Education. Acne (acne vulgaris) is a. Putting out the spot fires. ClinicalReview AUTHOR. Learning objectives

Transcription

1 ClinicalReview Learning objectives Understand the physiological determinants of acne development Understand the topical and systemic treatment of acne Understand the non-pharmacological treatment of acne Competencies: 6.1, 6.2, 6.3, 7.1, 7.2, 7.3 Putting out the spot fires Acne is a common presentation in community pharmacy. But what are its clinical features? And what are the best options for treatment and management? Acne (acne vulgaris) is a chronic inflammatory disorder of pilosebaceous units hair follicles that are associated with a sebaceous gland. Clinical features include: Seborrhoea: excessive oil (sebum) production; Non-inflammatory lesions: open comedones (blackheads) and closed comedones (whiteheads); Inflammatory lesions: papules (solid raised spots), pustules (raised spots containing pus), and nodules (large papules); Scarring. Acne occurs on the face, neck, chest, shoulders and back. These areas have the highest density of pilosebaceous units. Mild acne may only involve facial comedones. More severe cases have more lesions, more inflammatory pustules and nodules, and greater skin coverage, involving the chest or back. Almost all teenagers will experience at least mild acne, especially between 15 and 17 years of age. The onset is typically in puberty and usually resolves in the post-teenage years. It is more common in boys. Acne can persist into adulthood, especially in women. Pathophysiology In early puberty, increased androgen activity increases production of sebum. This is accompanied by altered keratinisation leading to formation microcomedones. Microcomedones act like a keratin plug, providing a lipid-rich and anaerobic environment that allows Propionibacterium acnes to flourish. Release of inflammatory mediators into the skin and follicle colonisation by P. acnes then trigger development of inflammatory papules and pustules. Risk factors Factors that increase risk of acne include family history, smoking and early colonisation of P. acnes. Emotional stress or menstrual cycle changes can worsen acne in AUTHOR Dr Angela Dean is a research pharmacist based at the University of Queensland and the Mater Children s Hospital, Brisbane. PharmacyNews May

2 susceptible individuals. It is not clear why acne usually eases in the post-teenage periods it may relate to changes in circulating cytokines. Conditions such as polycystic ovary syndrome may be associated with acne. Acne may also be triggered by some medications, including anabolic steroids, corticosteroids, isoniazid, lithium, progestin-only contraceptives, phenytoin, danazol, and some anticancer medications. Consider referral to review these medications if patients have problems with acne. Diet is commonly perceived to increase risk of acne, but no research has demonstrated a causal connection between dietary intake and worsening of acne, such as the post-chocolate flare. Diets with a high glycaemic load may indirectly affect androgen and retinoid signalling; one small study suggests that a low glycaemic diet may improve acne symptoms. BOTTLING IT UP: A variety of products are available for acne management. Impact Acne is more than just a cosmetic issue it results in soreness, itching, pain, and facial scarring. It is often accompanied by a range of psychological issues, including embarrassment, social inhibition, depression and suicidal ideation. Even young people with mild acne may experience significant emotional impact. One study reports that up to 14% of patients with acne experience such significant distress that they meet diagnostic criteria for body dysmorphic disorder. These issues can be more pronounced in teenage years a critical period for building social confidence but they can improve with effective treatment. If aggressive treatment of acne is not sufficient to improve psychological symptoms, patients may benefit from treatments focused on psychological distress, Even young people with mild acne may experience significant emotional impact. such as cognitive behavioural therapy. Management There are many different products available for treatment of acne. Choice of treatment is influenced by acne severity, patient preferences, potential adherence issues and history of positive response to therapy. Combining treatments that target different acne processes can improve treatment outcomes. The goals of treatment are to reduce the number of skin lesions, reduce lesion recurrence, improve appearance and improve quality of life. Most treatments, topical or systemic, require at least six weeks of treatment before improvement is observed. Sometimes, longer periods may be required. Topical treatments Topical treatments are first-line treatment for acne, especially for mild-moderate cases. They prevent development of new lesions, but only work where they are applied. phight pimples with phisohex ALWAYS READ THE LABEL. USE ONLY AS DIRECTED. IF SYMPTOMS PERSIST SEE YOUR DOCTOR. 44 May 2013 PharmacyNews

