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Module 6-Acne Vulgaris:
Terms in this set (22)
--Referred to as "acne", is a disorder of pilosebaceous follicles.
--Typically presents at ages 8-12 (often the 1st sign of puberty), peaks at 15-18, and resolves by age 25.
--Affects 90% of adolescents and affects races equally.
--Family history is often positive.
--12% of women and 3% of men will have acne until their 40's.
--In women it is not uncommon to have a first outbreak at 20-35.
--Acne affects mainly the face, neck, upper trunk and upper arms (where sebaceous glands are abundant).
--Begins with "clogged pores" (pores=pilosebaceous unit), aka comedones.
*Open comedones= "blackheads"
*Closed comedones= "whiteheads"
--Debris and bacteria collect in these clogged pores which then lead to inflammation: papules and pustules with erythema and edema.
--These pressurized follicles can rupture in the dermis, resulting in tender deep nodulocystic acne.
Skin exam findings:
--Numerous pustules, papules, open and closed comedones with some scarring.
Severe nodulocystic acne with presence of scarring.
Classification of Acne vulgaris:
--Classification of acne is based on the morphology.
*Comedonal: open and closed comedones
*Inflammatory: papules and pustules
*Nodulocystic: nodules and cysts
--It is equally important to describe the severity (each type can be mild to severe depending on the amount of acne) and note the presence of scarring for each pt.
Pathogenesis of Acne vulgaris:
--Related to 4 factors:
*Presence of hormones (androgens).
*Sebaceous gland activity (increased in presence of androgens).
*Plugging of the hair follicle as a result of abnormal keratinization of the upper portion (gives rise to comedones).
*P. acnes (bacteria) in the hair follicle (lives on the oil and breaks it down to free fatty acids which cause inflammation).
--Systemic and topical retinoids, systemic and topical antimicrobials, and systemic hormonal therapies are the main classes of treatment.
--Multiple agents are often used with activity against different pathogenic causes (eg, topical antibiotic plus retinoid).
--Use topical antibiotics with benzoyl peroxide to prevent the development of antibiotic resistance.
Acne scarring is difficult to treat, therefore aggressive prevention is important.
--Acne should be treated aggressively to avoid permanent scarring and cysts.
--Refer pt's with difficult to control acne or the presence of scarring to derm.
Common First-Line Treatments:
--Mild comedonal: topical retinoid, +/- topical benzoyl peroxide
--Mild papular/pustular: topical retinoid, topical antibiotics (clindamycin, erythromycin), topical benzoyl peroxide.
--Moderate papular/pustular: oral antibiotics with topical retinoid and benzoyl peroxide.
Common First-Line Treatments...cont:
--Moderate nodular without scarring: oral antibiotic with topical retinoid and topical benzoyl peroxide.
--Severe nodular: refer to a dermatologist for oral isotretinoin
--Scarring and keloids: refer to ta dermatologist for oral isotretinoin.
Topical retinoids--tretinoin, all trans retinoic acid:
--Topical retinoids are vitamin A derivatives.
--Used for acne vulgaris; photodamaged skin; fine wrinkles, hyperpigmentation.
--Pt's should be warned of common adverse effects:
*Dryness, pruritus, erythema, scaling
--Available as a cream or gel.
--Do not apply at the same time as benzoyl peroxide because benzoyl peroxide oxidizes tretinoin.
--Topical medication with both antibacterial and comedolytic properties.
--Available as a prescription and OTC, as well as in combinations with topical antibiotics.
--Pt's should be warned of common adverse effects:
*Bleaching of hair, colored fabric, or carpet.
*May irritate skin; discontinue if severe.
--Available as a cream, lotion, gel, or wash.
--Used to reduce the number of P. acnes and reduce inflammation in the inflammatory acne.
--DO NOT USE as monotherapy (often used with benzoyl peroxide to prevent the development of antibiotic resistance in the treatment of mild-to-moderate acne and rosacea).
*Erythromycin 2% (solution, gel)
*Clindamycin 1% (lotion, solution, gel, foam)
--Metronidazole 0.75%, 1% (cream, gel) is used in the treatment of rosacea.
Topical Acne Treatment--Side effects:
--Often irritating and can cause dry skin.
*When using retinoids or benzoyl peroxide, consider
beginning on alternate days. Use a moisturizer to
reduce their irritancy).
--Topical agents take 2-3 months to see effect.
--Pt's will often stop treatment too early due to "red, flakey" skin without improvement of their acne.
--Pt education is a crucial component to acne treatment.
--Tetracycline, doxycycline, minocycline.
--Use for moderate to severe inflammatory acne.
--Often combined with benzoyl peroxide to prevent antibiotic resistance.
--If the pt has not responded after 3 months of therapy with an oral antibiotic, consider:
*Increasing the dose.
*Changing the treatment, or
*Referring to dermatology.
Oral treatment--side effects:
--Tetracyclines (tetracycline, doxycycline, minocycline):
*Are contraindicated in pregnancy and in children < 8
*May cause GI upset (epigastric burning, nausea,
vomiting, and diarrhea can occur).
*Can cause photosensitivity (pt's may burn easier,
which can be easily managed with better sun
protection). Recommend sun block with UVA coverage
for all acne pt's on tetracyclines.
Oral tetracyclines--patient counseling:
--Major side effects:
*Tetracycline: GI upset, photosensitivity
*Doxycycline: GI upset, photosensitivity
*Minocycline: GI upset, vertigo, hyperpigmentation
--Pt's need clear instruction:
*If taking for acne, it is ok to take with food and dairy products for tolerability of GI side effects.
*Take with a full glass of water; avoids esophageal erosions.
*Tetracyclines do NOT interfere with birth control.
*It takes 2-3 months to see improvement.
--Pigmentation appears after months to years in a small percentage of pt's.
--First noticeable in the alveolar ridge, palate, sclera.
--Skin deposition can be brown or blue-grey. Blue-grey pigmentation can occur in scars.
--Skin pigmentation may not fade after discontinuation.
--Pt's on long-term minocycline should be screened; if seen on gums or sclerae, discontinue.
--A retinoic acid derivative, is indicated in severe, nodulocystic acne failing other therapies.
--Should be prescribed by providers with experience using this medication--not for NP's typically.
--Typically given in a single 5-6 month course.
--Isotretinoin is teratogenic and therefore absolutely contraindicated in pregnancy.
*Female pt's must be enrolled in a FDA-mandated
prescribing program in order to use this medication.
*Two forms of contraception must be used during
isotretinoin therapy and for 1 month after treatment
Androgens in Acne:
--In many post-adolescent women, antiandrogen therapy can improve acne:
*These women have hormonal acne; their serum
hormone levels are usually normal.
*Hormonal acne lesions are often perioral and along the
*Many women report a pre-menstrual flare.
--Not all women with hormonal acne are tested for hyperandrogenism.
*However, it should be considered in the female pt
whose acne is severe, sudden in onset, or associated
with hirsutism or irregular menses.
Hormonal acne--more examples:
--Inflammatory acne on the lateral and inferior face, especially along the jaw line.
Treatment of hormonal acne:
--Commonly used agents to treat hormonal acne:
*Spironolactone 50-100 mg po daily.
--The following oral contraceptives have been approved by the FDA for the treatment of acne: Yaz, Ortho Tri0cyclen, Estrostep.
--There is good evidence and consensus opinion that other estrogen-containing OCP's are also effective.
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