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Skin problems Acne. At the end of this chapter, students will be able to Identify the causes and risk factors for acne Determine acne severity Choose appropriate management for acne based on patient condition and acne severity.
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Skin problems Acne
At the end of this chapter, students will be able to • Identify the causes and risk factors for acne • Determine acne severity • Choose appropriate management for acne based on patient condition and acne severity. • Describe the common and important adverse of acne medications. • Identify the necessary laboratory monitoring parameters for patients on acne medications
Case • L.Y., a fair-skinned, 15-year-old, Caucasian girl asks a pharmacist the best way to treat “zits.” The problem began when she was 13 and has progressively worsened. • At first, lesions occasionally appeared on her chin and forehead; now she consistently has about two to four lesions, which have spread to her cheeks and nose.
She is increasingly frustrated and wants to see a dermatologist, but her mother insists acne “is just part of being a teen.” she uses a nonprescription 10% benzoyl peroxide gel as needed on lesions when her acne “gets really bad,” but doesn’t think it works very well. She tried a “medicated” soap in the past, but stopped because it dried out her skin. • L.Y. has no medical problems or drug Allergies and takes no chronic prescription medications. • She has had normal menstrual periods since 12 y
Both her older brothers have acne, one mild and one severe. • L.Y. denies alcohol, tobacco, or illicit drug use. • She wears a sweatband around her head while playing tennis and uses a hair-styling gel. • Examination reveals one pustule on L.Y.’s forehead, three papules on her cheeks and chin (which are covered with makeup), a well-healing area on her nose, and no open comedones or nodules. Her skin is slightly oily. Her chest, back, and arms are clear. She has no facial hair, and her voice is normal
What subjective and objective data support a diagnosis of acne? • Acne is a chronic inflammatory disease involving the pilosebaceous unit. It is typified by the eruption of a comedo within the follicle, which is preceded by a microcomedo. • The spectrum of acne lesions • Non inflammatory open or closed comedones (blackheads and whiteheads) • Inflammatory lesions, which may be papules, pustules, or nodules. • Lesions are most likely to occur on the face, neck, chest, and back, where there is a higher concentration of sebaceous glands.
Mild inflammatory acne lesions with comedones and few papules and pustules. Non inflammatory acne lesions consisting of open and closed comedones. Moderate inflammatory acne lesions with comedones, several papules and pustules, and few nodules. Severe inflammatory acne lesions with comedones, several papules and pustules, multiple nodules, and scarring. https://jamanetwork.com
What potentially contributing factors are present? Sunlight exposure :ultraviolet light may make sebum more comedogenic, but some of the visible wavelengths may reduce the follicular bacterial population Diet:studies have investigated lower milk intake and lower glycemic load diets for potential benefit in acne…. Reference: Applied Therapeutics, 10th ed, Koda-Kimble, 2013
Non pharmacological therapy • Twice-daily washing with warm water and a mild facial cleanser suffices; poor hygiene does not cause acne, and aggressive skin washing and abrasive cleansers needlessly traumatize the skin. • To minimize scarring, patients must resist squeezing or picking at acne lesions. • Drugs known to cause acne, oil-based cosmetics, and other known precipitants should also obviously be avoided.
Oil-free, noncomedogenic moisturizers formulated for facial skin can improve the penetration and tolerability of many topical acne drugs by improving the skin’s hydration, especially in patients with sensitive skin. • Many such moisturizers also contain sunscreen, which is recommended for use with many of the available acne therapies. • Dermatologists may use procedures such as surgical comedo extraction, chemical peels, and microdermabrasion as adjunct therapy to improve cosmetic appearance.
Current guidelines recommend drug therapy over light and laser therapies because of less stringent clinical testing for devices versus drugs, concern about long-term effects of therapies aimed at sebaceous gland function, and the inadequate research done on light and laser therapies to date. • well-established carcinogenic and photoaging effects of ultraviolet exposure. Moreover, inflamed skin is more susceptible to the damaging effects of ultraviolet light. Patients taking tretinoin may show heightened sensitivity • Acne scarring is treated with various microsurgical techniques as laser therapy, chemical peels, and tissue augmentation.
