INTRODUCTION

• Presenter: Danielle C. Ezzo, Pharm.D., BCPS

• Affiliation: Associate Clinical Professor at St. John's University

• Contact: ezzoD@stjohns.edu

• Topic: Pharmacotherapy of Acne Vulgaris

GUIDELINES

• Source: American Academy of Dermatology

• Date: May 2024

• Content:

  • 18 evidence-based recommendations

  • 5 good practice statements

DEFINITION: ACNE

• Type of Condition: Chronic inflammatory dermatosis characterized by both open and closed comedones.

• Nature of Disorder:

  • Self-limiting disorder

  • Excessive oil production from sebaceous glands leads to clogged hair follicles exhibiting various signs and symptoms.

• Prevalence:

  • Affects approximately 50 million people in the U.S.

  • 85% of cases occur in teenagers and young adults.

  • No associated mortality; however, significant physical and psychological morbidities exist such as scarring, poor self-esteem, depression, and anxiety.

GRADING SYSTEM FOR ACNE

• Current Status: No universal grading system established.

• Most Common System: Investigator Global Assessment (IGA)

  • Evaluation Criteria:

  • Type of lesions

  • Number of lesions

  • Extent & region of lesions

  • Commonly Affected Areas:

  • Primarily the face, also common on chest, shoulders, back, and trunk.

  • Assessment Metrics:

  • Quality of life

  • Psychosocial measures

  • Severity Scale:

  • 5-point ordinal scale from 0 to 4:

    • Clear

    • Almost clear

    • Mild

    • Moderate

    • Severe

  • Treatment Recommendations: Based on acne severity:

  • Topical therapies in mild to moderate cases, oral therapies for moderate to severe.

• Types of Lesions:

  • Non-inflammatory lesions:

  • Open comedones (Blackheads)

  • Closed comedones (Whiteheads)

  • Inflammatory lesions:

  • Papules

  • Pustules

  • Nodules (Cysts)

PHYSICAL ASSESSMENT

• Assessment Areas:

  • Severity of lesions

  • Types of lesions

  • Number and location of lesions

  • Scarring and skin discoloration

  • Skin type

• Suggested Patient Questions:

QUESTIONS AND REASONING

1. Which medications have been tried?

   • To evaluate previous effectiveness.

2. Which medications have been successful or not?

   • Same reasoning as above.

3. Were treatment failures due to improper technique or insufficient duration of use?

   • To determine if failures resulted from the drug or incorrect application.

4. Did adverse effects occur?

   • To assess medication tolerance; could affect patient compliance.

5. Is the patient using other products to treat acne?

   • Nonprescription products might irritate skin, limiting the effectiveness of other therapies.

6. Is the patient receiving other medications?

   • Certain drugs like corticosteroids can exacerbate acne.

7. Does the patient use cosmetics or hair greases?

   • Comedogenic products may provoke or worsen acne.

8. Are there recreational or occupational activities affecting acne?

   • Physical pressure or the application of oils can worsen conditions.

9. Other medical problems history?

   • History of atopic dermatitis or sensitive skin may limit treatment options.

10. For females:

    • Is the patient menstruating or experiencing premenstrual flares?

    • History of oligomenorrhea or hirsutism might suggest androgen excess (PCOS).

    • Are they sexually active?

    • Do they use hormonal contraception?

COMPLICATIONS

• Physical Complications:

  • Scarring

  • Hyperpigmentation

• Psychosocial Complications:

  • Social withdrawal

  • Low self-esteem

  • Negative self-image

  • Feelings of depression

GOALS OF THERAPY

• Target outcomes of acne treatment include:

  • Reduce number and severity of lesions

  • Improve patient appearance

  • Slow disease progression

  • Limit duration and recurrence of lesions

  • Prevent long-term consequences such as hyperpigmentation, scarring, and psychosocial issues

GENERAL SKIN CARE

• Cleansing Practices:

  • Excessive cleansing provides no benefits; can irritate skin.

  • Recommend “noncomedogenic” products

  • Soap Selection:

  • Should avoid high oil content.

  • Medicated or antibacterial soaps generally offer no benefit.

  • For non-inflammatory skin types, mildly abrasive cleansers are suggested.

  • For inflammatory/dry skin types, gentle soaps are recommended.

