Term
| the 4 mechanisms involved in the pathogenesis of acne lesions |
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Definition
INCREASED FOLLICULAR KERATINIZATION
keratinization within the hair follicle is a normal process
acne involves keratinocyte clumping and plugging in the hair follicle pore
increased sloughing of keratinocytes leads to microcomedo formation
INCREASED SEBUM PRODUCTION
sebum production influenced by androgen stimulation at puberty
acne affected pilosebaceous units have a hyperresponsiveness to circulating androgens
BACTERIAL GROWTH
Propionibacterium acnes resides in the follicle as normal flora
trapped keratinocytes and sebum leads to growth of P. acnes
P. acens causes lipolysis of sebum TGs to free fatty acids
INFLAMMATION
inflammation is due to P. acnes mediated T cells reponse, cytokine release, and production of free fatty acids |
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Term
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Definition
PRIMARY LESIONS
microcomedo - underneath the skin and CANNOT BE SEEN
NONINFLAMMATORY LESIONS
closed comedo (AKA white head) - a plug of sebum, keratinocytes, and microorganisms blocking a closed hair follicle opening (says beneath the skin surface); 1-2 mm diameter)
closed comedo (AKA blackhead) - a plug of sebum, keratinocytes, and microorganisms blocking a dilated hair follicle opening (reaches the skin surface); 2-5 mm diameter
INFLAMMATORY LESIONS
papule - a well defined, elevated, palpable, distinct area of skin (<5 mm diameter) involving the epidermis/dermis
pustule - a papule filled with purulent fluid (<5 mm diameter)
nodule - an elevated, firm, distinct, palpable, round or oval lesion (> 5 mm diameter) that occurs in the dermis/hypodermis
cyst - a docule filled with purulent fluid (>5 mm diameter) |
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Term
| classification and severity of acne by type of lesion |
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Definition
TYPE 1
comedonal acne
comedones only, fewer than 10 lesions on face, no lesions on trunk, no scaring
only classification that can be treated with OTC products
TYPE II
papular acne
10-25 papule lesions on face/trunk, mild scarring, inflammatory lesions < 5 mm
TYPE III
pustular acne
> 25 pustule lesions, moderate scarring, inflammatory lesions < 5 mm with visible purulent core
TYPE IV
severe/persistent pustulocystic acne
nodules/cycsts, extensive scarring, inflammatory lesions > 5 mm
RECALCITRANT SEVERE CYSTIC ACNE
extensive nodules/cysts |
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Term
| classification and severity of inflammatory acne |
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Definition
MILD
few to numerous closed comedones
few to numerous open comedones
possible papules/pustules
no nodules
no scarring
MODERATE
few to numerous closed comedones
few to numerous open comedones
NUMEROUS papules/pustules
few nodules
possible scarring
SEVERE
few to numerous closed comedones
few to numerous open comedones
NUMEROUS papules/pustules
EXTENSIVE nodules
EXTENSIVE scarring |
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Term
| non pharm treatment of acne |
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Definition
cleanse the skin:
clean gently BID
use mild soap, soapless cleanser and water
use hands or soft wash cloth, pat dry
minimize exacerbating factors:
avoid frequent touching of skin
avoid friction producing clothing/devices
choose noncomedogenic cosmetics (oil free)
do not pick of sqeeze lesions
minimize stress
avoid medications (PIMPLES): phenytoin, isoniazid, moisturizers, phenobarbital, lithium, ethionamide, steroids |
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Term
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Definition
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Term
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Definition
tretinoin (Retin-A, Retin-A Micro, Stalin, Renoza [wrinkles])
adapalene (Differin)
tazarotene (Tazorac, Avage [wrinkles]) |
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Term
| topical tretinoin indication |
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Definition
| 1ST LINE THERAPY (DOC) for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy |
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Term
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Definition
increase turnover (keratolytic) and decrease cohesiveness (comedolytic) of follicular epithelial cells
anti-inflammatory
inhibits formation of new and leads to extrusion of existing comedones |
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Term
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Definition
| skin irritation, erythema, peeling, sensitivity to sun, wind, and cold |
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Term
| topical tretinoin administration |
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Definition
AAA thin layer after washing/drying face at HS; wait 30 minutes after washing face to apply
start every other day then qHS
0.025% cream for mild acne with sensitive, non oily skin
0.01% gel for moderate acne with sensitive, oily skin
0.025% gel for moderate acne with non sensitive, oily skin
combination with benzoyl peroxide qAM and tretinoin |
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Term
| topical adapalene indication |
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Definition
| alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy |
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Term
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Definition
| 3rd generation retinoid with selective affinity for retinoic acid receptors (RARs) in the epidermis |
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Term
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Definition
| similar to tretinoin, skin irritation, erythema, peeling, sensitivity to sun, wind, and cold |
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Term
| topical adapalene administration |
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Definition
| AAA thin layer after washing/drying face at HS |
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Term
| topical tazarotene indications |
