Transcript Topical therapy

Acne Vulgaris
Mandy Jones, PharmD, PA-C, BCPS
Spring 2014
Clinical Types
• Noninflammatory
– Open & closed
comedones, papules,
few pustules
• Inflammatory
– Erythematous papules,
pustules, possible
scarring
Mild→ Moderate→ Severe
Post-inflammatory hyperpigmentation
Pharmacologic Treatment:
Patient Considerations
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Clinical type of acne (comedonal, inflammatory, nodular, etc)
Severity of acne
Skin type (Dry, Oily)
Presence of scarring or post-inflammatory hyperpigmentation
Menstrual history and signs of hyperandrogenism in women
History of prior successful and failed treatments
Allergies
Medication adherence patterns
History of acne promoting medications
Pyschological impact of acne on the patient
Patient preference and cost concerns
General Self Care Measures and NonPharmacologic Treatment
• Covered in OTC and listed in notes
General Treatment Pearls
• 8 weeks for microcomedo to mature
• Mild-Moderate→ Topical
• Moderate-Severe→ Systemic
• Topical therapy:
– Consider skin type and dosage
form
TOPICAL THERAPY
TOPICAL THERAPY
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Topical Retinoids (TRs)
Benzoyl Peroxide (BPO)
Azelaic acid 20% Cream
Dapsone 5% Gel
Salicylic acid
Topical antibiotics
Topical Retinoids
• tretinoin (Atralin™; Avita®; Renova®; Retin-A® Micro; Retin-A®; Tretin-X™)
• adapalene (Differin® XP; Differin®)
• tazarotene (Avage™; Tazorac®)
• MOA: Vitamin A derivatives----directly targets genes implicated in acne
pathogenesis
– Decreases comedogenesis by: binding to Retinoic acid receptors (RARs) and Retinoid X
Receptors inside keratinocytes→ activation of regulatory DNA sequencing called retinoid
hormone response elements→ transcription of target genes responsible for
keratinization→ normalization of follicular keratinization and decreases cohesiveness
of keratinocytes
– Decreases inflammation : Retinoid receptor complexes compete for AP-1 (a key
transcription factor in inflammation) and down regulates expression of toll-like receptor
(TLR-2), which is responsible for the inflammatory mechanism in acne
Topical Retinoids
Some specifics……..
Fact or Fiction?
It doesn’t matter which TR to
recommend….they’re all the same
Eh---it depends on the parameter
• Efficacy:
– ?? Tazarotene >> Tretinoin & Adapalene??
– Head-to-head trials do not definitely support one TR over
another in terms of efficacy
• Safety:
– In order of INCREASING skin irritation:
• Adapalene << Tretinoin << Tazarotene
• And other nuances:
– Atralin®- made with soluble fish proteins – avoid in fish allergy
– Tretinoin and tazarotene are deactivated by sunlight and
oxidized by BPO (can’t use together at same time)
– Adapalene is stable in sunlight & in presence of BPO …..Epiduo®
is combo product of adapalene and BPO
TOPICAL THERAPY
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Topical Retinoids (TRs)
Benzoyl Peroxide (BPO)
Azelaic acid 20% Cream
Dapsone 5% Gel
Salicylic acid
Topical antibiotics
Systemic Therapy
• For moderate to severe acne
– Oral Abx
• Minocycline, doxycycline (1st line)
• Erythromycin, clindamycin (2nd line)
• Sulfamethoxazole-trimethoprin (rarely)
– Isotretinoin
Oral Abx
• Some specifics……………..
Fact or Fiction?
Using antibiotics for acne increases the risk of
being infected with resistant bacteria.
Somewhat true….but not terrible
• Oral AND topical→
resistant P. acnes & CNS
& colonization with
Strep. pyogenes
• Increased risk of strep
throat and
impetigo….but
treatment is no
different
• Resistant p. acnes more
difficult to treat
Oral Abx: Recommendations
• Limit use to 12-18 weeks
• Never use as monotherapy…..combine with BPO
to prevent resistance, or with TR to decrease
duration of Abx use
• Once lesions clear, d/c Abx and use TR +/- BPO for
maintenance
• Rec. Doxy over Mino
– Mino higher cost, no definitive studies indicating Mino
superiority, Mino assoc. with more concerning ADRs
– If no response with Doxy, can switch to Mino (pts may
respond to one tetracycline but not the other)
But what about the Doxy shortage?
• If you only have one salt form on your shelves,
suggest using what you have
– Hyclate and monohydrate equally effective, but
hyclate associated with more GI upset
• Use TR plus BPO or topical Abx instead
• If oral Abx is needed, suggest
– Minocycline $$ or macrolide (erythro or clinda)
Isotretinoin
• Reserved for severe recalcitrant acne,
nodulocystic acne, or significant physical or
psychological scarring
• Only acne agent that works on all 4 mechanisms
of acne pathogenesis
• Exact MOA not known, but it:
– Shrinks sebaceous glands, decreases sebum secretion
thus reducing p.acnes growth
– Fosters keratinocyte differentiation and normalizes
desquamation
Isotretinoin, iPLEDGE, and other
specifics
Acne Vulgaris
Other therapies
• Oral contraceptives
• Spironolactone
• Oral corticosteroids
Special populations/situations
• Post-inflammatory
hyperpigmentation
• Pregnancy
• Pediatrics and adolescents
Oral Contraceptives TYPO in notes
• Preference/Pearls----should say:
– AVOID 2nd generation progestins in patients with
acne (i.e. levonorgestrel; norgestrel)
– 2nd generation progestions:
• High affinity for androgen receptor→ most androgenic
• 1st, 3rd, 4th generation OK to use