TOPICAL TREATMENT FORMS

• Forms:

  • Creams: Well-suited for winter due to moisturizing properties (for normal skin).

  • Lotions: Optimal for sensitive skin (winter use).

  • Washes: Better for sensitive skin.

  • Soaps: Convenient for any skin type.

  • Gels: Effective with consistent release of active ingredients (for oily to normal skin).

  • Foams: Suitable for oily to normal skin.

THERAPEUTIC AGENTS IN ACNE

Topical Therapy

• Antimicrobial Agents:

  • Benzoyl peroxide

  • Antibiotics:

  • Clindamycin

  • Erythromycin

  • Tetracycline

  • Meclocycline

  • Other Treatments:

  • Azelaic acid

  • Sulfur

  • Salicylic acid

  • Dapsone

• Comedolytics:

  • Tretinoin

  • Adapalene

  • Tazarotene

  • Azelaic acid

  • Benzoyl peroxide (minor)

  • Salicylic acid (minor)

  • Resorcin (minor)

Oral Therapy

• Antibiotics:

  • Clindamycin

  • Erythromycin

  • Tetracycline

  • Minocycline

  • Trimethoprim-sulfamethoxazole

• Isotretinoin:

  • Reduces sebaceous gland activity.

• Hormonal Therapy:

  • Estrogen

  • Cyproterone acetate

  • Spironolactone

BASELINE EVALUATION

• Management of Acne Vulgaris:

  • Adults, adolescents, and preadolescents (>9 years old) with acne should undergo severity assessment.

  • Use Physician Global Assessment (PGA) or similar scales.

  • Goals: Assess satisfaction with appearance, scarring extent, treatment satisfaction, long-term acne control, and quality of life.

  • Severity Assessment:

  • Mild: Typically managed with topical treatments.

  • Moderate to Severe: May require oral medications.

TOPICAL TREATMENTS

Multimodal Therapy

• Combining multiple mechanisms of action is recommended.

• Fixed-Dose Combinations:

  • Topical retinoids + BP

  • Topical antibiotics

  • Monotherapy not recommended.

• Concomitant Use of BP: Prevents antibiotic resistance.

Key Agents and Methods

• Clascoterone, Salicylic Acid, Azelaic Acid: Randomly selected options.

• Systemic Agents:

  • Antibiotics: Prefer limited use to avoid resistance; use Doxycycline or Minocycline.

  • Hormonal Agents:

    • Combined oral contraceptives

    • Spironolactone

• Intralesional Corticosteroids: Adjuvant treatment for large papules or nodules.

PHYSICAL MODALITIES

• Pneumatic Broadband Light:

  • Strong recommendation to support intervention.

ISOTRETINOIN THERAPY

• Indicated for: Severe inflammatory acne.

• Dosing: 0.5 mg - 1 mg/kg/day orally divided in two doses. Gradual increase as tolerated.

• Duration: 16 - 20 weeks (can extend in rare cases).

• Monitoring: Liver function tests and lipids.

• Risks: Includes mucocutaneous side effects, laboratory abnormalities, and potential neuropsychiatric effects.

• Pregnancy Risks: Requires mandatory pregnancy prevention strategies including testing and enrollment in the iPledge program.

MUCOCUTANEOUS SIDE EFFECTS OF ISOTRETINOIN

• Types of Side Effects:

  • Dry skin, eyes, nose, and mouth.

• Recommendations: Use moisturizers for skin, artificial tears for eyes, petrolatum for the nose, and hard candies for dry mouth.

LABORATORY ABNORMALITIES ASSOCIATED WITH ISOTRETINOIN

• Hyperlipidemia: Occurs in 25% of patients; risk factors include obesity and diabetes.

  • Monitoring: Baseline and repeated lipid profiles required.

• Liver Function Abnormalities: Seen in 15% of patients; requires dose adjustments.

TERATOGENICITY

• Risks: Congenital abnormalities affecting cranium, face, heart, brain, and thymus.

• Testing Requirement: Pregnancy tests before and monthly throughout treatment.

• Contraception Requirement: Use of two methods of contraception is necessary starting one month prior to treatment.

QUESTIONS?

• Open Floor for Queries

Note: The above notes are an exhaustive compilation of all significant points from the transcript provided.