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Managing adolescent acne: A primary care approach

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Contraceptive use? Fixed-Dose Topical Preparations Benzoyl ... S163-186 Patient 3 Moderate Acne Face Topical retinoid Alone Fixed-dose combination with ... – PowerPoint PPT presentation

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Title: Managing adolescent acne: A primary care approach


1
Managing adolescent acneA primary care approach
  • Daniel Krowchuk, M.D.
  • Departments of Pediatrics and Dermatology
  • Wake Forest School of Medicine

2
Disclosures
  • I have no relevant financial relationships with
    the manufacturer(s) of any commercial product(s)
    and/or provider(s) of commercial services
    discussed in this CME activity.
  • I do not intend to discuss an unapproved/
    investigative use of a commercial product/device
    in my presentation.

3
(No Transcript)
4
What are your patients using?
  • Benzoyl peroxide
  • Salicylic acid
  • Sulfur /- resourcinol

5
Whats Proactiv?
  • 2.5 benzoyl peroxide
  • 3-step program 19.95/mo for 3-month supply
    (29.95/mo for 5-step program)
  • New supply sent every 90 days
  • More than 5 million active customers 850
    million in annual sales1
  • Typical cost of benzoyl peroxide products 6.00
    7.00 for 1 oz2

1New York Times 10/18/07 2Drugstore.com 3/4/13
6
Phototherapy
Tanda Clear
  • Blue light may destroy P. acnes and red light is
    thought to reduce the inflammatory response
    combining the two is synergistic
  • Treatment varies depending on the device
  • Tanda Clear (blue) 3 minutes bid to affected
    areas
  • 36 reduction in papules after 8 weeks
  • Omnilux Clear-U (blue/red) 20 minutes qod to
    entire face
  • 69 reduction in lesion count after 8 weeks
  • Cost 143.22 to 349.00 at Amazon.com

Metelitsa AI, et al. Semin Cutan Med Surg
201130144-147.
Omnilux Clear-U
7
Heat
  • Device applies heat to individual lesions
    (induces bacterial self-destruction by heat-shock
    proteins)
  • Application times vary by device (2.5 sec 2.5
    min)
  • 44 to 55 reduction in number of lesions
    (compared to untreated side of face)
  • Cost 32 - 74 (Zeno), 149.95 (Thermaclear)

Med Lett Drugs Ther 2007 4951-52
8
Acne Pathogenesis
Adrenarche
Androgens
Sebum
Retention hyperkeratosis
Triglycerides
FFA
P. acnes
Open and closed comedones
Obstruction
Inflammation
Papules and pustules
Scars
9
Physical Examination
Closed comedones
Open comedones
DermAtlas
10
Physical Examination
Inflammatory lesions and scars
DermAtlas
11
Assessment
  • Mild
  • Few to several lesions, no nodules
  • ¼ of face involved
  • Moderate
  • Several to many lesions, few to several nodules
  • ½ of face involved
  • Severe
  • Numerous lesions, many nodules, scars
  • ?¾ of face involved

12
Patient Education
  • Describe causes of acne, treatment expectations
  • Role of dirt washing
  • Role of diet
  • Traumatizing lesions
  • Role of cosmetics
  • Hormonal influences
  • Environmental factors

13
Options for Acne Management
Adrenarche
Oral contraceptives
Androgens
Sebum
Retention hyperkeratosis
Triglycerides
FFA
P. acnes
Topical retinoid (e.g., Retin-A, Differin,
Epiduo) Azelaic acid Salicylic
acid Isotretinoin orally
Obstruction
Benzoyl peroxide Antibiotics BP/antibiotic Azelaic
acid
Inflammation
Scars
14
Cost of Some Acne Medications1
  • BP/clindamycin
  • Duac CS (45 g) 189.98
  • Benzaclin (50 g) 203.99
  • Topical retinoids (45 g)
  • Retin-A cream 0.025 171.44
  • generic 75.99
  • Retin-A Micro gel 0.1 245.99
  • Differin gel 0.1 308.85
  • Generic 159.99
  • BP/adapalene
  • Epiduo (45 g) 260.00
  • Oral antibiotics (60)
  • Doxycycline 100 mg cap 25.98
  • Monodox 938.42
  • Minocycline 100 mg cap 45.98
  • Minocin 616.72

Walmart 4 drugs erythromycin, tetracycline,
doxycycline, benzoyl peroxide wash http//walmart
.com/pharmacy
1drugstore.com 3/4/13
15
Patient 1
16
Mild Acne
  • Face
  • Comedonal
  • Topical retinoid qhs
  • Inflammatory or mixed
  • Benzoyl peroxide (BP)
  • BP/antibiotic fixed-dose
  • product
  • Topical retinoid fixed-dose
  • product
  • Chest or back
  • Consider BP wash for
  • use in shower qd

