PC 707 Module 9 Exam - Dermatology, Ophthalmic, Otic Q & A Acne Vulgaris: -common chronic skin condition caused by the bacteria P. Acnes
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[Show More] -non-inflammatory (closed & open comedones) -inflammatory (erythematous papules, pustules, nodules, cysts) What factors might be exacerbate acne outbreaks? -certain foods, dirt, stress -certain medications (anti-convulsants, anti-tuberculosis, antidepressants, steroids) Treatment of acne vulgaris: -depends on the severity and classification* -topicals (retinoids, benzoyl peroxide products, antibiotics) -orals (antibiotics & oral retinoid-Accutane) -hormonal agents (oral contraceptives or spironolactone) -keratolytics (Salicylics or azelaic acid) -it's important to inform patients that a complete resolution may not happen--the goal is to at least reduce the severity/symptoms* Benzoyl peroxide: -"antiseptic, comedolytic, bactericidal" -suppresses growth, reduces inflammation, promotes keratolysis -release free-radical oxygen which oxidizes bacterial proteins -avoid contact with eyes & mucous membranes -it can stain certain fabrics or pillow-cases or bleach hair -may cause mild skin irritation (burning, itching, peeling, redness, swelling)--reduce frequency or drug concentration* -discontinue if irritation is severe* -it does not promote bacterial resistance -likely safe with breastfeeding -potential for lethal hypersensitivity reactions especially in patients with asthma -typically used as mono-therapy in patients with mild acne* Topical retinoids-vitamin A derivatives (Retinol): -unplugs existing comedones & prevents future ones—comedolytic* -reduces inflammation & improves penetration of other retinoids -modifies epithelial growth and differentiation -can combine with other topicals & oral antibiotics if needed What acne medications are contraindicated in pregnancy? -ALL retinoid products oral & topical* -oral salicylates -no evidence for safety of topical salicylates -tetracyclines* (Category D can cause tooth discoloration, enamel dysplasia, bone deformation and growth restriction in the fetus) What acne medications should be avoided in lactation? -All retinoid products oral & topical -limited data on salicylates in lactation Caution use of retinoids in those with what kind of allergy? -fish* Tretinoin (topical derivative of vitamin A): -used for acne & fine wrinkles. -comedolytic* -normalizes hyper-proliferation of epithelial cells in hair follicles -thins skin allowing easier penetration of other topical agents -suppresses the genes that code for break-down of collagen & elastin -A/E-->blistering, peeling, dryness, photosensitivity* Topical antibiotics used for treatment of acne: -Clindamycin & Erythromycin -suppresses growth of bacteria & decreases inflammation -can lead to antibiotic resistance--combine with benzoyl peroxide reduces this risk* Oral antibiotics used for treatment of acne: -suppresses bacteria growth & decreases inflammation -can be combined with topical retinoids or benzoyl peroxide (this helps reduce antibiotic resistance) -takes 3-6 months to really show an effect* -as soon as improvement shows--back them down to a topical antibiotic* Hormonal agents: -combined oral contraceptive agents (estrogen or progesterone) -can also be combined with spironolactone -anti-androgenic effect which decreases testosterone (testosterone increases sebum production which plays a role in acne) -takes up to 3-6 months for improvement -can only use for those 15+ who have reached menarche and have not responded to topical treatment* Do not use COCs with: -pregnancy -current breast cancer -breastfeeding less than 6 weeks postpartum -heavy smoker who is 35+ years old -Severe hypertension -Diabetes with end organ damage -has had diabetes for >20 years -history of or current DVT or PE -major surgery with prolonged immobilization -ischemic heart disease -history of CVA active viral hepatitis -severely decompensated cirrhosis -liver tumor Spironolactone: -potassium sparing diuretic -particularly helpful in those with PCOS & acne -used off-label for acne treatment* -anti-androgenic effect (decreases testosterone levels) -treat with lowest effective dose -results usually within 4-8 weeks -baseline CBC & CMP -monitoring during treatment is not required* What is important to teach the patient who discontinues oral contraceptives for which was a treatment for acne? -the SHBG (sex hormone binding globulin) which decreased testosterone levels--will stay elevated for some time and will appear as though the acne is cured--however it can return once SHBG levels return to normal* Isotretinoin (Accutane): -oral vitamin A derivative* -Black box warning: severe birth defects can occur--contraindicated in pregnancy or anyone who could become pregnant -only able to prescribe using a iPLEDGE program--every patient with a functioning uterus and ovaries must receive written and oral warnings on pregnancy risks & have two forms of birth control while using -A/E-->nose bleeds, inflammation of the lips and eyes, elevated triglycerides (obtain baseline level and check after treatment), depression -increased adverse effects if taken with other vitamin A derivatives or tetracyclines* What is first line treatment for Acne Rosacea? -topical metronidazole (Flagyl, Metro-Gel) -causes inhibition of protein synthesis and cell death -no disulfiram reactions are seen with topical flagyl use* -oral flagyl might be indicated if topical does not work What is contraindicated with ORAL flagyl use? 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