Acne Vulgaris Scott Stadler, Pharmacy Intern
Description: Acne Vulgaris Scott Stadler, Pharmacy Intern Introduction Acne Vulgaris is a common skin condition in which pilosebaceous follicles are impacted through various inflammatory pathways This condition impacts approximately 50 million people
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slide1. Acne Vulgaris Scott Stadler, Pharmacy Intern<br>
slide2. Introduction Acne Vulgaris is a common skin condition in which pilosebaceous follicles are impacted through various inflammatory pathways
This condition impacts approximately 50 million people across the United States
Nearly 85% of teenagers experience acne, to some degree
No mortality associated with acne vulgaris - why treat?
Anxiety
Depression
Permanent scarring Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide3. Pathogenesis Involves several key pathways, and understanding of how each contributes is evolving:
Follicular hyperkeratinization
Microbial colonization with Propionibacterium acnes
Inflammatory mechanisms involving both innate and acquired immunity
Other mechanisms that are not as thoroughly understood:
Neuroendocrine regulatory mechanisms
Diet
Genetics Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide4. Classifications Mild acne vulgaris:
Scattered, small (<5 mm), comedonal or inflamed papules or pustules without associated scarring
Limited skin involvement (involvement of one body area or relatively few lesions in more than one body area)
Absence of nodules
Absence of near confluent skin involvement Moderate to Severe:
Refer to provider
Visually prominent acne consisting of many comedonal or inflamed papules or pustules
Presence of nodules
Involvement of multiple body areas with more than a few, scattered lesions
Associated scarring Graber, E.. (2021). Acne Vulgaris: Overview of Management. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.<br>
slide5. Classifications Mild Moderate-Severe Picture taken from: Yahia Albaili, DO, Dermatlas; http://www.dermatlas.org. Picture taken from: Douglas Hoffman, MD, Dermatlas; http://www.dermatlas.org.<br>
slide6. Treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide7. Treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide8. Benzoyl Peroxide (BP) MOA: Releases free-radical oxygen which oxidizes bacterial proteins in the sebaceous follicles decreasing the number of anaerobic bacteria and decreasing irritating-type free fatty acids
Can be used for mild papulopustular and mixed (comedonal and papulopustular) acne
Available in many formulations:
Gels, Creams, Lotions, Cleansers, Pads, Masks
Available strengths range from 2.5%-10%
2.5% recommended for optimal benefit:side effect ratio
Recommended use: Apply once daily
Onset: Usually take 8-12 weeks for noticeable improvement
Adverse reactions: hypersensitivity*, desquamation, contact dermatitis, redness
Clinical Pearl: Can bleach clothing! Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide9. Topical Retinoids MOA: Decreases the cohesiveness of follicular epithelial cells and decreases micromedo formation. Additionally, stimulates mitotic activity and increased turnover of follicular epithelial cells causing extrusion of the comedones
Can be used for comedonal acne
Available in many formulations:
Gels, Creams, Lotions, Foams
Products available:
Tretinoin, Adapalene*, Tazarotene, Trifarotene
Most products typically applied once daily in the evening
May see improvement beginning at week 2 to week 7
Adverse effects:
irritation, dryness, and flaking of the skin, an effect most notable during the first month of therapy
Patients may benefit by slowly titrating frequency/potency Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide10. Combination Therapy Topical Clindamycin can be combined with Benzoyl Peroxide or retinoids
Clindamycin + Benzoyl Peroxide may be more efficacious than Benzoyl Peroxide alone
Why not use Clindamycin alone?
ANTIBIOTIC RESISTANCE
Benzoyl Peroxide can be used in combination with retinoids
Do not use tretinoin at same time as BP
BP causes tretinoin to be less stable
Other topical retinoids are less susceptible to this interaction
Ideal to use BP in the morning and topical retinoid in the evening to avoid interaction altogether
More effective than either agent used alone Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide11. Alternative Agents Salicylic acid
Appropriate alternative for people who cannot tolerate retinoids
Azelaic acid
Antimicrobial and comedolytic properties
Typically well tolerated
Topical erythromycin
Can be used in place of clindamycin
Higher rates of resistance Ondo, W. G. (2021). Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.<br>
slide12. Role of Diet in Acne? Data are limited
Some research suggests that high glycemic index diets are associated with acne
Important to note: there may be confounding variables
When switching to LGI diet, participants lost weight, improved BMI, and improved insulin sensitivity
Also, consumption of dairy products may be associated with acne Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide13. Hormonal Agents Estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females
Weigh risk vs. benefit
Recommended “moderate” category, but use as monotherapy?
Spironolactone is useful in the treatment of acne in select females
Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide14. Complementary/Alternative Medicine Beware of social media trends
Often can pose unwanted risks
Always advise patient to check with their doctor/pharmacist first
Tea Tree Oil
Some studies show efficacy equivalent to BP
Safety data not robust, but may be better tolerated than BP Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide15. Take-home points Acne is a common skin condition and can impose severe mental health challenges for our patients
Set realistic standards:
It may take several weeks for patients to begin to see improvements after starting therapy, and the improvements may not reach their hopeful expectations
Know which products you carry over-the-counter and counseling points
Adverse reactions, timing, when to follow-up with doctor
Assess whether the acne is mild enough to be treated OTC
Clindamycin should not be used alone due to antibiotic resistance
Help patients make safe decisions<br>
slide2. Introduction Acne Vulgaris is a common skin condition in which pilosebaceous follicles are impacted through various inflammatory pathways
This condition impacts approximately 50 million people across the United States
Nearly 85% of teenagers experience acne, to some degree
No mortality associated with acne vulgaris - why treat?