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Definition
| alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy |
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Term
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Definition
new generation retinoid, prodrug, selectively binds to RARs
comedolytic, keratolytic, and antiinflammatory |
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Term
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Definition
dose related erythema, pruritis, stinging, burning
more severe ADRs than the other, but works better
pregnancy category X |
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Term
| topical tazarotene administration |
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Definition
| AAA thin layer after washing/drying face at HS |
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Term
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Definition
benzoyl peroxide (Benzac AC, Brevosyl, Lavclen, Triaz)
erythromycin (Eryderm, Ery Pads)
clindamycin (Cleocin T, Clindagel, ClindaMax, Evoclin)
azelaic acid (Azelax, Finacea [rosacea]) |
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Term
| topical benzoyl peroxide indication |
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Definition
alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy
adjunctive therpy with retinoids, topical and systemic antibiotics (to prevent resistance) |
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Term
| topical benzoyl peroxide MOA |
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Definition
bactericidal against P. acnes
liberates free oxygen radicals that oxidize bacterial proteins
P. acnes resistance is not known to develop
some comedolytic, keratolytic, and indirect anti-inflammatory activity |
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Term
| topical benzoyl peroxide ADRs |
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Definition
| dryness, irritation, may bleach or discolor fabric, sun sensitivity |
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Term
| topical benzoyl peroxide administration |
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Definition
10% strength not significantly more efficacious but can be more irritating
AAA thin layer 30 minutes after washing/drying face at HS
start with 15 minute titration to 2 hours then BID if needed
can also increase concentration 2.5% then 5%
combination with benzoyl peroxide qAM and tretinoin qHS
combination product Epiduo = benzoyl peroxide (2.5%) + adapalene (0.1%) gel AAA pea size amount daily (forehead, each cheek, chin) |
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Term
| topical erythromycin and clindamyin indication |
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Definition
alternative 1st line therapy (short to intermediate term) for treatment of mild to moderate inflammatory acne
adjunctive therapy with retinoids, benzoyl peroxide
combination has increased efficacy and reduced bacterial resistance |
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Term
| topical erythromycin and clindamycin MOA |
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Definition
| antibacterial against P. acnes with indirect suppression of inflammation |
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Term
| topical erythromycin and clindamycin ADRs |
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Definition
| erythema, peeling, dryness, burning |
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Term
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Definition
Benzamycin = benzoyl peroxide (5%) + erythromycin (3%) apply BID; stored in refrigerator; expires 3 months after dispensing
Benzaclin = benzoyl peroxide (5%) + clindamycin (1%) apply BID; store at room temperature; expires 3 months after dispensing
Duac = benzoyl peroxide (5%) + clindamycin (1%) apply qHS; store in refrigerator and after it is dispensed store at room temperature; good for 2 months after dispensing
Ziana = tretinoin (0.025%) + clindamycin (1.2%) apply qHS |
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Term
| topical erythromycin and clindamycin administration |
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Definition
| AAA thin layer after washing/drying face BID |
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Term
| topical azelaic acid indication |
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Definition
alternative therapy for mild to moderate acne for patients that cannot tolerate benzoyl peroxide
post inflammatory hyperpigmentation, as it has skin lightening properties |
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Term
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Definition
antibacterial against P. acnes with indirect suppression of inflammation, comedolytic activity
P. acnes resistance is not known to develop |
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Term
| topical azelaic acid ADRs |
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Definition
mild - burning, pruritus, stinging, tingling
erythema, dryness, rash, peeling, irritation, dermatitis < 1%
no systemic ADRs or photosensitivity |
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Term
| topical azelaic acid administration |
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Definition
| AAA thin layer after washing/drying face BID |
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Term
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Definition
ANTIMICROBIALS:
tetracyclines - minocycline (Minocin, Dynacin, Solodyn, Myrac), doxycycline (Vibramycin), tetracycline (Sumycin)
macrolides - erythromycin (Ery-Tab), azithromycin (Zithromax)
ORAL RETINOID:
isotretinoin (Accutane, Amnesteem, Claravis, Sotret)
HORMONAL ACNE TREATMENTS:
norgestimate/ethinyl estradiol (Ortho-Tri-Cyclen)
noresthindrone acetate/ethinyl estradiol (Estrostep)
dropsrienone/ethinyl estradiol (Yasmin, Yaz)
spironolactone |
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Term
| tetracyclines (minocycline, doxycyline, tetracycline) indications |
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Definition
MINOCYCLINE = 1ST LINE ORAL THERAPY for moderate to severe inflammatory acne used in combination with topical
