ACNE SURVEY

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ACNE SURVEY (?)

• Any good regimen for management of acne might
  include
• counseling re prognosis and course
• topical antibiotics
• topical retinoids
• topical benzoyl peroxide
• increased washing of affected areas
• abrasive cleansers
• restriction of chocolate, fries, pizza
• ultraviolet therapy

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Acne Rx Algorithm

• Comedonal acne? benzoyl peroxide
• (/- mild inflammation) tretinoin
• azelaic acid
• (A)? antibiotics
• exfoliants
• (Topical agents)

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Acne Rx Algorithm

• Moderate inflammatory
• acne? A
• Oral antibiotics(tetracycline,
  minocycline, doxycycline, macrolides, (B)?
  sulfonamides, amoxicillin) Antiandrogens
  (estrogens, cyproterone acetate,
  spironolactone 25-200 mg/day)

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Acne Rx Algorithm

• Severe cystic acne?
• /- A /- B /- oral 13-cis retinoid
  acid
• /- oral steroids

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Acne Rx-Whats New(er)? for 2006

• Antibioitics/resistance
• Comedolytics
• Exfoliants
• Combinations
• New devices
• 13 cis-retinoic acid

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P. acnes-Resistance

• Resistance to emycin, clindamycin, doxycycline
• Recommendations
• Avoid oral meds when topicals ok
• Reuse same drug when topicals reintroduced
• Use concommitant benzoyl peroxide
• Avoid different topical and oral antibiotic to
  minimize resistance to both agents
• Eady EA, Jones CE, et al. Antibiotic resistant
  propionibacteria in acne need for folicies to
  modify antibiotic usage. Br Med J
  1993306555-6.

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P. acnes-Resistance

• Combination topical benzoyl peroxide/erythromycin
  was compared to topical erythromycin alone in a
  double-blind study.
• P acne reduced in both groups, but more in combo
• Resistant strains reduced only in combo
• Eady EA, Bojar RA, et al. The effects of acne
  treatment with a combination of benzoyl peroxide
  and erythromycin on skin carriage of
  erythromycin-resistant proprionibacteria. Br J
  Dermatol 1996134107-13

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P. acnes-Resistance

• Pilot data suggested that Accutane could reduce
  the number of resistant P. acnes organisms.
• Coates P, Adams CA, et al. Does oral
  isotretinoin prevent P. acnes resistance?
  Dermatology 1997195(Suppl 1)4-9.

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Clindamycin 1/Benzoyl Peroxide 5 Gel

• The combination product was superior to either
  single agent in this well controlled study.
• Lookingbill DP, Chalker DK, et al. Treatment of
  acne with a combination clindamycin/benzoyl
  peroxide gel compared with clindamycin gel,
  benzoyl peroxide gel and vehicle gel combined
  results of 2 double-blind investigations. J Am
  Acad Dermatol. 19973759-0-5.

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Comedolytics

• Topical retinoids (tretinoin, adapalene,
  tazarotene)
• Azelex
• Salicylic acid
• Benzoyl peroxide
• Alpha-hydroxy acids

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Differin 0.1 gel, cr (adapelene)

• Modulates cellular differentiation,
  keratinization, inflammation
• Minimal absorption, excreted in bile
• Adverse reaction-hypersensitivity, irritation,
  sun sensitivity
• Safety in pregnancy, nursing mothers, children
  lt12???

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Adapalene

• The new stuff was comparable to retin A but less
  irritating. There was only 1 problem-most of us
  dont use the tretinoin 0.025 gel.
• Shalita AR, Weiss JS, et al. A comparison of
  the efficacy and safety of adapalene gel 0.1 and
  tretinoin gel 0.025 in the treatment of acne
  vulgaris a multicenter trial. J Am Acad
  Dermatol 199634482-5.
•  

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Tazorac 0.1 gel (tazarotene)

• Retinoid for psoriasis and acne
• Pregnancy category X
• Pregnancy test 2 wks before starting
• Contraception during therapy
• Not recommended in children

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New Rx-Tazarotene

• The stuff works, but watch out for irritation.
• Shalita AR, Chalker, et al. Tazarotene gel is
  safe and effective in the treatment of acne
  vulgaris a multicenter, double-blind,
  vehicle-controlled study. Cutis 199963349-54.