3 THE RIGHT TOUCH: Topical preparations should be started at lower strength to avoid irritation. Therefore, patients should be encouraged to apply topical preparations to all of the affected area, rather than just single spots. Some topical treatments can be continued for years if required. Combining topical agents with different mechanisms of action can be more effective than using one agent alone; although because inflammatory lesions stem from comedones, treatment that targets comedones can potentially prevent inflammatory lesions also. Topical products can cause skin irritation for many patients. To minimise this, start treatment with lower strength formulations and increase strength as required. Gels, washes, and alcoholbased solutions are more drying and irritating. Consider changing formulations to lotions, creams and ointments. Benzoyl peroxide Many over-the-counter products contain benzoyl peroxide (2.5% to 10%). It is most effective for comedones, but may improve inflammatory lesions. It acts against P. acnes by releasing oxygen within follicles, and can improve altered keratinisation. Adding benzoyl peroxide to antibiotics can reduce antibiotic resistance. Although early responses may be observed, longer treatment times are usually required. Patients may continue for extended periods. Formulations of 10% may be highly irritating, with negligible additional benefit. It is a potent bleaching agent it may bleach fabrics or other products. Topical retinoids Topical retinoids include adapalene (Differin), tretinoin (eg, Retin A), isotretinoin (Isotrex), and tazarotene (Zorac). They reduce comedones, improving altered keratinisation and preventing keratin plugs. They may also reduce inflammation by reducing release of inflammatory cytokines. They are highly effective treatments, especially for comedones, and often considered to be first line. They reduce lesions by 40-70%. Improvement should be observed after six weeks of treatment. If response is inadequate, benzoyl peroxide or topical antimicrobials may be added. Treatment should continue for 3-6 months. Benzoyl peroxide inactivates tretinoin so the two agents should not be applied at the same time. If both are used, apply one in the morning and the other at night. All topical retinoids can cause skin irritation. Minimise irritation by starting treatment on low-strength formulations, using small amounts in the early stages of treatment, or applying every second night (for two weeks) and then increase to nightly use. Washing off any remaining product in the morning may reduce sun sensitivity. If skin reactions are severe, topical retinoids should be discontinued. They are contraindicated in pregnancy....treat sensitive skin with ease. ALWAYS READ THE LABEL. USE ONLY AS DIRECTED. IF SYMPTOMS PERSIST SEE YOUR HEALTHCARE PROFESSIONAL. 46 May 2013 PharmacyNews

4 To submit answers, go to pharmacynews.com.au/education Topical antibiotics Topical antibiotics are commonly used for acne and are mainly effective for inflammatory lesions. Their therapeutic action relates to both anti-inflammatory effects and antimicrobial effects on P. acnes. Controlled trials show that clindamycin or erythromycin can reduce inflammatory lesions by 50-70%. Antibiotics should be used in combination with benzoyl peroxide as well as improving outcomes, combining therapy reduces the risk of antibiotic resistance. In more severe cases, combined benzoyl peroxide/clindamycin products may also be added to topical retinoid treatment. Once improvement is observed in inflammatory papules and pustules, topical antibiotics should be stopped. Retinoids or benzoyl peroxide are suitable options for long-term maintenance. Topical antibiotics are less irritating than benzoyl peroxide and topical retinoids. Other products Salicylic acid is a keratolytic agent, reducing comedones by removing keratin plugs. It is considered less effective than prescription topical agents, but little research has examined this. Tea tree oil: a review of four controlled trials was unable to demonstrate a benefit of tea tree oil, but a recent study suggested that it may improve mild-moderate acne. It probably has a slower onset of action than conventional topical agents. Dapsone: topical dapsone 5% is effective for acne, but products are not yet available in Australia. Azelaic acid may be less effective and more irritating than other agents. Systemic treatments The key systemic treatments for acne include antibiotics, hormonal treatments and isotretinoin. They are indicated for moderate to severe acne (including acne that covers the chest