Acne Lecture PDF

11/6/24 Reading Jamie L. Woodyard and Chelsea M. Bake, (2024), “Acne,” APhA OTC - Dermatologic Dr. Lucas Nicola...

11/6/24 Reading Jamie L. Woodyard and Chelsea M. Bake, (2024), “Acne,” APhA OTC - Dermatologic Dr. Lucas Nicolau Disorders. https://doi.org/10.21019/aphaotc-derm.acne ACNE PGY-1 Community- based Pharmacy Resident Self-care, November 2024 1 2 Epidemiology Define the epidemiology and pathophysiology of acne Discuss non-pharmacologic strategies to aid in control of acne 2010 Global Burden of Disease study ranks acne as 8 th most prevalent disease worldwide Objectives Evaluate OTC pharmacologic options for use by patients in controlling acne Inflammatory disorder of the pilosebaceous glands, Identify patients who can appropriately use OTC results in lesions most commonly found on the face acne controlling products based on self-care exclusion criteria Age of peak prevalence: Female: 14-17 years Practice using our skills with a patient case Male: 16-19 years 3 4 1  11/6/24 Why do we treat? Internet Acne/Anti-aging Remedies ◦ Negative impact on quality of life ◦ associated with embarrassment, low self-esteem, and stress ◦ Can contribute to clinical depression and anxiety ◦ Long term effects including scarring worsening psychosocial effects of acne ◦ Cost ◦ $607 million spent on OTC acne product annually! 5 6 Pathophysiology Terms Result from processes in the pilosebaceous unit located in the dermis Hair follicle and sebaceous glands Sebum normally serves to protect the skin Comedone = pimple, blackhead, white head Many factors play a role in the Comedolytic = lysis of comedones, decreases comedones development of acne Excess sebum production Keratin = fibrous protein in the skin, hair and nails, too much Follicular colonization of bacteria causes patches of rough bumpy skin Disruption of keratinization process Inflammation Keratolytic = lysis of keratin, smoothing of skin Sebum = the oily substance produced in the sebaceous Triggers Diet glands Hormone changes Stress Medications 7 8 2  11/6/24 Sebum production Follicular colonization by Clinical Presentation by the sebaceous Cutibacterium Non-inflammatory lesions gland Open comedone = black head acnes Closed comedone = white head Key Inflammatory lesions Redness and inflammation = papule Pathologic Acne Redness, inflammation, purulence in center of lesion = pustule Factors Release of Alteration of the inflammatory keratinization mediators in the process skin 9 10 Etiology Subtypes Drug-induced Acne Acne cosmetica Anabolic steroids Acne excoriee (excoriated) Bromides Acne mechanica Corticosteroids Chloracne Corticotropin Isoniazid Drug-induced acne Lithium Hormone-induced acne Phenytoin Hydration-induced acne Less common: azathioprine, cyclosporine, disulfiram, phenobarbital, Stress-induced acne quinidine, tetracycline 11 12 3  11/6/24 Grading Treatment Goals Mild Moderate Severe Few erythematous Many erythematous Extensive pustules, papules and occasional papules and pustules erythematous papules, pustules mixed with and prominent scarring and multiple nodules on comedones an inflamed background T reatm en t G oals: 1.Decrease number and severity of Adherence to regimens and avoidance lesions of exacerbating factors are the most Self care Exclusions 2.Prevention of future lesions, scar important items to consider when M oderate to severe acne formation, and hyperpigmentation discussing acne control Exacerbating factors (medications) 3.Improvement in quality of life Possible rosacea No clinical improvement after six weeks of treatment 13 14 Non-pharmacologic management Cleansers strategies Eliminate/avoid exacerbating factors Diet - limit high glycemic index, milk, saturated and trans fatty acids Physical irritant Stress Cleanse Mild soap or non-soap cleanser no more than twice daily, use of abrasive products and excessive cleansing may worsen acne Hydration Facial toners Overuse can cause increased skin irritation Physical treatments Brush Cleansing cloths Heating devices Light therapy Scrubs 15 16 4  11/6/24 Moisturizers PHARMACOLOGIC TREATMENTS 17 18 Adapalene 0.1% (Differin Gel) Benzoyl peroxide Most common topical acne product available Available as prescription and OTC Effect: Antibacterial properties against C. acnes and keratolytic Prevents or eliminates the development of treatment resistance by C. acnes Nonprescription formulations include gels, washes, and creams with varying percentage concentrations (2.5%-10%) 19 20 5  11/6/24 Benzoyl Peroxide Salicylic Acid (Beta-hydroxy acids) Side effects Effect: Comedolytic agent o Bleaching of clothes, hair, pillowcases, etc. o Concentration dependent o Photosensitivity Concentrations 0.5-2% Should be applied 1-3 times daily o Skin dryness or irritation Side effects o Dryness, pealing Once daily to 2-3 times daily if needed WARNING: salicylic acid toxicity o Associated with topical application to Results are not immediate – can take weeks extensive areas of the skin has been o Continuous use is best recognized, especially in children, who metabolize drugs differently CONTRAINDICATIONS o Patients with diabetes or poor blood circulation 21 22 Alpha Hydroxy Acids Dicarboxylic Acid Effect: Effect: Used in the treatment of post inflammatory Natural exfoliating acids dyspigmentation due to its anti-tyrosinase activity Do not penetrate the pilosebaceous unit Useful in prevention/treatment of hyperpigmentation Most common acids are: glycolic, lactic, and citric acids Available in several nonprescription formulations varying in Used as adjunctive treatment for mild/moderate adult acne concentration from 4-10% Available as non-prescription gels, creams, lotions varying Once acne is controlled, AHAs may be useful to help correct in concentration from 10-14% scarring and hyperpigmentation Rx formulations come in 15-20% strengths Apply thin layer to affected areas twice daily Polyhydroxy acids – subset of AHAs with fewer adverse effects Adverse effects: burning, tingling, peeling, dryness They are marketed for patients with more clinical sensitivity if persistent skin irritation → decrease to once daily and have moisturizing and humectant properties Clinical improvement typical in ~4 weeks. 