Acne Vulgaris PDF

ACNE VULGARIS Acne vulgaris is viewed by many as a rite of passage during the adolescent years. The psychosocial costs of acne are great. Adolescents are particularly affected by physical defects, no matter how minor they appear to others. The health care practitioner must be particularly sensitive...

ACNE VULGARIS Acne vulgaris is viewed by many as a rite of passage during the adolescent years. The psychosocial costs of acne are great. Adolescents are particularly affected by physical defects, no matter how minor they appear to others. The health care practitioner must be particularly sensitive to the perceived seriousness of the acne in addition to the clinical picture. What may seem inconsequential to the practitioner may be devastating to the patient. EPIDEMIOLOGY Up to 90% of all teenagers report having some form of acne. Adults suffer from the effects of acne as well: between 30% and 50% of adult women report experiencing acne. Consumers spend millions of dollars annually on prescription and over-the-counter (OTC) acne preparations. CAUSES Historically, numerous theories of the cause of acne vulgaris have been proposed, yet the exact cause remains unknown. Foods, stress, and dirt, although not causative, may exacerbate existing acne, which is why it is important to obtain a complete health history to ascertain precipitating factors. For example, a variety of drugs, physical occlusants, and conditions may exacerbate acne. Certain drugs used to treat tuberculosis, seizure disorders, or steroid- dependent chronic illness or depression (Corticosteroids, Isoniazid, Lithium, Phenytoin and Trimethadione) may cause a drug-induced acneiform rash. Acne may be exacerbated in teenagers and adults whose skin is exposed to oily agents, such as makeup, oil-based sunscreen, and oil-based hair products that come in contact with the forehead and temporal regions of the face (referred to as pomade acne). Friction acne from tight-fitting clothes, such as football helmets and hatbands, is found over the skin rubbed by the clothes. Women with a history of menstrual irregularities, hirsutism, and treatment-resistant acne should be evaluated for androgen excess associated with polycystic ovarian disease. Classification of acne and their physical appearance Comedonal acne; Open comedones (blackheads), closed comedones (whiteheads) Mild inflammatory acne; Papules Moderate inflammatory acne; Pustules, cysts Severe cystic acne Cysts; nodules, “ice-pick” scarring MANAGEMENT NON-PHARMACOLOGIC Skin care is the most important non-pharmacologic tool in the management of acne vulgaris.  The patient should be instructed to wash the face gently two or three times a day with a mild soap such as Basis, Cetaphil, Neutrogena, or Purpose.  Care should be taken to avoid harsh, drying cleansers.  Washing should be gentle because scrubbing the skin may exacerbate the acne.  Comedo removal, although therapeutic, should be undertaken only by someone skilled in the proper technique.  Picking or popping pimples may increase tissue damage and infection.  The health care provider should advise the patient to avoid manipulating the acne with the fingers.  The practitioner also needs to stress that ingestion of specific foods, such as chocolate, greasy foods, colas, and iodide containing foods, does not cause acne. Elimination diets are not considered therapeutic unless the patient reports an exacerbation associated with a certain food. Goals of Drug Therapy The goal of pharmacotherapy is to minimize the number and severity of new lesions, prevent scarring, and improve the patient’s appearance. The patient must be counseled that improvement of acne vulgaris takes time—usually 4 to 6 weeks. Some form of therapy will probably need to be continued throughout adolescence and even into young adulthood. PHARMACOLOGIC APPROACH Comedolytics Retinoic acid is available in cream (0.025%, 0.05%, and 0.1%), gel (0.01%, 0.025%), liquid (0.05%), and microsphere (0.04% and 0.1%) formulations. Retinoic acid is the acid form of vitamin A. When applied topically, retinoic acid acts on the epidermis with little systemic absorption to decrease cohesion between epidermal cells and increase epidermal cell turnover. The result is expulsion of open comedones and the conversion of closed comedones to open ones. When used properly, retinoic acid causes mild erythema and peeling of the skin. Some patients cannot tolerate daily use or prolonged contact at the initiation of therapy. For example, fair-skinned patients should be advised to start out using the product every other day. Adapalene (Differin), a topical medication for treating non-inflammatory acne, is a derivative of naphthoic acid, which binds to retinoid receptors. It is considered less irritating than retinoic acid. Comedolytic Bactericidals Benzoyl peroxide is both a comedolytic and bactericidal agent specific to P. acnes. It has a role in inflammatory acne because of its antibacterial qualities. By decreasing P. acnes levels, it decreases the inflammation caused by leukocytic and monocytic attraction to the pilosebaceous follicle. The major side effect of benzoyl peroxide is irritation. Azelaic acid is supplied as a 20% cream and is applied topically twice a day. Azelaic acid (Azelex) is believed to interfere with the deoxyribonucleic acid synthesis of acne-causing bacteria. The drug is considered as effective as topical macrolide antibiotics in treating papulopustular acne. Topical Antibiotics Topical antibiotics may be prescribed when comedolytic antibacterials are either not effective or not tolerated and systemic antibiotics are not desired. Topical antibiotics inhibit the growth of P. acnes and decrease the number of comedones, papules, and pustules. Clindamycin 2% (Cleocin T) or erythromycin 2% or 3% (many brands) is supplied in solutions, saturated pads, lotions, and gels. Oral Antibiotics When improvement cannot be achieved with topical therapy, oral antibiotics may be considered. Oral antibiotics are indicated for inflammatory acne because they suppress P. acnes as well as inhibit bacterial lipases, neutrophil chemotaxis, and follicular inflammation. Tetracycline is the most commonly used oral antibiotic for treating inflammatory acne. Doses begin at 500 to 1,000 mg/day are tapered to 250 mg/day after improvement occurs. Clinical improvement takes at least 3 to 4 weeks. Tetracycline permanently stains the teeth in children, so it should not be prescribed for patients younger than 12 years of age. Moreover, the drug is a teratogen. Side effects of tetracycline include photosensitivity and gastric irritation. Erythromycin and its derivatives are good alternatives when tetracycline fails or is not tolerated. Erythromycin 500 and 1,000 mg/day Retinoic Acid Derivatives Isotretinoin Isotretinoin (Accutane) has changed the management of acne therapy. It is reserved for patients with severe nodulocystic acne when other treatments fail. Isotretinoin is given at a dose of 0.5 to 1 mg/kg/day. Therapy continues for 15 to 20 weeks unless significant improvement occurs sooner. If therapy needs to be repeated, 2 months should elapse before restarting the drug. The most significant adverse effect of isotretinoin is teratogenicity. A 25-fold increase in fetal abnormalities has been documented. OTHERS Ethinyl Estradiol with Norgestimate Oral contraceptives that contain ethinyl estradiol and norgestimate (Ortho Tri-Cyclen, Tri- Sprintec) have been approved by the FDA for the treatment of acne. Relative to other therapies, oral contraceptives are inexpensive. Tazarotene Gel A retinoid pro-drug, tazarotene gel (Tazorac) is effective against both comedonal and inflammatory acne as well as psoriasis. Despite being a topical drug, tazarotene is considered teratogenic (pregnancy category X) and should be used only by women who take systemic contraceptives and who have a negative pregnancy test. Recommended Order of Treatment for Acne First line: Topical therapy (Improvement takes approximately 6 wk). Second line: Oral medications (Monitor in 6 weeks). Third line: Isotretinoin or refer to dermatologist (Prescribe with caution to women of childbearing age. Pregnancy category X)