Shaving • Males should try both electric and safety razors to determine which is more comfortable for shaving. When using a safety razor, the beard should be softened with soap and warm water or shaving gel. • Shaving should be done as lightly and infrequently as possible, using a sharp blade and being careful to avoid nicking lesions. Strokes should be in the direction of hair growth, shaving each area only once.
Comedone Extraction • Comedone extraction is useful and painless and results in immediate cosmetic improvement although it has not been widely tested in clinical trials. Pretreatment with a peeler for 4 to 6 weeks often facilitates the procedure. • Following cleansing with hot water, a comedone extractor is placed over the lesion and gentle pressure applied until the contents are expressed. This removes unsightly lesions, preventing progression to inflammation. • A physician should be consulted if this technique is too difficult for the patient to manage. Since the follicle is difficult to remove completely, comedones may recur between 25 and 50 days following expression
Prevention of Cosmetic Acne • Persistent low-grade acne in women after their mid-20s is frequently caused by heavy cosmetic use. Adolescent acne in younger women may be exacerbated with makeup overuse. • Advise patients to stop using oil-containing cosmetics and avoid cosmetic programs that advocate applying multiple layers of cream-based cleansers and cover-ups.
The second step is generally a “toner” or “refresher” which is usually water- or alcohol-based and might contain medicated ingredients such as α-hydroxy acids (e.g., glycolic acid), which are mild comedolytic agents, or even glycerin as a humectant. • How to Use Topical Preparations • Topical preparations should not be applied to individual lesions but to the whole area affected by acne to prevent new lesions from developing, using care around the eyelid, mouth, and neck to avoid chafing. Lotions should be applied with a cotton swab once or twice a day after washing or at bedtime if they leave a visible residue.
Pharmacological therapy Reference: Applied Therapeutics, 10th ed, Koda-Kimble, 2013
Pharmacological therapy • normalizing follicular keratinization(e.g., retinoids, benzoyl peroxide to some degree, azelaic acid) • decreasing sebum production (e.g., isotretinoin, hormonal therapies) • suppressing P. acnes(e.g., antibiotics, benzoyl peroxide, azelaic acid, systemic isotretinoin) • reducing inflammation (e.g., antibiotics, retinoids). • Topical therapy is generally preferable for mild to moderate acne.
Mild acne TOPICAL RETINOIDS • analogs of vitamin A • normalize keratinization by decreasing horny cell cohesiveness and stimulating epidermal cell turnover…These actions combine to unplug follicles and prevent microcomedo formation • Retinoids also reduce inflammation by inhibiting the production of inflammatory mediators. • Topical retinoids have NO antibacterial effect • Are preferred therapy in mild acne cases with mostly non inflammatory lesions.
They are combination therapies for moderate to severe acne, and first-line treatment to maintain remission of acne once it is controlled. • They are usually applied once daily; bedtime administration is standard because older formulations rapidly degrade in ultraviolet light. • Common adverse effects include skin irritation, peeling, erythema, and dryness. • Patients must use a sunscreen because the newly exfoliated skin burns easily.
Concomitant use of a gentle moisturizing cream with sunscreen may increase patient adherence by relieving skin irritation secondary to retinoid use and providing photosensitivity protection. Patients should recognize that acne may initially worsen during therapy, although this rarely occurs if topical antibiotics are also being used • Benzoyl peroxide inactivates some formulations of tretinoin, so they should not be used together, or should at least be applied at different times (morning and evening, respectively).