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Microspheres for Retin A

• This formulation (microspheres) is comparable to
  traditional formulations but supposed to be less
  irritating.
• Webster G. Topical tretinoin in acne therapy. J
  Am Acad Dermatol 199839538-44.
•  

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Avita (new vehicle)

• Tretinoin 0.025 cream in a vehicle containing
  polyprepolymer-2 (Avita, Penederm, Inc) was
  comparable in efficacy to Retin A 0.025 cream.
  A later study comparing Avita with Retin A 0.025
  gel showed Avita to be less irritating. Again,
  we do not use Retin A gel
• Lucky A, Cullen S, et al. Double-blind,
  vehicle-controlled, multicenter comparison of 2
  0.025 tretinoin creams in patients with acne
  vulgaris. J Am Acad Dermatol. 199838(Suppl)S24-
  30.

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Azelex (azelaic acid cream 20)

• Naturally occurring dicarboxylic acid
• Antimicrobial activity against P. acnes, S.
  epidermidis
• Inhibits microbial protein synthesis
• Normalizes keratinization?comedolytic

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Azelex (azelaic acid cream 20)

• Safety in pregnancy, nursing mothers, children lt
  12 ???
• Adverse reaction-irritant (may be gt4)
• But generally quite safe

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More on Azelex

• This dicarboxylic acid with antibacterial and
  comedolytic activity was approved in the US in
  1996. They summarized safety and efficacy data
  from studies comparing this agent with oral and
  topical agents.
• Its safe, effective, but irritating
• Graupe K, Cunliffe W, et al. Efficacy and
  safety of topical azaleic acid (20 cream) an
  overview of results from European clinical trials
  and experimental reports. Cutis 19965713-9.
•  

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Zeno Device

• Significant efficacy and safety of low level
  intermittent heat in patients with mild to
  moderate acne. Bruce S et al. (myzeno.com)
• Hand held device with 3/8 source at 49.4 C for
  2.5 minutes
• Double-blind placebo control trial
• Shortened time to improvement and resolution of
  inflammatory skin lesions

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ALA and Blue Light

• An open study to determine the efficacy of blue
  light in the treatment of mild to moderate acne.
  Morton CA, et al. J Dermatolog Treat.
  200516(4)219-23
• Eight 10-20 minute rxs over 4 wks worked
  (somewhat) at 5, 8, 12 wks.
• Expensive, painful, and maybe not worth the
  trouble

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ALA and PDL

• Long-pulsed dye laser-mediated photodynamic
  therapy combined with topical therapy for mild to
  severe comedonal, inflammatory , or cytsic acne.
  Alexaides-Armenakas M. J Drug Dermatol
  20065(1)45-55.
• In this pilot study kids who failed everything
  including Accutane cleared with 3 rxs with f/u
  of 6.4 months

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Accutane Update

• Use of topical rx in pregnancy-Lancet
  19973501143-4
• There was no difference in pregnancy outcome when
  94 first trimester exposed women were compared
  with 133 age matched controls.
•  
• Longterm safety and efficacy-Br J Dermatol
  1993128292-6
• 10 year followup of 88 patients was reported.
  Patients most likely to have recurrent disease
  were those who were treated with less than
  recommended dose for less than the recommended
  time. There were no biochemical abnormalities
  attributable to the med

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Accutane-Repeat Courses

• Risk factors include lower dose than recommended,
  presence of severe acne, being female gt25 years
  old, and having a prolonged history of acne.
• Need for repeat course-Br J Dermatol
  1993129297-301

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Accutane and Bone Metabolism

• 20 patients on Accutane were studied.
• No alterations in serum measurements of
  osteocalcin, calcium, 25-dihydroxyvitamin D,
  parathyroid hormone, or urinary hydroxyproline
  or calcium.
• Significant decrease in serum 1,25-dihydroxy
  vitamin
• D.
• No changes in bone mineralization of the lumbar
  spine or hip.
• Effects on bone in acne regimens-Arch Dermatol
  1996132769-74

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Accutane-Depression

• There is no good evidence that isotretinoin is
  associated with an increased risk of depression,
  suicide, or other psych disorders.
• Depression/suicide-JAMA 199881057, Arch
  Dermatol 20001361231-6.

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Accutane-Latest from Roche

• Warnings Psychiatric
• Aggressive and/or violent behavior based on
  post-marketing safety reports
• Pediatric Labeling Warnings Bone mineral
  density
• Precautions-General
• Patients with genetic predisposition for
  age-related osteoporosis, hx of childhood
  osteoporosis conditions, osteomalacia and other
  disorders of bone metabolism
• Increased risk for sports with repetitive impact

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Accutane-Latest from Roche

• Pediatric patients 29 low back pain
• 22 arthralgias
• Precaution phenytoin, systemic corticosteroids
• Pregnancy testing and qualification stickers
• iPLEDGE

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