and back), acne with high scarring risk, or acne unresponsive to topical therapy. Oral antibiotics Doxycycline (50-100mg/d) is considered the first-line antibiotic for treating acne. Minocycline (50-100mg/d) is also used, but considered less effective than doxycycline. Emerging antibiotic resistance limits the use of erythromycin ( mg twice daily), but it has a role for young children, pregnant women, or those unable to take tetracyclines. Limited data is available for most other antibiotics. Oral antibiotics should not be used for mild acne because of the risk of resistance or cases where topical therapy may be effective. Antibiotics reduce follicular P. acnes and have anti-inflammatory effects. They can reduce inflammatory lesions by 50-70%. Improvement should be observed within six weeks of treatment. Response may be improved by combining topical retinoids or benzoyl peroxide. Once improvement has been maintained for 2-3 months, the antibiotic should be reduced gradually topical therapies can be continued for longterm maintenance. Although concomitant benzoyl peroxide can reduce the risk of resistance, long-term use of antibiotics (more than six months) is not recommended because of the risk of resistance and reduced efficacy. If a relapse occurs, patients may be treatments with the same antibiotic. Oral antibiotics should not be used for mild acne because of the risk of resistance or cases where topical therapy may be effective. Hormonal therapies Combined oral contraceptives (OCPs) are commonly used in women with acne. Oestrogen has anti-androgenic effects and suppresses activity of sebaceous glands. OCPs are considered especially suitable in women who also require contraception, or with symptoms of hirsutism, seborrhoea or alopecia. Hormone abnormalities are not a prerequisite for treatment. Many OCPs are available. Cyproterone is the focus of anti-acne treatment, but all oestrogen-containing OCPs have anti-androgenic effects and are considered effective. Benefits are usually observed within six months. One trial reports that ethinyloestradiol/drospirenone and ethinyloestradiol/cyproterone combinations reduced lesions by about 60%. OCPs can be combined with topical agents or oral antibiotics to improve outcomes. Choice of OCP should be Specialist skincare for scars & stretch marks PharmacyNews May

5 based on patient preferences and tolerability. Levonorgestrel is the most androgenic of the progestins: low-dose preparations can still improve mild acne, but higher dose preparations may worsen acne. Progestin-only contraceptives also worsen acne and should be avoided in acne treatment. High-dose spironolactone inhibits 5-alpha reductase and has antiandrogenic effects. When response to OCPs is inadequate, spironolactone (50-100mg daily) can be added or used alone. Adding cyproterone (25-100mg daily, for the first 10 active days/cycle) to a standard OCP may also be effective. Hormonal therapies are not suitable for pregnant women or those trying to get conceive. ROOT CAUSE: Acne is a disorder of hair follicles associated with a sebaceous gland. Isotretinoin Isotretinoin is treatment of choice for severe acne, and cysts and acne with significant risk of scarring. It is also indicated for acne that has not responded to other treatments. It reduces abnormal keratinisation, reduces sebum production, has antiinflammatory effects and reduces P. acnes colonisation. Treatment for 5-6 months can lead to a major improvement in 85% of cases. Relapse rates may be dose dependent recurrence rates can be 20-30% with daily doses of 1mg/kg (or equivalent to mg/kg over the full treatment period), or may be up to 80% when lower doses are used. A second course of treatment may be suitable if acne recurs. Isotretinoin has diverse adverse effects. These are usually doserelated and reversible. Common adverse effects include: inflammation of the lips (cheilitis), facial dryness and redness, temporary worsening of acne, sun sensitivity, joint stiffness, lethargy, nosebleeds, elevated triglycerides, headaches, and nail infections. In many cases, these will disappear after a few months of treatment, and stopping treatment will not be required. More serious side effects include pancreatitis, impaired night vision, hepatotoxicity, blood dyscrasias, intracranial hypertension, and altered calcification. Isotretinoin is a potent teratogen. Women of child-bearing age should utilise contraception during treatment and for one month after treatment cessation. Isotretinoin has also been linked to depression and suicidal behaviour. Research has not verified a causal link between isotretinoin treatment and mood changes. However, mood changes may be present in young people with severe acne, and mood should be monitored throughout treatment. Effective acne treatment may improve mood. Lifestyle