Podcast
Questions and Answers
What is the primary use of salicylic acid in acne treatment?
What is the primary use of salicylic acid in acne treatment?
What is a significant concern regarding topical antibiotics in acne treatment?
What is a significant concern regarding topical antibiotics in acne treatment?
What is the recommended frequency for applying salicylic acid if excessive peeling occurs?
What is the recommended frequency for applying salicylic acid if excessive peeling occurs?
Which of the following statements about oral antibiotics in acne treatment is true?
Which of the following statements about oral antibiotics in acne treatment is true?
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Which of the following is a commonly used topical antibiotic in acne treatment?
Which of the following is a commonly used topical antibiotic in acne treatment?
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Why should tetracyclines be avoided in children under 9 years old?
Why should tetracyclines be avoided in children under 9 years old?
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What is the role of antibiotics in acne treatment?
What is the role of antibiotics in acne treatment?
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How should topical antibiotics be used in antibiotic regimens for acne?
How should topical antibiotics be used in antibiotic regimens for acne?
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What is a common characteristic of acne vulgaris?
What is a common characteristic of acne vulgaris?
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At what age does acne typically peak in boys?
At what age does acne typically peak in boys?
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Which phase is involved in the progression of acne due to hormonal influences?
Which phase is involved in the progression of acne due to hormonal influences?
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Which treatment is particularly important for patients with darker skin tones who have acne?
Which treatment is particularly important for patients with darker skin tones who have acne?
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Which medication class aims to reduce inflammation and bacteria in acne treatment?
Which medication class aims to reduce inflammation and bacteria in acne treatment?
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What is the primary action of salicylic acid in acne treatment?
What is the primary action of salicylic acid in acne treatment?
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Which of the following best describes the demographic most affected by acne vulgaris?
Which of the following best describes the demographic most affected by acne vulgaris?
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Which of the following components is NOT part of the pilosebaceous unit where acne occurs?
Which of the following components is NOT part of the pilosebaceous unit where acne occurs?
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What is the primary characteristic of azelaic acid in acne treatment?
What is the primary characteristic of azelaic acid in acne treatment?
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Which topical retinoid is considered the first choice for both treatment and maintenance therapy?
Which topical retinoid is considered the first choice for both treatment and maintenance therapy?
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Which treatment option is typically included for maculopapular acne in female patients?
Which treatment option is typically included for maculopapular acne in female patients?
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What should be noted about the use of topical retinoids?
What should be noted about the use of topical retinoids?
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Which of the following is NOT a typical treatment for comedonal acne?
Which of the following is NOT a typical treatment for comedonal acne?
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What is a key benefit of adapalene for patients with darker skin tones?
What is a key benefit of adapalene for patients with darker skin tones?
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What mechanism primarily describes the action of topical retinoids?
What mechanism primarily describes the action of topical retinoids?
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Which treatment is considered the most effective for nodular acne?
Which treatment is considered the most effective for nodular acne?
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Study Notes
Salicylic Acid
- Mild comedolytic and keratolytic agent available over-the-counter in concentrations ranging from 0.5% - 2%
- Considered a milder and less effective alternative to prescription tretinoin and benzoyl peroxide
- Typically applied once or twice daily in a gel formulation to the entire affected area
- Limit use to once daily or every other day if excessive peeling occurs
- Chronic use on large areas of the body may increase the risk of systemic salicylate toxicity
Topical Antibiotics
- Do not resolve existing lesions, but can prevent future lesions by decreasing P. acnes colonization and inflammation
- Inhibit the release of reactive oxygen species by P. acnes, reducing leukocyte recruitment
- Successful courses do not necessarily eradicate P. acnes
- Avoid use as monotherapy due to concerns for bacterial resistance
- Can augment topical retinoids in the initiation of therapy for comedonal and papular acne cases involving inflammatory lesions
- Used in regimens for patients failing monotherapy
- Typically applied once or twice daily for 3 months, followed by continuation of topical retinoid for maintenance therapy
- Clindamycin and erythromycin are commonly used agents
Oral Antibiotics
- Should not be used as monotherapy
- Preferred over topical agents when lesions are widespread or difficult to reach
- Used as a step-up therapy when topical antibiotic regimens fail to suppress acne
Doxycycline
- Most convenient and effective oral antibiotic
Tetracycline
- Used as an alternative for oral antibiotics
- Should not be prescribed for children younger than 9 years of age due to potential impairment of bone growth and discoloration of forming teeth
- Pregnant women must avoid tetracyclines due to bone growth effects on the fetus
Treatment Selection for Acne Type
Comedonal Acne
- Topical retinoid, azelaic acid
- Salicylic acid as an alternative or add-on
Maculopapular Acne
- Topical retinoid + topical antimicrobial (antibiotic or benzoyl peroxide)
- Topical retinoid + oral antibiotic + benzoyl peroxide
- For female patients:
- Combination oral contraceptive
- Androgen receptor antagonist
Nodular Acne
- Isotretinoin
Topical Retinoids
- Active keratolytics (the most potent comedolytic agents)
- Reduce obstruction within the follicle
- Inhibit microcomedone formation, decreasing the number of mature comedones and inflammatory lesions
- Do not have antibacterial properties
- Should be applied at bedtime (to avoid degradation in ultraviolet light), a half-hour after cleansing, starting with every other night for 1 to 2 weeks to avoid irritation and hyperpigmentation
- Doses can be increased after 4 to 6 weeks
Tretinoin
- First generation retinoic acid and vitamin A acid
- Should not be used in pregnant women due to the risk to the fetus
Adapalene (Differin)
- Topical retinoid of first choice for both treatment and maintenance therapy
- Effective comedolytic and anti-inflammatory agent
- Less irritating than other topical retinoids
- Should be considered for patients with darker skin due to a reduced risk of hyperpigmentation
Tazarotene (Tazorac)
- Second generation topical retinoid
- As effective as tretinoin for comedonal acne, and more effective for inflammatory lesions
- Applied once daily
- Less tolerated than tretinoin
Azelaic acid (Azelex)
- Dicarboxylic acid with antibacterial, anti-inflammatory, and comedolytic activity
- Limited efficacy compared with other therapies
- Used as an alternative to topical retinoids for maintenance therapy for patients unable to tolerate them
- Foams, sprays, and lotions are especially useful for areas that pose application challenges such as the scalp, other hairy areas, and locations that are difficult to reach
Acne Vulgaris
- Chronic inflammatory dermatosis notable for open or closed comedones (blackheads and whiteheads) and inflammatory lesions, including papules, pustules, or nodules (also known as cysts)
- Most common skin condition in the United States, affecting an estimated 40 million to 50 million people
- Roughly 85% of people with acne are adolescents, but acne can occur at any age
- Peak severity: 13 for girls, 15 for boys
- Severity and extent reduce after adolescence (80% by 18-19, 95% by 25), but most experience occasional lesions into adulthood
- Upward of 40% of men and women older than 25 years of age have acne
Pathophysiology
- Acne is the result of several pathologic processes that occur within the pilosebaceous unit
- Located in the dermis
- Site of acne disorder
- Consists of:
- Hair follicle: tubular infolding (invagination) of the epidermis containing the root of hair
- Sebaceous gland (secretes sebum): sebum is a light yellow, oily fluid responsible for keeping skin & hair moisturized
- Arrector pili muscle: involuntary muscle responsible for hair erection when it contracts in case of cold and fear
Pathogenic Stages for Acne
- Androgenic hormonal triggers and increased follicular keratinization
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