However, benzoyl peroxide can be used in combination with either adapalene or tazarotene to provide additive benefit….(0.1% adapalene/2.5% benzoyl peroxide gel, Epiduo, and 0.025%tretinoin/1.2% clindamycin gel, Ziana) • Tazarotene is pregnancy category X (contraindicated in pregnancy), and all topical retinoids should be avoided during pregnancy because systemic agents are so notoriously teratogenic and alternative acne therapies have better characterized pregnancy risk potential.
Same side effects Reference: Applied Therapeutics, 10th ed, Koda-Kimble, 2013
Benzoyl peroxide • Topical works as: • An antibacterial • Relieve comedones by exfoliating and opening pores through keratolytic activity. • The lipophilic nature of benzoyl peroxide allows it to penetrate to the site of acnes growth and release oxygen free radicals that damage bacterial cell walls. • The irritant effects of benzoyl peroxide also cause vasodilation and increase blood flow, which may hasten resolution of inflammatory lesions.
Benzoyl peroxide is often paired with antibiotics to prevent the development of antibiotic resistance. • Benzoyl peroxide is available over the counter and by prescription in a variety of dosage forms (cleansers, lotions, creams, gels, foams…) and concentrations (2.5%–10%). Combination products exist with adapalene, erythromycin, clindamycin, salicylic acid, and sulfur. • It is usually applied to the affected area once or twice daily. Because cleansers are easy to apply and leave on for a few minutes in the shower.
Topical salicylic acid • a concentration-dependent keratolytic but less effective than topical benzoyl peroxide or tretinoin. • It may be useful in patients with mild acne who cannot tolerate other comedolytics and may augment the effectiveness of other agents when used in combination. It is available • in nonprescription creams, lotions, and gels in strengths ranging from 0.5% to 2% (higher strength products are intended for other uses, such as wart removal).
Sulfur preparations • Have mild comedolytic properties, but can produce skin discoloration and odor, and may be comedogenic with continued use. • sulfur products succeed for some patients who have failed first-line therapies. They are available in strengths of 2% to 10%, often in combination products with resorcinol or benzoyl peroxide.
Moderate to severe acne • Guidelines state that moderate acne should be treated with a topical retinoid coupled with a topical or oral antibiotic • Topical Clindamycin and erythromycin are commonly used agents. • Topical antibiotics are usually applied once or twice daily for 3 months • Oral administration is preferred over topical if lesions are widespread or in difficult-to-reach areas
Doxycycline is most convenient and effective • Tetracyclines cannot be prescribed for children younger than 9 years of age because of potential impairment of bone growth and discoloration of forming teeth. Pregnant women must avoid tetracyclines because of bone growth effects on the fetus. • Erythromycin is associated with higher rates of resistance, but can be useful in patients who cannot use the drugs previously mentioned, such as pregnant women.
Clindamycin is not used systemically to treat acne owing to high rates of diarrhea and the risk of pseudomembranous colitis. • If gram-negative folliculitis is suspected, oral trimethoprim/ sulfamethoxazole should be considered • Isotretinoin: reduces P. acnes colonization by reducing the production of sebum, which P. acnes requires for survival, dose up to 40 mg twice daily
Other options • Hormonal therapies: treatment of moderate acne in female , reducing sebum production, response require 3 to 6 months. • Combination Oral Contraceptives: ethinyl estradiol, reducing ovarian androgen production and by increasing sex hormone binding globulin concentrations in the serum, thereby lowering free testosterone levels. • Androgen Receptor Antagonists: Spironolactone at doses of 50 to 200mg/day reduces acne because it is an androgen receptor antagonist , Flutamide (prostate cancer) , Cyproterone (Antiandrogen) • S.E: menstrual irregularities in females , Gynecomastia in men
References • Applied Therapeutics, 10th ed, Koda-Kimble, 2013 • Diagnosis and Treatment of Acne, STEPHEN TITUS, MD, Am Fam Physician. 2012;86(8):734-740 • Guidelines of care for acne vulgaris management, John S. Strauss, MD, J Am Acad Dermatol 2007;56:651-63.