doxycyline = alternative oral therapy to minocycline used in combination with topical
tetracycline = 2nd line alternative oral therapy to minocycline/doxycyline used in combination with topical |
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Term
| tetracycline (minocycline, doxycyline, tetracycline) MOA |
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Definition
| antibacterial against P. acnes with indirect suppression of inflammation |
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Term
| tetracyclines (minocycline, doxycyline, tetracycline) ADRs |
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Definition
GI upset, hepatotoxicity, predisposition to superinfections (vaginal candidiasis)
photosensitivity, chelation (dairy/antacid interaction)
cannot use in children < 10 years old or pregnant women
tooth discoloration
inhibition of skeletal growth in developing fetus
cannot use with systemic retinoids due to risk of intracranial HTN
minocycline - dose related dizziness, urticaria, autoimmune hepatitis, systemic lupus erythematosus like syndrome, serum sickness like reaction
MUST take with a full glass of water
minocycline hyperpigmentation 4 distinct types:
1) blue-black pigmentation confined to sites of scarring or inflammation on the face
2) blue-gray circumscribed pigmentation of normal skin on the lower legs and forearms
3) diffuse muddy brown pigmentation of normal skin accentuated in sun exposed areas
4) circumscribed blue-gray pigmentation within acne scars confined to the back |
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Term
| tetracyclines (minocycline, doxycycline, tetracycline) administration |
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Definition
minocycline - 50 mg BID or 100 mg daily as initial and maintenance doses
more effective than tetracycline
high lipid solubility leads to enhanced penetration into tissue and sebaceous follicles
doxycycline - 100-200 mg daily, 30 minutes before meals
when improvement seen, decrease dose to 50 mg daily
tetracycline - 500 mg BID 1 hour before meals
after 1-2 months, when improvement is seen, decrease dose to 500 mg daily for another 1-2 months |
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Term
| macrolides (erythromycin and azithromycin) indication |
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Definition
erythromycin - alternative oral therapy to tetracyclines for moderate to severe inflammatory acne used in combination with topical
used in patients who cannot tolerate or develop resistance to tetracycline
azithromycin - alternative oral therapy to erythromycin for moderate to severe inflammatory acne used in combination with topical
clindamycin is NOT used for acne due to risk of pseudomembranous colitis |
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Term
| macrolides (erythromycin and azithromycin) MOA |
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Definition
| antibacterial against P. acnes with indirect suppression of inflammation |
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Term
| macrolides (erythromycin and azithromycin) ADRs |
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Definition
| GI upset (N/V, abdominal pain, diarrhea) - more common with erythromycin |
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Term
| macrolides (erythromycin and azithromycin) administration |
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Definition
erythromycin - 250 mg QID with food
azithromycin - 500 mg three times weekly |
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Term
| oral isotretinoin indication |
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Definition
1ST LINE ORAL THERAPY (DOC) for the treatment of severe, recalcitrant, nodular acne
conventional treatment failure, scarring acne, chronic relapsing acne and acne with severe psychological distress |
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Term
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Definition
induction of atrophy of sebaceous gland with decreased sebum production and change in sebum composition
inhibition of P. acnes growth
inhibition of inflammation
altered patterns of keratinization |
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Term
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Definition
MAIN ADRS:
depression - monitor and counsel on risk
dryness - mouth (sugar free candy, lozenges, gum), eyes (eye drops, avoid contact lenses), nose (lubricant), skin (nondrying moisturizers), lips (lip moisturizers with sunscreen)
muscles and joint pain - NSAIDs
alopecia - reversible when treatment DC
hypertriglyceridemia - reversible when treatment DC
acne flare - continue treatment
photosensitivity - sue moisturizing sunscreen, protective clothing
SERIOUS ADRS:
increased CPK, hyperglycemia, photosensitivity, hepatomegaly, abnormal LFTs, arthralgia, muscle stiffness
pregnancy category X
RELATIVE CONTRAINDICATIONS:
hyperlipidemia, DM, severe osteoporosis
MONITORING:
FLP, LFT, CBC |
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Term
| oral isotretinoin administration |
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Definition
0.5-2 mg/kg/day in 2 divided doses with food for 20 weeks
cumulative dose of 120-150 mg/kg/treatment course
lower dose (<0.5 mg/kg) may be used but is associated with higher relapse rate
50% reduction in pustules after 2-4 weeks |
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Term
| isotretinoin and teratogenicity |
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Definition
isotretinoin causes severe birth defects
pregnancy prevention and management program (iPLEDGE)
FDA/manufacturer run risk management program
MD, patient, RPh, wholesalers, and manufacturers must register
program to prevent female patient starting therapy if pregnant and female patient on therapy becoming pregnant
contraception required
begin OC 1 month prior to treatment, continue during treatment, and for 1 month (usually 4 months) after completion
female must commit to use 2 forms of effective contraception
approved forms of contraception:
primary forms - tubal sterilization, partner's vasectomy, IUD, hormonal (OC, patches, injection, implants, ring)
