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Welcome back to The Deep Dive.
Today we're jumping into Chapter 15, Acne, Vulgaris, and Rosacea.
Now, these are conditions we see all the time in primary care, right?
And they might seem relatively minor, sometimes clinically, but our sources really stress something important.
The psychosocial cost, especially for teens, can be, well, huge.
That's absolutely right.
And it frames the first step, really, before we even think about drugs, we just need to ask the patient, do you want to treat this?
No matter how mild it looks to us, acne is just incredibly common.
We're talking, what, up to 90 % of teenagers and a lot of adult women too, maybe 30 to 50%.
Wow, yeah.
And when we get to treatment, the key, the absolute foundation is combination therapy, using different things together.
Okay, so let's unpack the why first, the pathophysiology.
Understanding that really maps out the treatment, doesn't it?
There are like four main things going on with Acne, Vulgaris.
Yeah, four key factors.
It starts with androgens ramping up sebum production, too much oil.
Then factor two, and this is crucial,
abnormal keratinization.
The skin cells basically get sticky, plug up the follicle, that traps the sebum, and boom, you get comedones, whiteheads, blackheads.
Right.
And then the bacteria enters the picture, cutobacterium acnes.
Exactly.
It's normal skin flora, but it's enzymes.
They trigger factor three, they break down the sebum, create irritating substances.
And that's the switch, isn't it, from just being there to causing actual inflammation?
Precisely.
Those substances attract white blood cells, monocytes.
That's factor four, the big inflammatory response.
If that inflammation goes deep, you risk scarring, nodules, cysts.
So the treatment goal is clear.
Reduce lesions, prevent scarring.
Yes.
And almost always, that means hitting it from multiple angles with different drug classes working together.
Oh, and a critical patient education point right away.
This takes time.
Tell them four to six weeks, usually, before they'll see real improvement.
Patience is key.
Definitely need to manage expectations.
Okay, let's dive into the agents.
Starting with the first line for comedonal acne,
the comedolytics.
We're talking topical retinoids, tretinoin, adipoline, differin,
tessertine, tesserac, comedolytic, meaning they break up those plugs.
That's the core function.
They work by decreasing how tightly the skin cells stick together, and they speed up cell turnover.
So existing comedones get expelled, and new ones are less likely to form.
Some formulations, like retinomicro, use tiny spheres to release the drug slowly, which can sometimes help with irritation.
And typically used once a day, usually evening, right?
Right.
Because of sun sensitivity.
Generally, yes.
But hang on, before we go further, we absolutely have to hit the major warning here.
This is vital for advanced practice students.
I'll be late on this.
Teradogenicity.
It's a huge risk.
All retinoids, and yes, that includes the topical one, like tessertine and adipoline, are considered teradogenic.
This is an absolute no -go for anyone pregnant or planning pregnancy.
Rigorous counseling, ensuring effective contraception.
It's non -negotiable, even with topicals.
That's a crucial point.
So beyond that really serious warning, what are the common things patients complain about?
The side effects.
Expected stuff, mostly.
Redness, dryness, peeling.
Especially at first, as the skin adapts.
The advice is always start low, go slow.
Maybe every other night to begin.
Or for really sensitive skin, tell them put it on for just 15, maybe 30 minutes, then wash it off.
Gradually leave it on longer.
And applying it to dry skin, that's a specific instruction.
Why is that so important?
It really matters.
Damp skin absorbs much more of the retinoid much faster.
And that directly translates to more irritation, more burning.
So wash, wait a good 20 minutes until totally dry, then apply.
And one more practical thing, tell patients to stop using it about three days before any waxing.
Helps prevent skin irritation or stripping.
Good practical tips.
Okay.
Moving to the next group.
Topical anti -inflammatory and bactericidal agents.
First up, benzoyl peroxide.
BPO.
BPO.
A real workhorse for inflammatory acne.
It does two things.
It's chamelelytic, like the retinoids, but also strongly bactericidal against the acnes.
Knocking back the bacteria reduces that whole inflammatory cascade we talked about.
Right.
And the classic counseling point everyone forgets until it happens.
Slight chuckle.
The bleaching.
Yes.
You absolutely have to warn them.
