Acne

State the general clinical features, signs and symptoms, and factors for the development/exacerbation of acne vulgaris

• Clinical Features

  • Onset correlates with onset of puberty

• Signs and Symptoms

• Factors for development of acne vulgaris

  • Onset of puberty

  • Hyperkeratinization and abnormal exfoliation → follicular plugging

  • Genetics

  • Western diet

    • High glycemic index foods

    • Milk

• Exacerbating factors

  • Irritation/friction from clothing, excessive contact between face and hands

  • Oil based cosmetic use, other health and beauty products

  • Occupational (dirt, cooking oils, industrial chemicals, etc)

  • Picking/squeezing lesions, stress

  • Humidity, sweatings

  • Medications

    • Phenytoin

    • Isoniazid

    • Moisturizers

    • Phenobarbital

    • Lithium

    • Ethionamide

    • Steroids

Differentiate between mild, moderate, and severe acne as well as acne rosacea and state when self treatment is indicated and appropriate and when patients need to be referred for further care

Mild	Few erythematous papules and occasional pustules mixed with comedones
Moderate	Many erythematous papules and pustules and prominent scarring
Severe	Extensives pustules, erythematous papules and multiple nodules on an inflamed background
Acne Rosacea	Pimple-like breakouts,  no blackheads Eye problems Redness in center of face, can come and go or permanent Large pores Visible blood vessels  Very sensitive skin: Skin care products, makeup, sunscreen, or perfume can cause burning, stinging, or itching

• Exclusion Criteria

  • Moderate - severe acne presenting as

    • Papules and pustules

    • Nodules

    • Inflammation and/or scarring

  • Exacerbating factors

    • Comedogenic medications (“PIMPLES”)

    • Possible acne rosacea

Identify lifestyle modifications/nonpharmacologic therapies that may help relieve acne vulgaris

• Identification and avoidance of patient specific exacerbating factors

• Gently cleansing skin with warm water and mild soap BID

• Maintain hydration to limit inflammation

• Use facial toners to prevent oily skin, remove makeup, dirt (may increase skin irritation with overuse)

• Dietary changes

  • Lower glycemic index foods

  • Reduce saturated and trans-fatty acids

  • Reduce consumption of milk, chocolate

  • Increase fruit and vegetable consumption

• Physical Treatments

  • Acrylate glue-based material strips

    • Ex) Pore strips, oil absorbing sheets

    • Aids in extraction of impacted comedones

    • Better alternative to picking acne (scarring)

  • Professional comedone extraction

    • Removes blackheads

    • $$$

  • Light-based treatments

    • Target reduction of C. acnes

    • Disruption of sebaceous gland function

Compare and contrast nonprescription products, including supplements, for the treatment of acne vulgaris and describe their MOA’s, application and use, ADR’s, precautions, contraindications, and pertinent patient counseling information

• Adapalene Gel 0.1% (Differin)

  • RX to OTC, 1st line option

  • MOA: anti-inflammatory, comedolytic, improved dyspigmentation, maintain acne clearance

  • Full strength retinoid product

  • Apply a thin layer to affected, intact skin QHS

  • ADR: 

    • Redness

    • Scaling

    • Dryness

    • Itching 

  • Counseling

    • Protect from sun (SPF 15 or higher)

    • Acne may worsen in the first few weeks, needs 8-12 weeks for full effect

    • If acne lesions worsen or no improvement occurs in 3 months with proper use, refer

    • Stop use if pregnant or planning on becoming pregnant

    • Discontinue and refer if no improvement or acne worsens within 3 months

• Benzoyl Peroxide

  • OTC: 2.5, 5, and 10% strengths, also available as RX

  • MOA:

    • Antibacterial, keratolytic and comedolytic

    • Prevents, eliminates treatment-resistant C. acnes

  • Application

    • Apply to 1-2 small AAs over three days to test tolerance

    • If tolerated, may increase from QD to TID applications PRN, can also increase concentration

    • Can reduce concentration and/or application frequency to reduce ADRs

  • ADRs:

    • Skin irritation (increases with increase concentration)

    • Drying

    • Peeling/scaling

    • Erythema

  • Counseling

    • May bleach hair and dye fabric

    • Avoid excessive sun exposure, use sunscreen with SPF of 15 or higher

    • Mild stinging or peeling is normal and diminishes with continued use

• Salicylic Acid

  • OTC: 0.5-2% strengths

  • Alternative to retinoids, benzoyl peroxide (milder, less effective)

  • MOA:

    • Comedolytic

  • Application

    • 1-3 times daily PRN

    • Can reduce concentration and/or application frequency to reduce ADRs

  • ADRs:

    • Burning sensation

    • Erythema

    • Pruritus

    • Stinging

    • Salicylism

      • Up to 20% of dose can be systematically absorbed

  • Counseling

    • Do not apply over extensive areas b/c of potential for systemic toxicity (tinnitus, loss of hearing, N/V, dizziness, lethargy, hyperpnea, diarrhea, psychic disturbances)

    • Avoid drug exposure to eyes, nose, mouth, or broken/injured skin areas

    • Protects against UVB, still need to wear sunscreen

      • SPF 15 or higher

• Sulfur, Sulfur/Rescorcinol 

  • Monotherapy: 3-10% strengths

  • Adjunct to existing

  • MOA:

    • Keratolytic, antibacterial

    • Comedolytic, but comedogenic over time/continued use

  • ADRs: odor, dry skin

  • Combination: 3-8% with 2-3% recorcinol

    • Enhances the effects of sulfur

  • Resorcinol additional effects

    • Antibacterial

    • Antifungal

    • Keratolytic

  • ADRs: dry skin, irritation

• Dietary Supplements (Adjunct)

  • Topical Tea Tree Oil

    • Antibacterial

    • Antifungal

    • Anti-inflammatory

  • Oral Vitamin A

    • Natural retinol

    • 300,000 IU (women)

    • 500,000 IU (men)

    • Fat soluble vitamin

  • Oral Zinc

    • Bacteriostatic

    • Alternative to tetracyclines

    • N/V/D

  • Nicotinamid

    • Vitamin B3 derivative

    • Anti-inflammatory

    • Decreases sebum production

Compare and contrast and select appropriate dosage forms for the treatment of acne vulgaris

• Gels

  • Astringent

  • Remains on skin longest

  • non-greasy

• Solutions/Washes

  • Non-greasy

  • Astringent

• Ointments

  • AVOID (occlusive, greasy)

• Creams and Lotions

  • Less irritating

  • May counteract drying and peeling

  • Good for dry/sensitive skin

Recommend a nonprescription product for the treatment of acne vulgaris given patient specific information and provide general and specific counseling information

• Minimize/eliminate specific exacerbating factors

• Regardless of therapy, need to wash face BID, don’t pick/squeeze acne

• Stress adherence to therapy

  • Refer after 6 weeks if no response (benzoyl peroxide, salicylic acid)

  • Refer after 8-12 weeks (adapalene)

• Recommend oil free moisturizer and cosmetics as appropriate

• Start with low strength → then increase to optimal concentration to minimize irritating effects

• Decrease application frequency/strength if excessive peeling or other ADRs occur

• Supplements for adjunct treatment only