Acne Rx For Primary Care

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1 Acne Rx For Primary Care Step by Step Renee Howard MD Associate Professor of Dermatology University of California San Francisco Disclosures Off label treatment No conflicts of interest Sandy Goldstein M.D. First taught me the stepwise approach to acne therapy Kaiser Permanente website Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne Lawrence F. Eichenfield, Andrew C. Krakowski, Caroline Piggott, James Del Rosso, Hilary Baldwin, Sheila Fallon Friedlander, Moise Levy, Anne Lucky, Anthony J. Mancini, Seth J. Orlow, Albert C. Yan, Keith K. Vaux, Guy Webster, Andrea L. Zaenglein and Diane M. Thiboutot Pediatrics 203;3;S63 DOI: 0.542/peds B /Supplement_3/S63.full.html

2 Stepwise Acne Treatment for Pediatricians: an Update 4 levels of therapy and how to use What you (we) should change Steps To Success 4 critical steps for successful acne treatment in adolescents 4 levels of therapy and how to use 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan 2

3 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan Grand Staircase on the Titanic. Assess Expectations Endpoint is control while minimizing adverse effects 3

4 Perfectionism Manage expectations Patient s Yours Instant improvement Gradual You will be better in three months Clearing by prom Control (tomorrow) 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan 4

5 2. Grade Acne: Type, Severity Comedonal Papular 2. Grade Acne: Type Comedonal Papular Pustular Nodular palpate Scarring? Texture Color 2. Grade Acne: Severity=Density Use good light, sidelighting g 5

6 2. Grade Acne Severity: Extent Body surface area Always examine to waist 2. Grade Acne Severity Number of Lesions, Extent Topical Therapy Systemic Therapy Scarring Truncal Psychosocial impact Superficial Type of Lesions Deep 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan 6

7 Self Treatment of Acne in Teens Survey of 24 students in New Jersey 0-8 years old Most don t think of acne as a medical condition 57% treated it themselves 7% sought medical care TV source of acne information Corey Pediatric Derm 203;30:36 From: Perspectives on Acne: What Twitter Can Teach Health Care Providers Figure Legend: JAMA Dermatol. 203;49(5): doi:0.00/jamadermatol Date of download: 0/3/203 Copyright 202 American Medical Association. All rights reserved. 7

8 7% self rated as severe did not seek medical care Input of misleading marketing of OTC/subscription acne products on TV, internet, social media Subscription OTC s for Acne Intensely marketed on internet/media popular with women, teens Inertia -- product mailed every month Can be hard to cancel 2.5% benzoyl peroxide, glycolic acid 3. Education: Pore clogging Hormones+sebum+genetics abnormal keratinization in pilosebaceous follicules at a microscopic level= microcomedone No strip, scrub, mask, deep cleanser, or toner can alter this process Like rolling boulders over gopher holes Best treatment topical retinoids Microcomedone 8

9 3. Education: Dispel Myths Not dirt Not chocolate/milk Mediterranean diet Makeup is fine Water based Stress can worse but isn t the cause 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan Acne Skin Care Plan /9/3 AM Take Doxycycline with breakfast, large glass of water Apply sunscreen PM Take Doxycycline with dinner, large glass of water Wash with benzoyl peroxide wash 3.5% in shower Pat dry, apply clindamycin Pea-sized amount of tretinoin cream to face Layer of moisturizing lotion 9

10 4 Steps to Treatment Success. Assess expectations 2. Grade acne 3. Educate 4. Develop simple Rx and OTC care plan Stepwise Acne Treatment 4 levels of therapy and how to use Eichenfeld et al Pediatrics 203;3:S63 Goals of Acne Therapy Control pro-inflammatory P. acnes Prevent and treat abnormal follicular keratinization Control inflammation to reduce pain, tenderness, scarring, psychosocial problems In women, moderate androgen effects on skin by altering hormonal milieu 0

11 Stepwise Acne Treatment. Benzoyl peroxide +/- topical antibiotics 2. Topical retinoids 3. Systemic antibiotics 4. Other systemic agents Stepwise Acne Treatment. Benzoyl peroxide +/- topical antibiotics 2. Topical retinoids 3. Systemic antibiotics 4. Other systemic agents Step : Benzoyl Peroxide Antimicrobial, mild comedolytic and antiinflammatory Prevents resistance OTC, inexpensive Wash or leave-on 2.5-5% water based gel

