spironolactone as a androgen receptor blocker