17
Benzoyl Peroxide Preparations
  • Benzoyl peroxide (BP)
  • Actions
  • Antibacterial, comedolytic
  • Preparations
  • 2.5 - 10
  • Gel, cream, lotion, wash
  • Use apply qd bid
  • Adverse reactions stinging, dryness, redness,
    contact dermatitis
  • Combination products
  • Actions
  • Antibacterial, comedolytic
  • Preparations
  • BP 5/clindamycin (Benzaclin, Duac)
  • BP 2.5/clindamycin (Acanya)
  • BP 5/erythromycin (Benzamycin)
  • Use apply qd bid depending on product

18
Applying Topical Medications
  • Dispense a pea-sized amount onto a finger tip
  • Touch to each side of forehead, each cheek, and
    chin
  • Spread with finger tips to create a thin coat to
    all affected areas

19
Patient 2
20
Mild Acne
  • Face
  • Comedonal
  • Topical retinoid qhs
  • Inflammatory or mixed
  • Benzoyl peroxide (BP)
  • BP/antibiotic fixed-dose
  • product
  • Topical retinoid fixed-dose
  • product
  • Chest or back
  • Consider adding BP wash
  • for use in shower qd

21
Topical Retinoids
  • Actions
  • Normalize keratinization
  • Anti-inflammatory
  • Use
  • Apply every 2nd night progressing to every night
    as tolerated
  • Adverse effects
  • Irritation, redness, dryness, post-inflammatory
    pigmentary changes
  • Products available
  • Tretinoin (Retin-A)
  • Cream 0.025, 0.05, 0.1
  • Gel 0.01, 0.025
  • Gel micro 0.04, 0.1
  • Adapalene (Differin)
  • Cream 0.1 gel 0.1, 0.3.
  • Aolution and lotion 0.1
  • Tazarotene (Tazorac)
  • Cream, gel 0.05, 0.1
  • Tretinoin 0.025/ clindamycin 1.2 (Ziana)
  • Adapalene 0.1/ benzoyl peroxide 2.5 (Epiduo)

Eichenfield L, et al. Pediatrics 2013131 Suppl
3S163-186
22
Patient 3
23
Moderate Acne
  • Face
  • Topical retinoid
  • Alone
  • Fixed-dose combination
  • with benzoyl peroxide
  • (BP) or antibiotic
  • BP /- topical antibiotic
  • Alone
  • Fixed-dose combination
  • with antibiotic or
  • retinoid
  • Face and chest/back
  • Add oral antibiotic
  • Consider adding BP wash for
  • use on chest and back in shower qd

24
Oral Antibiotics
  • Actions
  • Anti-inflammatory
  • Antibacterial
  • Options
  • Tetracycline, erythromycin (250-500 mg bid) -
    Avoid
  • Doxycycline, minocycline (50-100 mg bid)
  • Use
  • Use in combination with a topical retinoid
    benzoyl peroxide
  • Use only for moderate to severe acne
  • Discontinue as soon as possible
  • Counsel regarding potential adverse effects

Eichenfield L, et al. Pediatrics 2013131 Suppl
3S163-186
25
Patient 4
26
Severe Acne
  • High-dose antibiotic
  • Topical retinoid
  • Alone
  • Fixed-dose combination
  • product with benzoyl
  • peroxide (BP) or
  • antibiotic
  • BP if not used as part of a
  • fixed-dose product
  • containing a retinoid

In girls, consider oral contraceptive as adjunct
Consider referral to dermatologist
27
Patient 5
28
Moderate to Severe Comedonal Acne
  • Counsel regarding hair preparations
  • Limit hair greases to scalp
  • Topical retinoid (e.g., Retin-A cream 0.025,
    Differin applied nightly)

29
Patient 6
30
Moderate Mixed Acne
  • Option 1
  • Topical retinoid applied nightly, and
  • Antibiotic
  • Face, mild to moderate benzoyl peroxide gel or
    combination product each morning
  • Face and trunk, moderate oral antibiotic
  • Option 2 (face, mild to moderate)
  • Azelaic acid applied bid
  • Adjunctive therapy
  • Consider hydroquinone cream OTC (1-2) or
    prescription (3-4, e.g., Eldoquin forte 4)
    daily to hyperpigmented areas

31
Patient 7
32
Severe Inflammatory Acne Refractory to Therapy
  • Refer to dermatologist (unless registered with
    IPledge)
  • Isotretinoin
  • Indication severe scarring or nodular acne that
    has not responded to standard therapies
  • Treatment course 16-20 weeks
  • Outcome majority of patients clear and remain
    clear
  • Serious adverse effects teratogenic, concerns
    regarding association with depression and suicide

33
Patient 8
DermAtlas
34
Acne Look-Alikes
DermAtlas
Keratosis pilaris
DermAtlas
Angiofibromas (tuberous sclerosis)
Periorificial dermatitis
35
Follow-Up
  • Return visit 2-3 months after initiating therapy
    to assess compliance, adverse effects, and
    response
  • Inadequate clearing of comedones
  • Increase strength of topical retinoid
  • Inadequate clearing of inflammatory lesions
  • Topical combination product consider oral
    antibiotic
  • Oral antibiotic select different antibiotic

