Define white head
- closed comodone
- first clinically visible lesion of acne
- completely obstructed
Define black head
- open comodone
- dark colour due to contents being oxidized (lipid and melanin)
What is the difference between papule, pustule, nodule, and cyst?
Papule = solid, elevated lesion
Pustule = vesicle filled with purulent liquid <5mm
Nodule = deep lesion, warm, tender, and firm, >5mm diameter
Cyst = nodule containing liquid
What are the three classifications of acne?
Mild/comedonal = presence of comedones, papules or pustules or a mix
Moderate/papulopustular = primarily several/many papules and pustules
Severe/papulopustular and nodular = several/many papules and pustules plus nodules and cysts
What are the risk factors for exacerbation of acne?
Medications: anabolic steroids, COCs high in progestin, coal tar products, crystal meth, gabapentin, lithium
Cosmetics, hair products, bacteriostatic soaps
Use of occlusive garments: helmets, chin straps and hijabs
What are the red flags associated with the presentation of acne?
- <12 years
- new onset >30 years
- widespread distribution of lesions beyond face
- severe acne (risk of scarring) –> URGENT derm referral
- significant psychosocial impact
- signs of hyperandogenism (infrequent menses, infertility, insulin-resistant diabetes)
- sudden onset associated with fever or arthralgias –> URGENT ER referral
- unresponsive to therapy or unclear diagnosis
What are the goals of therapy for the treatment of acne?
- Clear existing lesions and prevent new ones
- Lessen physical discomfort from inflamed lesions
- Improve dermal appearance
- Prevent or minimize potential adverse psychological effects
- Prevent or minimize scarring or dyspigmentation
Which products should be used for dry/sensitive skin versus oily skin?
Dry/sensitive –> use cream or lotion which are less drying
Oily –> less greasy formulas like gel
To improve adherence to treatment, what should treatment be chosen according to?
- symptoms
- skin type
- skin sensitivity
- risk of adverse effects
- patient preference
When should systemic therapy be considered?
- moderate/severe acne
- lesions affecting a large number of sites (back, chest, face)
- patient presents with scarring
- patients with significant psychosocial impact
- topical therapy fails
What is the first line agent for mild-moderate acne (comedonal)?
Benzoyl peroxide 2.5%
Evidence suggests that it is no better to use >2.5%
What are some important counselling points to communicate to patients when recommending BPO? (onset, peak effectiveness, how to use, AEs)
- effective in prevention of bacterial resistance; always added to oral or topical antibiotics to decrease resistance
- avoid washes and soaps because they don’t have enough contact time with the skin
- starts working within a week but optimal improvement is 8-12 weeks (possibly gets worse before it gets better)
- apply topically to entire effected area and start applying for 15 minutes/night, to eventually overnight
- AE: dryness, peeling, irritation, burning, bleaches clothing, smell lingers, CD possible
- safe in pregnancy and breastfeeding
When is salicylic acid appropriate in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
Available as another non-prescription product for comedonal acne; mildly comedolytic, keratolytic, mildly antibacterial and anti-inflammatory
Strength: 0.5-3.5% twice daily strength, anything under 20% is unscheduled
Onset: optimal improvement seen in 8-12 weeks
Directions: TID usually but follow package instructions
AE: drying, burning, stinging, peeling
When should azelic acid be used in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
PRESCRIPTION topical product for comedonal acne which helps reduce hyperpigmentation, less irritation than BPO but less efficacy
MOA: camedolytic and antibacterial Strength: 15% gel (good for oily skin) Onset: optimal improvement in 8-12 weeks Directions: TID AE: well tolerated
EFFECTIVE AND SAFE IN PREGNANCY
When should dapsone be recommended in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
PRESCRIPTION topical product used for inflammatory acne and has no cross reactivity with sulphonic allergies
MOA: synthetic anti-inflammatory and anti-bacterial sulfone
Strength: 5% gel
Onset: optimal improvement in 8-12 weeks
Directions: TID
AEs: mildly irritating and MAY DISCOLOUR SKIN
Safety in pregnancy NOT ESTABLISHED
When should topical retinoids be used in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
Can be used as first lime for all types of acne as mono-therapy of combination
MOA: decreases inflammatory and non-inflammatory lesions, normalizes follicular desquamation
Strength: various but all Schedule 1 as single entity or combination products
Onset: maximum response at 12 weeks but IT WILL GET WORSE FIRST
Directions: apply pea sized amount to dry skin at night, start 15 minutes and increase to overnight application (used at night due to skin sensitivity)
AE: skin irritation, burning, hypopigmentation, photosensitivity
NOT SAFE IN PREGNANCY
When should topical antibiotics (clindamycin and erythromycin) be used in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
PRESCRIPTION topical product used for inflammatory acne
MOA: decreases skin colonization of C. acnes and decreases inflammation
Strength: 1% solution (clindamycin only, erythromycin is not readily available)
Onset: optimal improvement in 8-12 weeks
Directions: TID and MUST be used with BPO
AEs: mildly irritating, peeling, itching, dryness (contraindicated with history of colitis)
SAFE in pregnancy
Why use combination topical products?