12 Step : Benzoyl Peroxide 2 year old with mild superficial comedonal and inflammatory acne Step : BP + Topical Antibiotics Topical antibiotic. Clindamycin gel, lotion 2. 5% sulfur/0% sulfacetamide lotion, wash 3. Azeleic acid cream 4. Dapsone gel With BP orange stain Use BP as wash Fixed Dose Combination. BP + clindamycin gel 2. BP + adapalene gel 3. Tretinoin + clinda gel All less irritating, easy, pricey Stepwise Acne Treatment. Benzoyl peroxide +/- topical antibiotics 2. Topical retinoids 3. Systemic antibiotics 4. Other systemic agents 2

13 Step 2: Topical Retinoids Comedolytic Anti-inflammatory All Rx Underused by pediatricians Yentzler Pediatr Dermatol 2008;25: Step 2: Topical Retinoids Superficial comedonal acne Why Retinoids Are Underused: Adverse Effects Mild photosensitivity Irritating, drying Prevent by Use small amount: pea size for whole face Start QOHS or even 2 days/week, gradually increase to QHS Moisturize after application Sunscreen every morning Remove other irritants from skin care 3

14 Tretinoin Generic, covered by most pharmacy plans for teens Cream, gel, solution Inactivated by sun--use PM Irritating Wait 30 min. after face washing to apply generic Use.025% cream first Adapalene.% Now generic Gel or cream Easier to use Good for young children with early acne Can use in AM & right after face washing Step 2: BP + Topical Retinoid Comedonal Papular 4

15 Step 2: BP+Clindamycin+Retinoid Moderate comedonal and inflammatory acne Stepwise Acne Treatment. Benzoyl peroxide +/- topical antibiotics 2. Topical retinoids 3. Systemic antibiotics 4. Other systemic agents 3. Systemic Antibiotics Number of Lesions, Surface Area Topical Therapy Systemic Therapy Scarring Truncal Psychosocial impact Superficial Type of Lesions Deep 5

16 3. Systemic Antibiotics Hyperpigmented scarring Extensive truncal acne 3. Systemic Antibiotics Large, deep, inflammatory, dense, scarring, or truncal anti-inflammatory Doxycycline yy 75-00mg BID 2 weeks to maximal effect; total 6-2 months Bacterial resistance a problem long term 6

17 3. Systemic Antibiotics Inflammatory facial acne Antibiotic Resistance Big problem for patient, bigger for public health worldwide Always combine with BP (All of us) Always try retinoids (Pediatricians) Limit maintenance course (Dermatologists) Think shift to hormonal therapy for older girls Think referral to dermatology/isotretinoin Moon J Dermatol 202; 39: 833. Step 4: Other systemic Inflammatory facial acne already on chronic oral antibiotics, topicals 7

18 Procedure-oriented Acne Treatment? May help as initial Rx to control acne or in patients that don t tolerate standard treatments Not required to meet stringent FDA criteria i met by prescription medications Harper JC J Am Acad Dermatol2004;5:S36 Susceptible consumers paying out-of-pocket for these procedures in medispas Insurance won t cover 4. Other Oral Agents: OCP s OCP s for older girls (at least year postmenarche) requiring chronic antibiotic Think about endocrine referral if irregular menses, obesity, hirsutism, androgenetic alopecia to evaluate for polycystic ovary, metabolic syndrome 4. OCP s OCP s FDA-approved for acne Estrostep (Pfizer), Orthotricyclen (Ortho) Yaz has Drospirenone = 25 mg aldactone but concern about increased risk of blood clots Can use any low estrogen OCP Orthotricyclen, Allese, Yasmin all studied Orthocept, microgestin fine 8

19 NOT FDA approved Peripheral androgen-receptor blocker Dose mg BID 50-70% improvement Should use in combination with OCP; teratogen Screen for kidney dz, eating disorders, athletic activity 4. Spironolactone 4. Other Systemic: Isotretinoin Papulopustular, nodular facial acne 4. Other Systemic: Isotretinoin 9

20 4. Other Systemic: Isotretinoin First line in severe scarring nodular acne Failure of conservative therapy in moderately severe acne High risk, high benefit Medico-legally problematic, teratogen Ipledge nightmare 8 year old boy after isotretinoin Stepwise Acne Treatment. Benzoyl peroxide +/- topical antibiotics 2. Topical retinoids 3. Systemic antibiotics 4. Other systemic agents 20

21 Stepwise Acne Treatment. Comedonal: BP +/- Retinoid 2. Comedonal + inflammatory BP/clinda/retinoid 3. Deeper, denser pustular, nodular or truncal acne BP/clinda/retinoid/oral antibiotics 4. Deep, dense, scarring or persistent isotretinoin and/or hormonal therapy for girls Steps To Success 4 critical steps for successful acne treatment in adolescents 4 levels of therapy and how to use TANNING = CANCER BOXES KEEP KIDS OUT 2.3 million adolescents tan/yr 2

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