36
http//www.skincarephysicians.com/acnenet/
37
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38
Potential Practice Changes
  • Prescribe a topical retinoid for those who have
    moderate or severe acne, even if comedones are
    absent
  • If a systemic antibiotic is needed consider
    doxycycline or minocycline
  • Simplify treatment regimens
  • Consider cost when prescribing medications

Yan AC, et al. Semin Cutan Med Surg
201130S16-S21
39
Acne Vulgaris
  • 30 million Americans have acne prevalence in
    adolescence is 85
  • Skin disease most commonly treated by physicians
  • In 2006
  • 4.6 million visits to physicians
  • Prescriptions written
  • 1.3 million prescriptions written for topical
    benzoyl peroxide/antibiotic preparations
  • 1.2 million for topical retinoids
  • 1.1 million for tetracyclines

40
History
  • Duration of acne?
  • What medications have been tried?
  • Other medications?
  • Hair greases?
  • Recreational or occupational factors?
  • Menstrual history
  • premenstrual flares?
  • oligomenorrhea?
  • Abnormal facial hair?
  • Sexually active?
  • Contraceptive use?

41
Fixed-Dose Topical Preparations
  • Benzoyl peroxide/antibiotic
  • Actions
  • Antibacterial, comedolytic
  • Preparations
  • BP 5/clindamycin (Benzaclin, Duac)
  • BP 2.5/clindamycin (Acanya)
  • BP 5/erythromycin (Benzamycin)
  • Use apply qd bid depending on product
  • Retinoid-containing
  • Actions
  • Comedolytic, anti-inflammatory
  • Preparations
  • Tretinoin 0.025/ clindamycin 1.2 (Ziana)
  • Adapalene 0.1/ benzoyl peroxide 2.5 (Epiduo)
  • Use applied qd

42
Selected References
  • Callender VD. Acne in ethnic skin Special
    considerations for therapy. Dermatol Ther
    200417184-195.
  • Goldsmith LA, Bolognia JL, Callen JP, et al.
    American Academy of Dermatology Consensus
    Conference on the Safe and Optimal Use of
    Isotretinoin Summary and recommendations. J Am
    Acad Dermatol 200450900-906.
  • James WD. Acne. N Engl J Med 20053521463-1472.
  • Krowchuk DP. Managing adolescent acne. A guide
    for pediatricians. Pediatr Rev 200526250-261.
  • Strauss JS, Krowchuk DP, Leyden JJ, et al.
    Guidelines for the care of acne vulgaris
    management. J Am Acad Dermatol 200756651-663.
  • Zaenglein AL, Thiboutot DM. Expert committee
    recommendations for acne management. Pediatrics
    20061181188-1199.

43
Mild AcneTreatment Options
Lesion Type Initial Treatment If Inadequate Response
Add topical retinoid or topical antibiotic or
substitute BP/topical antibiotic combination.
BP
Comedonal
or
BP/topical antibiotic combination
Add topical retinoid.
or
Inflammatory/Mixed
Add BP or BP/topical antibiotic combination.
Topical retinoid
Determined by physician assessment and patient
satisfaction.
44
Moderate Acne Treatment Options
Lesion Type Initial Treatment If Inadequate Response
Increase strength or change type of topical
retinoid add BP or BP/topical antibiotic
combination to topical retinoid.
Topical retinoid BP or BP/topical antibiotic
combination
Comedonal
Add topical retinoid or oral antibiotic. Consider
oral contraceptive for females. Consider referral
to dermatologist.
BP or BP/topical antibiotic combination topical
retinoid oral antibiotic
or
Inflammatory/Mixed
Increase strength or change type of topical
retinoid. Consider oral contraceptive for
females. Add BP or BP/topical antibiotic
combination. Consider referral to dermatologist.
Oral antibiotic topical retinoid
Determined by physician assessment and patient
satisfaction.
45
Severe Acne Treatment Options
Lesion Type Initial Treatment If Inadequate Response
Consider referral
Oral antibiotic and topical retinoid
Refer to dermatologist
Comedonal
BP or BP/topical antibiotic combination
Inflammatory/Mixed
Refer to dermatologist
oral contraceptive for female patients
Refer to dermatologist
Determined by physician assessment and patient
satisfaction.
46
Light Treatment
  • P. acnes produces porphyrins that absorb light at
    the near UV and blue light spectrum
  • Photoactivation of porphyrins leads to bacterial
    destruction
  • Red light also may have anti-inflammatory
    properties
  • Light therapy may be administered alone or after
    topical photosensitizer (e.g., aminolevulinic
    acid)

Acnelamp red and blue 2-head (449.00)
http//www.acnelamp.com/
47
Light Treatment
  • 107 patients 14-50 yrs with mild to moderate acne
    randomized to
  • Blue light (415 nm)
  • Blue-red light (415 nm and 660 nm)
  • Cool white light
  • Benzoyl peroxide 5
  • 12-week observer blinded study
  • Results improvement at 12 weeks

Inflam Comed
Blue-red light 76 58
Blue light 63 58
Benzoyl peroxide 58 50
White light 25 -8
Papageorgiou P, et al. Br J Dermatol
2000142973-978
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