Presentation by: Francine Carson SUNY IT Utica-Rome NUR 652 Acne Vulgaris Presentation by: Francine Carson SUNY IT Utica-Rome NUR 652

Definition of the Problem Pathophysiology Etiology Inflammatory disorder of pilosebaceous unit Hormonal influence Androgens (Lavers, 2014, p.330) pilolsebacesous Four key processes are involved in the pathogenesis of acne: 1. Androgen-driven excessive sebum production 2. Abnormal keratinization (hyperkeratinization) 3. Colonization with Propionibacterium acnes (P. acnes ) 4. Release of inflammatory mediators (Lavers, 2014, p.330) Normal pilosebaceous unit [Illustration]. 2005. Retrieved September 14, 2014 from http://images.niams.nih.gov/detail.cfm?id=89

Incidence Effects persons of all ages “Most common dermatological condition worldwide”(Lavers, 2014, p.330) Effects persons of all ages 80-100% will be effected in their lifetime Begins around puberty; peaks in adolescence; tends to resolve third decade of life May be present in the newborn (Watkins, 2013) May be present in the new born (under influence of maternal hormones

Screening/Risk Factors Drugs Family History Stress Hormonal changes Pregnancy, menstrual cycle Conditions with excess androgen production Polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing’s Syndrome Smoking Occlusion of skin surface Cosmetic products (Lavers, 2014 p.332; Lavers & Courtenay, 2011, p.58) Corticosteroids Polycystic ovary syndrome, congenital adrenal hyperplasia and Cushing’s (condition with excess androgen production) Stillunclear if diet has an effect. Still need evidence based studies to determine. Cosmetic products with oils

Clinical Findings Other findings Diagnosis based on clinical findings, H&P : Other findings Inflammatory & Noninflammatory lesions (Titus & Hodge, 2012) Noninflammatory Open or Closed Comedones Inflammatory Lesions Papules, pustules, nodules, and cysts May feel hot, painful, and tender to pressure Visible to naked eye (Lavers & Courtenay , 2011, p.58) Distributed to face, neck, chest, upper back, and shoulder (Lavers, 2013) Seborrhoea Scarring Post-inflammatory pigmentation Grading severity helps determine treatment A diagnosis of acne vulgaris cannot be confirmed unless typical comedones are seen, with the naked eye, in one or more of the following areas: face, neck, chest, upper back and shoulders ( - these are areas with many sebacous glands

Images Retrieved September 14th , 2014 from http://emedicine.medscape.com/article/1069804-clinical

Assessing Severity of Acne Mild Seborrhoea Predominantly comedonal lesions Micro-comedones (first stage of comedone formation) Open (blackheads) and closed (whiteheads) comedones Few papular inflammatory raised lesions Typically limited to the face Moderate Open and closed comedones Moderate acne presents with greater numbers of inflammatory papules and pustules, involving face and trunk Severe Papular and pustular inflammatory lesions Nodular-cystic lesions Scarring (Lavers, 2014, p.334) (Image from British Journal of School Nursing, 2011, p. 382)

Differential Diagnosis Rosacea Seborrheic dermatitis Drug-induced acne Bacterial folliculitis Perioral/Periorbital dermatitis Keratosis pilaris (Lavers, 2014; Lavers & Courtenay, 2011; Titus & Hodge, 2012)

Social/Environmental Considerations Psychological impact (Lavers, 2014, p.333) Stress Anxiety Depression Suicidal ideations Low self-esteem Poor body image Social withdrawal & higher rates of unemployment - especially in teenagers (Joseph & Sterling, 2010, p. 122) These do not correlate with severity of acne.

Laboratory Testing/Diagnostics Acne vulgaris is diagnosed by clinical appearance Culture for sensitivities (Watkins, 2010, p.115) Test for underlying condition Hyperandrogenism LH, FSH, Free testosterone (Domino, 2013, p.16) Grading acne Hirsutism

