Derm/Rheum/Opth Week 2 Combined

what is the general pathogenesis of acne?

follicular hyperkeritinization, androgens —> increased sebum, cutibacterium acnes, inflammation.

blockage in hair follicle, excess keratin in hair shaft, sebum can build up behind blockage, bacteria can grow, WBCs flow to cause inflammation, and external sources such as makeup can cause blockages

how long does acne last?

may last weeks to months if untreated

when is acne typically worse?

in the fall and winter month

what are comedones?

small bumps found on face, a single lesion is comedo and are non-inflammatory

what are whiteheads?

closed comedeones — little, flesh colored or white lumps that form on the skin’s surface

what are blackheads?

open comedones — resemble whiteheads but are darker in cplor because the clogged material has been exposed to the air (oxidation of substance in the follicle)

what is cystic ance?

the severe type of acne that is characterized by the appearance of nodules and big, inflammatory cysts — may cause severe acne scars and be excruciatingly painful

what can papules on the skin transition to?

nodules (harder and larger)

how does black skin differ with acne?

tends to present more as inflammatory acne (papules and pustules) than non-inflammatory (whiteheads, blackheads), tends to have fewer severe acne lesions (nodules and cysts), tends to scar less, has the highest incidence of hyperpigmentation, has higher change of keloid scarring, and does not tend to suffer with rosacea

what is a keloid?

raised scar after injury has healed

what is rosacea?

a condition that causes redness and often small, red, pus-filled bumps on the face

what are some of the etiologies of acne?

emotional stress (role of corticotropin releasing hormone)

repetitive stress

occlusion and pressure — clothing (acne mechanica), comedogenic beaty products (acne cosmetica, pomade acne)

insulin resistance (increased insulin like growth factors leads to increased facial sebum production)

heat and humidity (tropical acne - beware of 2nd infection such as S. aureus)

occupational acne (tar derivatives, cutting oils, fryer grease, “chloracne”

what is the relationship between foods and acne?

food alone does not cause acne, but some foods may make it worse (skim milk, sugar, carbs, chocolate, greasy foods)

high fiber foods may improve acne

salmon, has omega-3s which may lower inflammation

what are acneiform drug reactions?

reactions from medications that appear as acne/acne-like but are NOT true acne

which drugs can cause acneiform drug reactions?

corticosteroids, NSAIDs, antihistamines, immunosuppressants, antibiotics (decrease good bacteria which can increase fungal acne), lithium

what are the treatments for acneiform drug reactions?

d/c offending agent, if possible, benzoyl peroxide or salicylic acid, retinoids

what are some of the general guidance’s for acne treatment (non-Rx)?

wash your face twice daily with a gently synthetic cleanser, wash with fingers not cloths, use an oil-free moisturizer, avoid touching your face throughout the day, change your pillowcases often, do not pick/squeeze pimples, get regular exercise, eat a healthy diet, get enough sleep, manage stress, see a dermatologist if your acne is severe or persistent, avoid scrubs, skin should be dry before applying topicals

when should you see a doctor for acne?

if self care does not clear acne, severe emotional distress from acne, if acne persists and/or is severe, acne near eyes, when comedogenic drugs cause acne that should be treated, pregnancy

in older adults, sudden onset of severe acne may be a sign of underlying disease

how is mild acne defined?

easily recognizable - less than half the face is involved; some comedones and some papules and pustules

how is moderate acne defined?

more than half the face is involved - many comedones, papules, and pustules; one nodule may be present

how is severe acne defined?

entire face is involved, covered with comedones, numerous papules and pustules, and few nodules and cysts

how is mild acne treated?

topical treatments — multimodal therapy combining multiple mechanisms of action is recommended

topical retinoids

benzoyl peroxide

topical antibiotics

T/F: topical antibiotic monotherapy is not recommended for acne

true

what are some of the fixed-dose combinations of topical agents for mild acne?

topical antibiotic + benzoyl peroxide

topical retinoid + benzoyl peroxide

topical retinoid + ttopical antibiotic

T/F: concomitant use of benzoyl peroxide can prevent the development of antibiotic resistance

true

what are second line treatment options for mild acne?

clascoterone, salicylic acid, and azelaic acid

how is moderate-severe acne treated?

systemic antibiotics, hormonal agents, or isotretinoin

which systemic antibiotic is preferred for mod-sever acne?

doxycycline

what should be used with systemic antibiotics for mod-severe acne?

benzoyl peroxide and other topical treatments

facts regarding use of systemic antibiotics for acne:

limit use when possible to reduce the development of antibiotic resistance and other antibiotic-associated complications

what are some second line systemic antibiotic options for acne?

minocycline, sarcycline

what hormonal agents can be used for mod-severe acne?

combined oral contraceptives, spironolactone, and intralesional corticosteroids

facts regarding spironolactone for acne

potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia

facts regarding intralesional corticosteroids

is an adjuvant treatment for larger acne papules or nodules at risk of acne scarring or for rapid improvement in inflammation and pain

what monitoring should be done while using isotretinoin?