measures There is no evidence that face washing improves acne. Excessive washing may actually worsen acne by removing oil from the skin. Avoid scrubbing as it can rupture follicles and worsen acne. Advise patients not to squeeze acne lesions: squeezing can worsen inflammation and increase risk of scarring. Patients should ensure that all facial products are non-comedogenic, and minimise exposure to factors that can worsen acne, such as oily skin products and hot, humid conditions. Non-drug interventions A range of specialist surgical or photodynamic interventions are used to treat acne. These include treating acne with manual extraction of comedones, steroid injection into inflammatory nodules, or diverse photodynamic therapies. Scarring may be treated with chemical peels or microdermabrasion. Practice points Help patients choose skin care products that won t exacerbate acne. Advise patients to avoid excessive sun exposure. Considering patient preferences when choosing treatments will enhance adherence. Inform patients there is no quick fix initial response may take 6-12 weeks and long-term treatment may be needed. It is not just severe acne that warrants treatment with prescription medication. Mild acne can also benefit significantly from appropriate treatment, but it may be overlooked by health professionals. Let young people know many effective treatments are available, many of them on prescription. Recommend using topical products on the whole affected area not just spots. Inform patients about side effects of treatment, especially when products may initially worsen acne. Ask about emotional issues - and refer when necessary. References available on request CPD points online To submit answers, go to pharmacynews.com.au, click on education Or scan the QR code with your smartphone to complete the quiz 48 May 2013 PharmacyNews

6 CPD Questions Acne: Accreditation No. A1305PN0 1. Which of the following is not a clinical feature of acne? a) excessive sebum production b) inflammatory lesions such as papules and pustules c) photosensitivity d) scarring 2. Which of the following is false regarding acne? a) acne may occur on the face, neck, chest, shoulder and back b) almost all teenagers will experience at least mild acne, particularly between 15 and 17 years of age c) increased androgen activity in early puberty contributes to the development of acne d) acne is more common in teenage girls 3. Which of the following are not risk factors for acne? a) family history of acne b) high-sugar or high-fat diet c) early colonisation of P acnes d) smoking 4. Acne may be triggered by some drugs. Cough: Accreditation No A1305PN1 1. An acute cough caused by the common cold is a common infectious-based symptom presented to primary health carers. Which of the following viruses are not implicated in the common cold? a) rhinoviruses b) influenza viruses c) respiratory syncytial virus d) enteroviruses 2. Which of the following is not a cause of upper airways cough syndrome? a) gastro-oesophageal reflux disease (GORD) b) allergic rhinitis c) bacterial sinusitis d) rhinitis medicamentosa 3. Select the correct statement regarding cough and asthma. a) 30 39% of asthma patients experience chronic cough as part of their condition b) A cough is the only presenting symptom in a subset of asthma patients, called cough variant asthma (CVA) c) CVA rarely responds to normal asthma treatment (inhaled corticosteroids and beta-2 agonists) d) Zafirlukast, a leukotriene agonist, may be useful in the treatment of CVA Which of the following drugs are not associated with acne? a) minocycline b) corticosteroids c) lithium d) phenytoin 5. Which of the following is a treatment goal of acne therapy? a) reduce the number of skin lesions b) reduce the recurrence of lesions c) improve quality of life d) all of the above are treatment goals of acne therapy 6. Which of the following is false regarding oral antibiotics for acne treatment? a) Doxycycline mg/day is the first-line antibiotic for acne. b) Emerging resistance to erythromycin is limiting its use in acne treatment. c) Improvement of acne should be seen in six days of starting antibiotics treatment. d) Long-term use of oral antibiotics (more than six months) is not recommended due to the risk of antibiotic resistance and reduced efficacy 4. Which of the following is false regarding expectorants? a) Bromhexine is an example of an expectorant that reduces the volume of secretions b) Bromhexine is an example of an expectorant that reduces sputum viscosity c) Ipratropium is an example of an expectorant that reduces sputum production d) Guaiphenesin is an example of an expectorant that increases the volume of secretions 5. Which of the following is true regarding cough and the common cold? a) All viruses implicated in the common cold cause vasodilatation and