BPO’s oxidizing action may inactivate retinoids and antibiotics use premixed formulas
Benzoyl peroxides + retinoids are GREAT –> tactupump
When should oral antibiotics be considered in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
Reserved for moderate to severe acne, acne on diffuse area or topical therapies have failed
MOA: targets C acnes and is anti-inflammatory
Strengths: various
Onset: 6-8 weeks to see if effective, d/c if no improvement or if goals are reached in 3-6 months
Directions: USE WITH BPO
AE: long term therapy may increase bacterial resistance, upset stomach, photosensitivity, vaginal candidiasis
May decrease effectiveness of oral contraceptives, decreases absorbtion of iron, aluminum, bismuth, calcium, and magnesium (space 2 hours dosing)
DO NOT USE IN PREGNANCY
What are the oral antibiotic options for the treatment of acne?
Doxycycline –> pretty well tolerated
Minocycline –> large SE profile (hyperpigmentation, dizziness, upset stomach, risk of lupis)
Tetracycline –> dosed TID, take on empty stomach to avoid decrease in absorption
Erythromycin and trimethoprim are second and third line
What are the options for hormonal therapy in the management of acne?
COC pills
- antiandrogenic effect
- useful for flares during menstrual cycle
- response time 3-6 months
- Diane 35, Yasmin, Tri-cyclen, alesse
Spironolactone
- antiandrogenic effect
- 25-200mg/day
- AE: hyperalkemia, diuresis, irregular menses, breast tenderness, nausea, headache, fatigue, dizziness, feminization of make sex fetus
When should Isotretinoin be considered in the management of acne and what are important counselling points to communicate when recommending it? (MOA, strengths, onset, directions, AEs)
Most powerful anti-acne reserved for severe acne, scarring and induces prolonged remission
MOA: binds to nuclear retinoid receptors and affects transcription factors resulting in reduction of sebaceous glands, sebum production, excretion, inflammation and C. acnes
Strengths: build up tolerance to 120-150mg/kg or until clear skin is achieved
Onset: clinical worsening for 4-8 weeks possible
Directions: take with high fat meal to increase absorption
AE: teratogenic, mucocutaneous dryness, myalgia, arthralgia, suicidal ideation
*** must be stopped at least 1 month before becoming pregnant
What are some of the basic care measures to recommend to patients presenting with acne?
- avoid picking or scratching
- encourage healthy eating plan
- avoid harsh cleansing systems and abrasive cleaners
- cosmetics; oil-free makeup, wash off at night, d/c hairspray and occlusive products if possible
- sunscreen MINIMUM SPF 30
- stress management if this is a contributing factor
When is appropriate follow-up from a RPh and what monitoring parameters are important to check on?
RPh to follow up 2-3 months after initiating treatment
Evaluate:
- acne severity
- scar severity
- acne extent
- impact on QOL
- treatment satisfaction
- perceived improvement
- any AEs
- treatment modification if needed