Management/Treatment Guidelines Pharmacologic (Lavers, 2014, p.334-335) Topical Retinoids – for all grades of acne (except when oral retinoid used) First line treatment Adapalene – best tolerated Antibiotics – mild-to-moderate inflammatory lesions Combination with benzoyl peroxide or topical retinoid Limit treatment to 12 weeks First line: Clindamycin or Erythromycin Benzoyl peroxide – Comedolytic, anti-inflammatory Azelaic acid Salicylic acid Oral – moderate-to-severe or mild-to moderate acne Antibiotics - moderate-to-severe inflammatory acne Tetracycline (avoid use in pregnant women), Doxycycline Limit course :12 weeks Combine treatment with topical retinoid or benzoyl peroxide Hormonal therapy – moderate-to-severe acne Combined oral contraceptives, Spironolactone Results: 3-6 months Retinoids - severe acne First line treatment Accutane (Isotretinoin) 16-24 week course Teratogenic Treatment goals (Titus & Hodge, 2012, p.740) Prevention of scars Reduction of psychological manifestations Resolution inflammatory/noninflammatory lesionsRetinoids – for all grades of acne (except when oral retinoid used) – first line treatment Adapalene – best tolerated Antibiotics – mild-to-moderate inflammatory lesions, use in combination with benzoyl peroxide or topicalretinoid, limit treatment to 12 weeks (antibiotic resistance) First line: Clindamycin or Erythromycin Benzoyl peroxide – comedolytic ,anti-inflammatory, non-antibiotic antimicrobial Azelaic acid - normalizes keratinocytes, anti-inflammatory, treats post-inflammatory pigmentation Salicylic acid - desquamating, comedolytic,

Management/Treatment continued Non-pharmacological Surgery; I&D for abscesses (Domino, 2013, p.17) Laser and light therapy (Titus & Hodge, 2012, p.739) Biofeedback Acupuncture Microdermabrasion

Complications Scarring Psychological manifestations Antibiotic resistance (Joseph & Sterling, 2010; Lavers, 2014, p.336)

Follow-up 4-6 weeks Reevaluate response to treatment Adverse effects (Dunphy, Winland-Brown, Porter, & Thomas, 2011, p. 209)

Counseling/Education Avoid picking at scabs or acne (Lavers & Courtenay, 2011, p.64) If acne doesn’t improve, return for reevaluation Wash face twice daily with a gentle cleanser Wash oily hair regularly Use medication as directed and give it time to work 6 weeks (Titus & Hodge, 2012, p. 740) Scarring – ick at spots May get worse first 2 weeks of treatment

Consultation/Referral Dermatology Family and peer group support Psychological counseling

10 Questions 1. A client returns after 2 weeks of treatment for acne and states it isn’t working. What should the practitioner tell the client? a) Return in 4 weeks, b) Let’s change your treatment, c) Refer to dermatology 2. T/F : Popping acne is ok because it gets the pus out. 3. Which lab study should the provider obtain prior to starting a female client on Isotretinoin? a) CBC, b) ESR, c) pregnancy test 4. Why are acne vulgaris lesions mostly located the face, back, neck, and chest a) Lower concentration of ebaceous glands, b) Higher concentration of sebaceous glands, c) Skin pigmentation 5. A client says they have been scrubbing their face to get rid of the oils and their acne isn’t getting any better. What should you say to the client? Scrubbing can irritate the skin and make the acne worse It takes about 1 week of scrubbing to see improvement Let’s take a look at your acne medication

10 Questions (continued) 6. Who should the provider refer a client who is feeling embarrassed and depressed about their acne? a) Psychologist, b) Plastic surgeon, c) School nurse 7. Why should the provider limit the duration of antibiotic treatment for clients? a) Cdiff, b) Photosensitivity, c) Antibiotic resistance 8. Which medications can one use for treatment of acne? (Multiple correct) a) Retinoids, b) Antibiotics , c) Oral contraceptives 9. Acne vulgaris is diagnosed based on: a) Culture results, b) clinical appearance, c) TSH studies 10. T/F: Clients taking corticosteroids or women with polycystic ovarian syndrome are at risk for acne vulgaris?

References British Journal of School Nursing, Oct 2011, Vol. 6 Issue 8, p379-384, 5p, 2 Color Photographs, 1 Black and White Photograph, 1 Diagram, 1 Chart Color Photograph; found on p382 Domino, F. (2014). Griffith’s 5-minute clinical consult (22nd ed.). Philadelphia: Lippincott Williams & Wilkins Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis. Joseph, D., & Sterling, A. (2010). The psychological effects of acne in teenagers. British Journal Of School Nursing, 5(3), 122-126. Lavers, I. (2013). Therapeutic strategies for acne vulgaris. Nursing Times, 109(48), 16-18.

References Lavers, I. (2014). Diagnosis and management of acne vulgaris. Nurse Prescribing, 12(7), 330-336. Lavers, I., & Courtenay, M. (2011). A practical approach to the treatment of acne vulgaris. Nursing Standard, 25(19), 55-55-6, 58, 60 passim. Titus, S., & Hodge, J. (2012). Diagnosis and treatment of acne. American Family Physician, 86(8), 734-740. Watkins, J. (2013). Looking at the potential impact and management of acne. British Journal Of School Nursing, 8(3), 115-117.