hypersecretion, leading to congestion, nasal discharge and cough b) One study showed improvement of cough caused by post-nasal drip using pseudoephedrine and a sedating antihistamine c) One theory suggests that inflammatory substances released during a cold increases the sensitivity of cough receptors in the upper respiratory tract d) All of the above are true 6. Select the incorrect statement. a) Non-sedating antihistamines are more useful for non-allergic rhinitis than for allergic rhinitis 7. Combined oral contraceptives are commonly used in women with acne. Select the incorrect statement regarding OCPs and acne. a) Oestrogen has anti-androgenic properties and suppresses activity of sebaceous glands b) OCPs are suitable for women with acne who also require contraception or have hirsuitism, seborrhoea or alopecia c) Benefits of OCPs are typically seen within six months d) Hormone levels should be assessed prior to starting an OCP in a woman with acne 8. Select the true statement regarding Isotretinoin. a) Isotretinoin increases keratinisation and sebum production b) Isotretinoin is indicated for severe acne and cysts, acne with significant scarring risk and acne that has not responded to other treatments c) Adverse effects of Isotretinoin include cheilitis, sun sensitivity and nosebleeds, and are almost always irreversible d) Isotretinoin is contraindicated in patients with a history of mood disorders such as depression b) Nasal corticosteroids, antihistamines, cromolyn, and oral antihistamines and leukotriene inhibitors are effective for allergic rhinitis c) Antihistamines such as diphenhydramine have a central antitussive effect, but it is unclear how important this is in treating post-nasal drip d) Post-nasal drip is now defined as upper airways cough syndrome 7. Gastro-oesophageal reflux disease (GORD) a) causes cough by stimulation of an oesophageal-bronchial reflex b) may cause cough but no GI symptoms in up to 75% of patients c) antireflux medication should be used in patients where GORD is highly likely to be causing cough, and symptoms monitored d) all of the above are correct 8. Select the untrue statement. a) All types of cough can be treated with over-the-counter products b) Only acute cough should be treated in a community pharmacy, unless a chronic cough has been assessed by a physician c) An acute cough is defined as a cough with a duration of less than three weeks d) As a general rule, coughs lasting longer 9. Which of the following lifestyle measures may assist a patient with acne? a) washing the affected area may help to remove dirt from the skin and reduce acne recurring b) scrub the affected area regularly to remove keratin plugs c) avoid squeezing acne lesions as this will worsen inflammation and increase scarring d) using oil-based skin products can help to replace the skin s natural oils and therefore assist with reducing acne scarring 10. Select the incorrect statement regarding practice points for patients with acne. a) Patients should be advised to avoid excessive sun exposure b) Patients should be informed of all potential adverse effects of acne treatment, especially those that may initially worsen acne c) Topical products should be used to treat the whole affected area, not just individual spots d) Acne treatment may take 2-4 weeks for an initial response, and long-term therapy should be avoided where possible than three weeks need to be assessed by a doctor to exclude more serious conditions 9. Which of the following is true regarding codeine? a) mg of codeine was shown to reduce cough counts by 60% in COPD in a small study of 12 b) 60mg codeine was required to reduce cough frequency by 47% in chronic bronchitis c) Codeine 50mg improved cough frequency and severity in URI, but not in LRI d) A small study of 8 people with asthma had reduced cough counts with mg codeine 10. Select the incorrect statement regarding dextromethorphan. a) Dextromethorphan 30mg used to suppress cough in URI had varying results across four studies b) A small study of eight with chronic bronchitis showed reduced cough counts by 50% with dextromethorphan 60mg, but no effect at 7.5mg c) No significant difference was found in cough frequency or severity with mg dextromethorphan in respiratory infections in 78 people d) Dextromethorphan is a locally acting cough suppressant Each of these activities has been accredited for 1 Group One CPD credit. This can be converted to 2 Group Two CPD credits upon successful completion of the corresponding assessment, for inclusion on an individual pharmacists CPD record. Complete the assessment and elect to submit answers to your Guild Pharmacy Academy My CPD record. Australian College of Pharmacy members can submit their answers online at To submit answers, go to pharmacynews.com.au, click on education 50 May 2013 PharmacyNews