Acne VulgarisKMP r1_2012

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FNP lecture

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Acne Vulgaris:

Acne Vulgaris Dermatology Module Family Nurse Practitioner Program University of Southern Mississippi K. Michelle Pendergrass PhD(c), PNP, FNP-BC

Definition:

Definition Acne vulgaris is a chronic inflammatory dermatosis which is notable for open and/or closed comedones (blackheads and whiteheads) and inflammatory lesions including papules, pustules, or nodules.

Overview:

Overview Probably multiple factors. Overproduction of sebum, increases under the influence of hormones. insufficient shedding of exfoliating dead skin cells, plugs hair follicles. Medications such as lithium, cortisone, hormones, iodides, some seizure medications, or isoniazid No cure Acne can result in scarring, so minimizing breakouts is important.

Clinical Presentation:

Clinical Presentation affects 85–100% of people at some point Usually begins at puberty. Can persist into the 30s and beyond. All ethnic backgrounds.

Signs/symptoms:

Signs/symptoms Variety of lesions. Most common -face, neck, chest, and back, along the jaw line is a common location in adults. Comedones are follicular plugs that are either sitting below the skin surface (whitehead) or oxidized from being exposed to the air (blackhead). Papules are small pink to reddish-brown bumps, pustules are pus-filled lesions, and nodules or cysts are deeper pus-filled lesions. Mild: few papules/pustules and/or comedones . Moderate: increased number of lesions. Severe: numerous comedones , papules, pustules, and may have painful nodules. Acne can result in permanent scars, which can appear to be depressions in the skin or hyperpigmentation , which is dark red or brown flat marks where the acne lesions were.

Differentials:

Differentials Folliculitis Androgen excess Acne Rosacea Steroid Rosacea Molluscum contagiosum

Diagnostic Tests:

Diagnostic Tests Usually None

Management of Acne Vulgaris Mild to Moderate:

Management of Acne Vulgaris Mild to Moderate

Exacerbating factors to avoid:

Exacerbating factors to avoid Medications that exacerbate acne Androgenic steroids (e.g. Danazol , Testosterone Corticosteroids Lithium Oral Contraceptives Isoniazid Phenytoin ( Dilantin ) Environment Hot Greasy (fast-food kitchen, garage) Oil based Cosmetics Cosmetics with Lanolin or petroleum jelly Oil based Shampoos or Sunscreens Emotional Stress Physical Pressure (acne mechanical) Tight chinstrap Helmet

Myths (non-causes of Acne Vulgaris):

Myths (non-causes of Acne Vulgaris ) Foods DO NOT worsen acne Pizza Nuts Sweets Chocolate Acne is not a result of poor hygiene Constant washing does not improve acne Scrubbing dries and irritates skin further

General recommendations::

General recommendations: Do not squeeze lesions Forces pus into Dermis Causes inflammation and scarring Limit washing face to 2-3 times per day Avoid abrasive soaps Gear soap to skin condition Skin dry: Purpose soap Skin oily: Dial soap Change cosmetics to water based products Change Oral Contraceptive Increase Estrogen (50ug Ethinyl Estradiol minimum) Decrease androgenic effects of Progestin

Topical Therapies:

Topical Therapies Topical therapy is standard of care in acne treatment. Topical retinoids are important in acne treatment. Benzoyl peroxide and combinations with erythromycin or clindamycin are effective acne treatments. Topical antibiotics ( erythromyicin and clindamycin ) effective acne treatment. But can increase bacterial resistance.

Step 1: :

Step 1: OTC topical medications for 6 weeks Acne washes ( Phisohex ) regularly Topical Benzoyl Peroxide 2.5% gel in morning Benzoyl Peroxide 2.5% is as effective as 5-10% Lower strength is much less irritating than 5-10%

Step 2::

Step 2: Comedolytics and Topical Antibiotics for 6 weeks Continue topical Benzoyl Peroxide in morning Add Comedolytic at night First-line options Topical Tretinoin ( Retin A) 0.025% cream each night Adapalene ( Differin ) 0.1% gel May be better tolerated than Retin A Topical Tretinoin microsphere 0.1% Warn regarding redness and irritation Use only pea size amount per triangle of face Use only at night-time

Step 3: Consider adding topical antibiotic :

Step 3: Consider adding topical antibiotic Precaution: Topical Antibiotics are falling out of favor due to growing resistance Use Topical Antibiotics with Benzoyl Peroxide to prevent resistance Consider skipping to add oral antibiotic instead (see Severe Acne Vulgaris Management) Sample protocol Benzoyl Peroxide (instead of topical antibiotic) applied in the morning and Retin A applied at night and Oral antibiotic such as Tetracycline or Doxycycline

Step 3 continued:

Step 3 continued Apply topical antibiotic in the morning Apply topical Comedolytic at bedtime (see above) Continue Tretinoin or Adapalene or Consider Tazarotene ( Tazorac ) 0.05% gel or cream More irritating than Retin A, but more effective Indicated if no Tretinoin or Adapalene response Pregnancy Category X

Topical Antibiotic Preparations:

Topical Antibiotic Preparations Clindamycin HCl ( Cleocin -T) Erythromycin ( Akne-mycin , Erygel ) Lotion (1.5% 2%) Tetracycline HCl ( Topicycline ) Lotion 2.2 mg/ml Consider sulfa agents if intolerance to other meds Combination agents ( Comedolytic with antibiotic) Refrigeration required Erythromycin with Benzoyl Peroxide ( Benzamycin ) Refrigeration not required Benzoyl Peroxide, Glycolic Acid, Zinc ( Triaz ) Clindamycin 1%/ Benzoyl Peroxide 5% Gel ( BenzaClin ) More effective than Clindamycin alone

Severe Acne Management:

Severe Acne Management

Step 1: Incorporate Moderate Acne Vulgaris Management:

Step 1: Incorporate Moderate Acne Vulgaris Management Initiate Comedolytic (e.g. Retin A) Initiate topical antibiotic (e.g. Cleocin T)

Step 2: Start Oral Antibiotics:

Step 2: Start Oral Antibiotics General Do not anticipate an effect for 6 to 8 weeks Continue antibiotic for minimum of 6 months First Line Tetracycline 1 g/day given in 2-4 divided doses Erythromycin 1 g/day in 2-4 divided doses Increasing resistance decreases its efficacy Second Line Doxycycline 100-200 mg/day in divided doses Trimethoprim 300 mg bid Third Line (risk of serious adverse effects) Minocycline 50-200 mg/day in divided doses

Note::

Note: Do not use tetracycline derivatives in pregnant women, nursing mothers, or children under the age of 12.

Step 3: Maximal medical therapy (cystic or refractory acne):

Step 3: Maximal medical therapy (cystic or refractory acne) Referral to Dermatology Isotretinoin ( Accutane ) Only qualified clinicians may prescribe Adverse effects Extremely Teratogenic Monitor Triglycerides and Liver Function Tests

Follow Up:

Follow Up 3 follow-up visits (over 8-10 weeks) generally needed to establish successful program

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