BPO can bleach colored fabrics, towels, pillowcases, shirts.
It's a simple thing but important.
Okay.
Next, azelaic acid, like azalex.
Azelaic acid.
Generally milder, less irritating than BPO for many people.
The thinking is it messes with the DNA synthesis of the bacteria.
One thing to note though, it can sometimes cause hypopigmentation, loss of skin color, particularly in patients with darker skin tones.
So counsel about that.
Good flag.
And the last one in this topical group.
Dapsone.
Brand name Axome.
Dapsone.
It's anti -inflammatory, antibacterial.
The exact MOA isn't perfectly clear.
The main tricky thing with Dapsone is an interaction.
If you use it at the same time as topical BPO, it can cause this temporary orange brown staining on the skin.
It wipes off, but it can be alarming.
And critically, though rare, there's a potential for a serious side effect.
Methamoglobinemia.
Problems with oxygen transport in the blood.
Very rare, but potentially lethal.
So need to be aware of that.
Okay.
So if these topicals aren't quite cutting it, we move up to systemic therapy.
Oral antibiotics for inflammatory acne.
Why go systemic when we have topicals targeting inflammation?
Good question.
It's because the oral antibiotics, especially the tetracycline family, doxycycline, minocycline, the neuro -1, serocycline.
They do more than just suppress C -acnes.
They have significant anti -inflammatory effects, too.
They inhibit things like neutrophil chemotaxis systemically.
Makes sense.
But tetracyclines come with their own set of major warnings, don't they?
Especially age -related.
Absolutely critical warnings.
They are contraindicated in children under 12.
Why?
Because they permanently stain developing teeth.
A yellow -brown discoloration.
You can't reverse it.
They're also teratogenic, so contraindicated in pregnancy.
Okay.
Under 12 and pregnancy are absolutely contraindications.
What are the side effects?
Common ones are photosensitivity, increased sunburn risk, and GI upset.
Less common, but more serious, is pseudotumor cerebre, which is basically increased pressure inside the skull.
And because of growing antibiotic resistance concerns, long -term continuous use really isn't recommended anymore.
We try to use them for bursts, then taper.
So what's the alternative if you do have a child, say, 10 years old, who needs systemic therapy?
The main alternative there is erythromycin.
It avoids the teeth staining issue.
The downside is it often causes more significant stomach upset than the tetracyclines.
And for really tough refractory cases, sometimes trimethoprimsulfamethoxazole is used, but that's further down the line.
Got it.
Now, the big gun, the drug that really revolutionized treatment for severe acne,
isotretinoin, systemic retinoid.
Yeah, isotretinoin, reserved strictly for severe nodulocystic acne that hasn't responded to anything else.
It's incredibly effective.
What are the risks?
The risks are profound, especially teratogenicity.
That's why we have the mandatory iPledge program.
We're talking a 25 -fold increase in severe birth defects, heart, brain, face.
Devastating.
And even exposed babies without obvious defects have a high risk of subnormal intelligence later on.
It's incredibly serious.
So the iPledge system, what exactly does that entail?
What do students need to know, Colt?
Okay, everyone involved must be registered.
Prescribers, pharmacies, and all patients, male and female.
For females who could become pregnant, two negative pregnancy tests a month apart before starting, then monthly pregnancy tests during treatment or for one month after stopping.
They also have to commit to using two effective forms of birth control simultaneously, no exceptions.
And there's mandatory lab work too.
Baseline and monthly checks of CBC, liver function, and especially fasting, lipids, cholesterol, and triglycerides because isotretinoin could spike those.
Wow.
That level of monitoring just underscores the potential systemic impact.
Before we leave acne, briefly, what about hormonal approaches specifically for women?
Right.
Oral contraceptives are a good option.
Specifically, certain combined pills containing ethinylestradiol plus specific progestins.
They work well for both inflammatory and comedonal acne in women.
And then there's spironolactone.
Often used for that cyclical jawline acne, right?
Exactly.
Great for adult women with that pattern, painful flares around their cycle often along the jaw.
Spironolactone acts as a weak diuretic, but its main benefit here is blocking androgen receptors.
Dosing usually starts low.