23 24 6  11/6/24 Sulfur + resorcinol Other Products Sulfur Tea Tree Oil Vitamin A Effect: Keratolytic and antibacterial in concentrations of 3-10% Antibacterial, antifungal and anti- Naturally occurring retinol with Generally accepted as effective in promoting inflammatory properties several metabolites resolution of existing comedone Active against Staphylococcus Used for fine lines and wrinkles Comedogenic with prolonged use aureus Oral or topical Other forms including zinc thiosulfate, zinc Should be diluted before use Side effects: dry skin, cracked lips sulfate, zinc sulfide – not GRASE No conclusive data on efficacy but Adverse events/reactions: noticeable odor may reduce lesion counts and dry skin Sulfur/Resorcinol Effect: Keratolytic, antibacterial, antifungal and fosters cell turn over Resorcinol is not effective alone, enhances effect of sulfur 25 26 Other Products Pharmacologic Comparison Chart Oral Zinc Nicotinamide/Niacinamide May be an alternative to W ater soluble derivative of vitamin tetracyclines b3 Bacteriostatic against C. acnes – Active form of niacin shown effectiveness against Anti-inflammatory improves skin severe acne texture of sun damaged skin and Adverse events/reactions: nausea, decreases sebum production vomiting, diarrhea (intolerable to No concrete data many, leads to poor adherence) 27 28 7  11/6/24 Product Selection Considerations OTC and Skin cleansers and Gels are most nonprescription topical acne products effective since they products are only are available in a act as astringents indicated for use in variety of vehicles and remain on the mild acne and strengths skin longest Creams and lotions are generally less Ointments are not Patients should start irritating to the skin used because they with lowest strength are occlusive, tend to available and than gels and solutions worsen acne gradually increase 29 30 Special Populations Antibiotics Doxycycline, minocycline Young Women Pregnant Patients Pediatric Patients clindamycin Most cases of infantile and Assess for impact of Acne may develop because hormone imbalance Patients may benefit from of hormonal imbalances neonatal acne are self-limiting Best to consult with Prescription Tretinoin Products If pregnancy occurs during oral contraceptive pills to pediatrician help correct androgen treatment with any acne Isotretinoin (Accutane, Claravis, medication, the medication Use of aspirin and aspirin- levels Myorisan) should be discontinued containing products, such as Refer to PCP if appropriate In Rhode Island – salicylic acid, in children REMS Patient’s provider will pharmacists may prescribe evaluate risk vs. benefit should be avoided due to the hormonal contraception - risk of salicylic acid toxicity Spironolactone regulations pending for and Reye’s syndrome 2025 implementation 31 32 8  11/6/24 Collect Patient Case 18, female, 5 ft 5 in., 135 lb College student who studies dance. HPI/CC: She states that her acne gets worse whenever she has a dance performance, A young woman, Ms. Marshall, comes to the pharmacy which is nearly once a week. counter requesting a treatment option for acne. She expresses She states that she has been wearing some concealer to “hide” the spots. distress over her visible facial lesions: “I hate going to my dance classes because I feel people are staring at the pimples on my Eats a healthy breakfast and lunch; has a homecooked dinner most nights. On face.” She has noticed a few yellowish pimples but states that dance recital nights she usually eats fast food while traveling. most of the spots are red raised bumps. She reports that she has had occasional mild “breakouts” since her early teens but NKDA or Adverse Events Related to Medications notes the condition has been worsening over the past 3 weeks. PMH: History of mild acne that responded to self-treatment with salicylic acid face wash, Asthma Medications: albuterol inhaler 90 mcg; inhale 1–2 puffs every 4–6 hours as needed 33 34 The current presentation of papule formation accompanied by few pustules is consistent with mild acne Recommend self- Refer Ms. care with Marshall to an Assess – available Likely stress-induced from her dance appropriate nonprescription health care products and performances What are provider. nondrug lifestyle modifications. Assess Makeup could be exacerbating factor our Recommend self- options? care until the patient can see her regular health Take no action. EXCLUSIONS: care provider. If her acne worsens or begins to cause scarring if she is pregnant or plans to become pregnant soon 35 36 9  11/6/24 Recommend patient use an over-the- Counsel and educate on how to use product: counter acne treatment product and implement nondrug measures to Apply a thin layer of the gel once daily to a few minimize/control her acne. affected areas for 2-3 days Increase application as tolerated up to 2-3 times a day Plan OTC formulation of a benzoyl peroxide gel and lifestyle modifications Implement Counseling on side effects and when to see effect: Slight skin irritation is normal Stress management techniques Effects seen anywhere from 5 days to a few Benzoyl peroxide will help with her mild form of weeks acne and help in controlling breakouts Continued and consistent use is important for Product will be patient specific based on cost, maximum effectiveness availability, and preference May bleach clothing, hair, bedding 37 38 Contact Ms. Marshall in 2 weeks to see if she has experienced any Thank you! decrease in her acne and to check Exam Questions Follow-Up: for toleration of the product recommended Case based questions Monitor Please reach out with questions about material☺ and Recommend that she contact her regular health care provider if her Evaluate acne worsens or if she does not [email protected] see improvement after 6 weeks of consistent treatment. 39 40 10