secondary forms: diaphragm, cervical cap, male latex condom, vaginal sponge (all must be used with spermicide)
not approved: OC w/o estrogen, IUD progesterone T, female condoms, natural family planning, breastfeeding, fertility awareness, withdrawal, cervical shield
must have 2 negative urine or blood pregnancy tests before receiving initial Rx
each month of treatment, patient must have a negative pregnancy test
MD enters patient's pregnancy results and 2 forms of contraception use into iPLEDGE system
iPLEDGE system verifies that all criteria have been met prior to allowing pharmacy authorization to fill and dispense Rx |
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Term
| oral contraceptives (norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol) indication |
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Definition
effects on acne of patches and vaginal rings has not been studied
alternative treatment for women with moderate acne
first line treatment of moderate to severe acne in women with laboratory evidence of hyperadrogenism |
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Term
| oral contraceptives (norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol) MOA |
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Definition
antiandrogen effect leading to decreased sebum production
decreases free trestosterone levels
inhibit ovarian production of androgens by suppressing ovulation |
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Term
| oral contraceptives (norgestimate/ethinyl estradiol, norethindrone/ethinyl estradiol, drospirenone/ethinyl estradiol) ADRs |
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Definition
N/V, breast tenderness, spotting and breakthrough bleeding, weight gain, acne flare
thromboembolism |
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Term
| spironolactone indication |
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Definition
| alternative, off label treatment for moderate to severe acne in women with laboratory evidence of hyperandrogenism |
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Term
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Definition
| antiandrogen and inhibitor of 5alpha-reductase decreases sebum production |
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Term
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Definition
| dose dependent, hyperkalemia, irregular menses, breast tenderness |
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Term
| spironolactone administration |
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Definition
50-200 mg daily in 1-2 divided doses
higher doses than those used for BP lowering |
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Term
| which topical formulation do you recommend? |
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Definition
solutions, gels, creams, lotions, washes, disposable wipes:
gels have better stability, more potent, contain alcohol, propylene glycol, or water
alcohol based products cause more drying/irritation
cleansing washes - good for larger reas such as back and chest but not enough contact time to make an impact on the acne
skin type:
oily to normal skin = gels, solutions, otions
normal skin = gels, solutions, lotions, creams
normal to dry skin = lotions, creams (help moisturize dry skin)
apply product to entire affected area not individual lesions |
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Term
| recommend appropriate treatment options based on severity of disease: mild comedonal |
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Definition
1st choice -> topical retinoid
alternatives -> alternate topical retionid OR salicylic acid OR azelaic acid
alternatives for females -> topical retinoid
maintenance -> topical retinoid |
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Term
| recommend appropriate treatment options based on severity of disease: mild papular pustular |
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Definition
1st choice -> topical retinoid PLUS topical antibiotic
alternatives -> alternate topical retinoid PLUS alternate topical anticiotic OR azelaic acid
alternatives for females -> topical retinoid PLUS topical antibiotic
maintenance -> topical retinoid |
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Term
| recommend appropriate treatment options based on severity of disease: moderate papular pustular |
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Definition
1st choice -> oral antibiotic PLUS topical retinoid +/- benzoyl peroxide
alternatives -> alternate oral antibiotic PLUS alternate topical retinoid +/- benzoyl peroxide
alternatives for females -> oral antiandrogen PLUS topical retinoid/azelaic acid +/- topical antibiotic
maintenance -> topical retinoid +/- benzoyl peroxide |
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Term
| recommend appropriate treatment options based on severity of disease: moderate nodular |
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Definition
1st choice -> oral antibiotic PLUS topical retinoid +/- benzoyl peroxide
alternatives -> oral isotretinoin OR alternate oral antibiotic PLUS alternate topical retinoid +/- benzoyl peroxide/azelaic acid
alternatives for females -> oral antiandrogen PLUS topical retinoid +/- oral antibiotic +/- alternate topical antibiotic
maintenance -> topical retinoid +/- benzoyl peroxide |
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Term
| recommend appropriate treatment options based on severity of disease: severe nodular/conglobate |
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Definition
1st choice -> oral isotretinoin
alternatives -> oral antibiotic PLUS topical retinoid PLUS benzoyl peroxide
alternatives for females -> oral antiandrogens PLUS topical retinoid +/- alternate topical antibiotic
maintenance -> topical retinoids +/- benzoyl peroxide |
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Term
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Definition
topical products may take 4-8 weeks (up to 12 weeks) to see improvement
adverse effects usually resolve with continued use
acne may get worse before better
oral antibiotic may take 3-6 months to see improvement
dangers of overtreatment |
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