25 or 50 milligrams a day can go up to 200.
Takes a few months, maybe three to see the full effect.
Okay.
Good overview.
So we've covered acne strategies targeting the follicle, bacteria, inflammation.
Now let's switch gears entirely to rosacea.
Looks similar sometimes, but it's a different beast needing different treatments.
Totally different.
Rosacea is an inflammatory disorder.
Yeah.
Usually starts midlife, 30s, 40s, 50s.
Typically affects fair skin people, central face, cheeks, nose, forehead, chin, symmetrical rash.
But the absolute hallmark sign, the thing that really clinches the diagnosis and separates it from acne, is fixed telangiectasia.
Those visible tiny blood vessels that don't go away.
Exactly.
They're persistent.
You don't see true comedones, blackheads, whiteheads, in rosacea, which you do see in acne.
And treatment is all about managing the inflammation and the redness.
Oh, and sometimes men get a more severe form involving thickening of the nose skin called rhinophyma.
Okay.
So first line topicals for the inflammation and rosacea.
Metronidazole is key.
Metrogel.
It works mainly via its anti -inflammatory effects.
Patients usually see some improvement in about three months, but the full effect takes longer, maybe nine weeks.
And often they need to stay on it long -term for maintenance.
Isoleic acid again, but specifically the 15 % gel or foam formulation finacea is approved for rosacea.
And we also use topical ivermectin, which is technically an anti -parasitic, but it helps reduce inflammation here too.
Can be used alone or combined.
All right.
What about specifically targeting the redness, the erythema?
For that, we have topical vasoconstrictors.
Oxymenazoline, HCO, and bromonadine.
Simple mechanism.
They constrict the small blood vessels in the skin, making it look less red.
You apply it once a day, usually in the morning.
The effect lasts about eight to 12 hours.
Just one caution.
Be careful using these in patients with narrow angle glaucoma as there's a theoretical risk.
Good to know.
And oral therapy.
We mentioned doxycycline for acne.
Is it used here too?
Yes.
And this is a really important distinction for learners.
It's used very differently.
For rosacea, we use doxycycline at low sub -antimicrobial doses, like 20 milligrams twice a day, or a 40 -milligram slow release formulation.
At these low doses, its primary effect is anti -inflammatory, not killing bacteria.
Ah, okay.
So you get the anti -inflammatory benefit without the higher dose needed for antimicrobial effects in acne.
Exactly.
And that helps reduce the risk of antibiotic resistance and some side effects associated with the higher doses.
So if we were to sort of talk through the treatment steps for rosacea, like visualizing that algorithm in the book, how does it typically progress?
Okay.
First line,
try topical therapy alone.
Give it a good six weeks or so.
If that's not enough, second line, add one of those low dose oral antibiotics like the doxycycline we just discussed.
But the plan is usually to taper and stop the oral antibiotic after maybe six weeks or so, while continuing the topical for long -term maintenance.
If things are still really severe, third line might involve a short course of low dose oral
or more likely referral to dermatology.
That maps it out clearly.
So wrapping up this deep dive, the big themes seem to be combination therapy for both conditions and really intensive patient education.
Absolutely.
Can't stress that enough.
Remind patients.
Apply topicals to clean, completely dry skin.
Use just a small amount.
Start low, go slow with retinoids, and hammer home the time factor.
Results take weeks, minimum four to six.
They need to stick with it.
And circling back one last time to those crucial safety points, those absolute contraindications.
Yes.
No tetracyclines in pregnancy or kids under 12 because of the pith staining.
And isotretinone, the extreme teratogenicity risk, means strict adherence to iPledge is mandatory for everyone involved.
It really highlights something, doesn't it?
These strict rules, the intense monitoring required for drugs like isotretinone.
It reflects the seriousness of the potential harm.
And it brings us back to beginning.
That skin condition, even if it looks minor to us, can be deeply distressing for the patient.
Managing these isn't just about picking a cream.
It's about navigating significant risks, ensuring patient understanding and adherence.
It really turns these common conditions into high -stakes management challenges, demanding careful pharmacologic knowledge.
A powerful reminder of the responsibility involved.
Thank you so much for walking us through all that crucial information today.