LFTs and lipids

what is the first-line treatment for mild and mild-mod acne?

topical retinoids (retinoic acid, adapalene, tretinoin)

what are oral antibiotics such as doxycycline indicated for?

mod-severe acne and for acne that does not improve with topical treatments

what are the goals of acne management?

always consider the psychological aspects (aggressive treatment), remove keratin plug, reduce bacterial inflammation, reduce sebum production, reduce or eliminate scarring

what questions should be considered for patients with acne?

current skin care regimen?

current meds/products?

skin type? oily? dry?

presence of acne scarring?

presence of hyperpigmentation?

psychological impact of acne?

T/F: basic soaps should not be used since they are too harsh on the skin

true

what vehicles should be used on dry skin?

lotions or creams

what vehicles should be used on oily skin?

gels or foams

what vehicles should be used on hairy areas?

foams

which vehicle types are good for covering large areas of skin?

solutions and pledgets

which medications can be used to inhibit follicular hyperproliferation (comedolytic)?

oral/topical retinoids, azelaic acid, salicylic acid, hormonal therapies, benzoyl peroxide

which medications can help with reducing sebum production?

oral/topical retinoids (shrink sebaceous gland), hormonal therapies, clascoterone cream, benzoyl peroxide

which medications can help reduce C. acnes proliferation?

benzoyl peroxide, antibiotics, azelaic acid, dapsone topical

which medications are anti-inflammatory for acne?

oral/topical retinoids, oral/topical antibiotics, azelaic acid, clascoterone cream, dapsone topical, salicylic acid, benzoyl peroxide

which medications are androgen receptor inhibitors?

clascoterone cream

how long does it take to see improvement with topical retinoids?

8-12 weeks

T/F: topical retinoids are teratogenic (avoid in pregnancy/breastfeeding)

true

what is the role of topical retinoids for acne?

included as initial management of most patients, used as monotherapy with comedonal acne, normalize follicular hyperkeratosis, prevent formation of microcomedo, and may improve inflammatory acne

T/F: clascoterone cream should be avoided in pregnancy/breastfeeding

true

what has been reported with clascoterone cream use?

HPA suppression — concern with occlusive dressings

how should clascoterone cream be stored?

store at 2-8 degrees celsius priod to dispensing, patients may store at room temperature

discard 180 days after dispensing or 30 days once opened, or expiration date, which ever comes first

what is the brand of clascoterone cream?

Winlevi

what are the brands names for tretinoin?

Atralin, Renova for wrinkles and photoaging and acne, Retin-A and Retin A micro, Altreno

what is the brand name for adapalene?

Differin 0.1% and 0.3%

what are the brand names for tazarotene?

Tazorac 0.1% cream or gel, Arazlo, Fabior foam, Avage 0.1% cream (for wrinkles or photoaging and acne)

what is the brand name of trifarotene?

Aklief 0.005% cream

what is the brand name for adapalene + benzoyl peroxide?

Epiduo Forte gel 0.3%/2.5% once-a-day

what is the brand name for tretinoin + benzoyl peroxide?

TWYNEO cream 0.1%/3%

what is TWYNEO indicated for?

the treatment of acne vulgaris in adults and pediatric patients nine years of age and older

how is TWYNEO formulated so that tretinoin and BP can be together?

entrap tretinoin, a retinoid, and benzoyl peroxide within silica-cased microcapsules to stabilize tretinoin from being degraded by benzoyl peroxide

how should topical retinoids be applied?

gently clean area, pat dry, wait 20 minutes, apply pea-sized amount of retinoid to the entire effected area (not spot treatment), apply moisturizer

apply once daily at night to avoid photosensitivity

what should not be appleid at the same time as benzoyl peroxide?

retinoids

why should retinoids not be applied at the same time as BP?

oxidation decreases stability of retinoids (especially during light exposure)

what are the ADRs for topical retinoids?

irritation, dryness, flaking of skin, transient worsening of acne, photosensitivity, avoid OTCH irritating products, gentle exfoliation with wash-cloth, facial moisturizers on top of retinoid

which retinoid contains soluble fish proteins?

