Managing adolescent acne: A primary care approach

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Managing adolescent acneA primary care approach

• Daniel Krowchuk, M.D.
• Departments of Pediatrics and Dermatology
• Wake Forest School of Medicine

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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.

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What are your patients using?

• Benzoyl peroxide
• Salicylic acid
• Sulfur /- resourcinol

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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
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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
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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
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Acne Pathogenesis
Adrenarche
Androgens
Sebum
Retention hyperkeratosis
Triglycerides
FFA
P. acnes
Open and closed comedones
Obstruction
Inflammation
Papules and pustules
Scars
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Physical Examination
Closed comedones
Open comedones
DermAtlas
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Physical Examination
Inflammatory lesions and scars
DermAtlas
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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

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Patient Education

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

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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
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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
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Patient 1
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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

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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

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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

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Patient 2
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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

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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
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Patient 3
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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

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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
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Patient 4
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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
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Patient 5
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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)

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Patient 6
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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

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Patient 7
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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

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Patient 8
DermAtlas
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Acne Look-Alikes
DermAtlas
Keratosis pilaris
DermAtlas
Angiofibromas (tuberous sclerosis)
Periorificial dermatitis
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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

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http//www.skincarephysicians.com/acnenet/
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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
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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

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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?

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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

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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.

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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.
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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.
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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.
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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/
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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