Anxiety
Depression
Permanent scarring Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide3. Pathogenesis Involves several key pathways, and understanding of how each contributes is evolving:
Follicular hyperkeratinization
Microbial colonization with Propionibacterium acnes
Inflammatory mechanisms involving both innate and acquired immunity
Other mechanisms that are not as thoroughly understood:
Neuroendocrine regulatory mechanisms
Diet
Genetics Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide4. Classifications Mild acne vulgaris:
Scattered, small (<5 mm), comedonal or inflamed papules or pustules without associated scarring
Limited skin involvement (involvement of one body area or relatively few lesions in more than one body area)
Absence of nodules
Absence of near confluent skin involvement Moderate to Severe:
Refer to provider
Visually prominent acne consisting of many comedonal or inflamed papules or pustules
Presence of nodules
Involvement of multiple body areas with more than a few, scattered lesions
Associated scarring Graber, E.. (2021). Acne Vulgaris: Overview of Management. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.<br>
slide5. Classifications Mild Moderate-Severe Picture taken from: Yahia Albaili, DO, Dermatlas; http://www.dermatlas.org. Picture taken from: Douglas Hoffman, MD, Dermatlas; http://www.dermatlas.org.<br>
slide6. Treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide7. Treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide8. Benzoyl Peroxide (BP) MOA: Releases free-radical oxygen which oxidizes bacterial proteins in the sebaceous follicles decreasing the number of anaerobic bacteria and decreasing irritating-type free fatty acids
Can be used for mild papulopustular and mixed (comedonal and papulopustular) acne
Available in many formulations:
Gels, Creams, Lotions, Cleansers, Pads, Masks
Available strengths range from 2.5%-10%
2.5% recommended for optimal benefit:side effect ratio
Recommended use: Apply once daily
Onset: Usually take 8-12 weeks for noticeable improvement
Adverse reactions: hypersensitivity*, desquamation, contact dermatitis, redness
Clinical Pearl: Can bleach clothing! Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide9. Topical Retinoids MOA: Decreases the cohesiveness of follicular epithelial cells and decreases micromedo formation. Additionally, stimulates mitotic activity and increased turnover of follicular epithelial cells causing extrusion of the comedones
Can be used for comedonal acne
Available in many formulations:
Gels, Creams, Lotions, Foams
Products available:
Tretinoin, Adapalene*, Tazarotene, Trifarotene
Most products typically applied once daily in the evening
May see improvement beginning at week 2 to week 7
Adverse effects:
irritation, dryness, and flaking of the skin, an effect most notable during the first month of therapy
Patients may benefit by slowly titrating frequency/potency Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide10. Combination Therapy Topical Clindamycin can be combined with Benzoyl Peroxide or retinoids
Clindamycin + Benzoyl Peroxide may be more efficacious than Benzoyl Peroxide alone
Why not use Clindamycin alone?
ANTIBIOTIC RESISTANCE
Benzoyl Peroxide can be used in combination with retinoids
Do not use tretinoin at same time as BP
BP causes tretinoin to be less stable
Other topical retinoids are less susceptible to this interaction
Ideal to use BP in the morning and topical retinoid in the evening to avoid interaction altogether
More effective than either agent used alone Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide11. Alternative Agents Salicylic acid
Appropriate alternative for people who cannot tolerate retinoids
Azelaic acid
Antimicrobial and comedolytic properties
Typically well tolerated
Topical erythromycin
Can be used in place of clindamycin
Higher rates of resistance Ondo, W. G. (2021). Clinical features and diagnosis of restless legs syndrome and periodic limb movement disorder in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.<br>
slide12. Role of Diet in Acne? Data are limited
Some research suggests that high glycemic index diets are associated with acne
Important to note: there may be confounding variables
When switching to LGI diet, participants lost weight, improved BMI, and improved insulin sensitivity
Also, consumption of dairy products may be associated with acne Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide13. Hormonal Agents Estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females
Weigh risk vs. benefit
Recommended “moderate” category, but use as monotherapy?
Spironolactone is useful in the treatment of acne in select females
Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide14. Complementary/Alternative Medicine Beware of social media trends
Often can pose unwanted risks
Always advise patient to check with their doctor/pharmacist first
Tea Tree Oil
Some studies show efficacy equivalent to BP
Safety data not robust, but may be better tolerated than BP Journal of the American Academy of Dermatology. (2016). Guidelines of Care for the management of acne vulgaris. Retrieved from https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext<br>
slide15. Take-home points Acne is a common skin condition and can impose severe mental health challenges for our patients
Set realistic standards:
It may take several weeks for patients to begin to see improvements after starting therapy, and the improvements may not reach their hopeful expectations
Know which products you carry over-the-counter and counseling points
Adverse reactions, timing, when to follow-up with doctor
Assess whether the acne is mild enough to be treated OTC
Clindamycin should not be used alone due to antibiotic resistance
Help patients make safe decisions<br>