Atralin (micronized tretinoin 0.05%)

what are some considerations for topical retinoids?

enhances penetration of other topical acne medications, start low and go slow, adapalene is least irritating, gel microsphere-slow release is less irritating (Retin A micro), and tazarotene is the most irritating

what is the role of topical antimicrobials in acne?

decreases number of C. acnes colonizing skin, reduce inflammatory response, combo therapy with topical antimicrobial + topical retinoid is more effective than either alone, to prevent resistance use with BP

what antimicrobials can be used topically for acne?

clindamycin, erythromycin, dapsone, and minocycline (Amzeeq)

how often is clindamycin topical applied?

twice daily, or once daily if foam

how often is erythromycin applied for acne?

twice daily

how often is dapsone applied for acne?

twice daily for 5%

once daily for 7.5% gel

how often is minocycline applied for acne?

once daily

facts regarding clindamycin topical

rare risk of pseudomembranous colitis, usually prescribed with BP to decrease resistance.

facts regarding erythromycin topical use for acne

usually prescribed with BP to decrease resistance

facts regarding dapsone topical

yellow-orange skin discoloration when applied at the same time as BP

which topical antibiotic may cause headaches?

minocycline

what are some of the topical combinations for acne?

BP + clinda

BP + erythromycin

BP + tretinoin

BP + adapalene

what is azelaic acid topical?

is an antimicrobial, comedolytic - has mild anti-inflammatory properties, mechanism of action on C. acnes is unknown, limits melanin production via inhibitory effect on tyrosine

which medication can improve acne induced post inflammatory hyperpigmentation?

Azelaic acid topical

how often can azelaic acid be used?

BI or QD (if burning)

what are some ADRs of azelaic acid topical (cream/gel)?

burning, itching, redness, hives, anaphylaxis very rare

how long does it take azelaic acid to work

usually within 4 weeks

what can be done to reduce resistance from oral antibiotics?

limit duration, avoid changing too soon, if stopped restart same ones if still effective, do not combine MOA even if oral and topical, use with BP, use with topical retinoids

which oral antibiotics are typically used for acne?

tetracycline, doxycycline (Doryx), minocycline (minocin), minocycline extended release (Solodyn), sarecycline (Seysara)

what are some ADRs for tetracycline, doxycycline, and sarecycline?

photosensitivity, GI distress, CI in pregnancy and young children

ADRs for minocycline

dizziness, drug-induced lupus, skin discoloration, CI in pregnancy and young children.

how does benzoyl peroxide work?

benzoyl peroxide —> benzoic acid —→ releases free radical oxygen species and oxidizing bacterial proteins

kills acne bacteria, opens clogged pores, promotes flow of sebum, reduces inflammation, combines with other treatments for an enhanced effect

when does BP start to work?

benefits within 3 weeks and maximum within 12 weeks

how should BP be used?

apple once a day and may increase to BID or TID after two weeks if tolerated

start at 2.5% and may increase strength weekly if needed and as tolerated to 5%, then 10% after another week

concentrations higher than 2.5% seem to be no more effective

ADRs for BP

erythema, scaling, xerosis, stinging/burning, bleaching of hair, clothing, etc, rare reports of life-threatening HS

what is salicylic acid?

it is in the same class as beta-hydroxy acids 0.5-2%

is a desquamating agent that causes shedding of dead cells from outer most layer of skin — lipophilic properties enable it to penetrate pilosebaceous follicle, mild anti-inflammatory properties

T/F: salicylic acid has synergistic effects with BP

true

facts regarding sulfur for acne

interacts with cysteine in keratinocytes (produces hydrogen sulfide, keratolytic effect), inhibits proliferation of C.acne

prescription products combin with sulfacetamide

facts regarding alpha hydroxy acids for acne

glycolic acid or lactic acid: remove top layer of dead skin cells —> desquamation and diminished corneocyte cohesion

improve post-inflammatory hyperpigmentation, diminished signs of aging skin

may work synergistically with retinoids but less effective as monotherapy

facts regarding tea tree oil for acne

antimicrobial and anti-inflammatory properties, toxic if used internally, slower MOA than BP

what are the indications for hormonal agents?

for mod-severe acne in women who are not trying to become pregnant — particular benefit to adult women who present with inflammatory acne involving lower face/neck with premenopausal flares