Page 43 - Demo

AN OVERVIEW OF SEVERE ACNE TREATMENT David McLaren David graduated with a Bachelor of Pharmaceutical Science and a Master of Pharmacy from the University of Canberra. Since 2017 he has worked as a locum pharmacist in hospitals and community pharmacies across the east coast of Australia. Since completing his Master of Public Health at the University of Queensland he has begun work at the Australasian College of Pharmacy as a professional development pharmacist. LEARNING OBJECTIVES After completing this CPD activity, pharmacists should be able to: • Describe the pathophysiology of acne. • Describe the key counselling points for topical treatment for acne. • Describe the key counselling points for treatment with oral retinoids. 2016 Competency Standards: 2.2, 3.1, 3.2, 3.5, 3.6. Accreditation Number: A2106RP1 (exp: 31/05/2023) Acne vulgaris (vulgaris being Latin for ‘common’)1 is the most common skin condition in adolescents.2 Acne affects more than 85 per cent of teenagers, often more severely in males than females.3 While it predominantly affects adolescents, for up to 50 per cent of individuals, their acne symptoms may continue into adulthood.2 Acne should not be accepted as a natural part of adolescence. Instead, persons with acne should be offered early treatment with evidence-based interventions.2,4 The burden of acne extends beyond cosmetic changes and discomfort. Studies have demonstrated that there is significant stigma, psychological distress and social isolation that accompanies this skin condition.5 Severe acne is associated with higher unemployment rates,6 being bullied in school7 and anxiety or social phobias.4 The impact on an individual’s health- related quality of life from acne is not necessarily correlated with the severity of the condition.8 Even patients with mild acne can experience profound changes in psychological health, potentially developing depression and suicidal ideation.9 The Therapeutic Guidelines has accommodated for this, stating that it may be appropriate to treat mild acne, if it causes significant distress for the patient, as if it were severe.10 As community pharmacists are often the first point of contact, this provides a unique opportunity to offer advice regarding referral, management options and monitoring the outcome of pharmacotherapy. Prompt treatment has been demonstrated to decrease the likelihood of scars developing, and reduce the psychological impact of the disease.7,11 Pathophysiology Although antibiotics are sometimes used to treat certain presentations of acne, it’s important for pharmacists to recognise that acne is a chronic inflammatory disease.2 There is a clear association between high circulating androgens and the appearance of acne during adolescence and early adulthood.12,13 Hormone imbalances are a causative factor only in a minority of cases. Instead, acne is usually associated with an increased sensitivity to hormones.2,3 Acne is associated with the pilosebaceous unit that consists of a hair follicle, an attached erector pili muscle and a sebaceous gland that produces sebum under the influence of circulating androgens.2 Acne is predominantly distributed in areas of high sebaceous gland activity such as the face, upper back and chest. The following processes have a pivotal role in the pathogenesis of acne: • Hyperproliferation of keratinocytes leading to obstruction of a follicle.15 • Excessive sebum production stimulated by the presence of androgens.2 • Follicular colonisation by Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes, within the sebum.2,12,16 • An inflammatory and foreign body response resulting in acne appearing morphologically as a papule, pustule, nodule or cyst.2 The combination of the rupture of the follicle and intense inflammation within the dermis leads to long term scarring.8,11 In studies of tertiary students and adolescents, up to 20 per cent of respondents believed that acne was contagious.13,14 Patients should be reassured that the development of acne is not due to an infection, nor is it contagious.11,15 It’s most likely that the presence of C. acnes on the skin doesn’t result in the development of acne; rather, certain strains can aggravate its pathophysiology. A study by Fitz-Gibbon et al in 2013 found that the amount of C. acnes present on the skin was the same between groups with or without acne.16 However, some particular strains of the C. acnes bacteria may be more likely to cause disease than others. Topical Treatment Treatment for mild acne generally starts with topical agents, such as keratinolytics, while topical antibiotics and retinoids may be used for moderate to severe acne.10 With all topical treatments, patients should be instructed to apply the treatment over the whole area that is usually affected by acne, and not to use them as a ‘spot treatment’.17,18 Patients should expect to use these products for several weeks to months before noticing any benefits in their symptoms.9,19 The Therapeutic Guidelines recommends starting treatment of mild acne with agents available over the counter.10 Benzoyl peroxide (BPO) is able to break down the keratinocytes that obstruct the follicles, as well as inhibit the growth of the C. acnes bacteria.20 Topical treatments with BPO are available in 2.5 per cent, 5 per cent and 10 per cent strengths. For initial therapy of mild acne on the face, the 5 per cent products should be preferred.10 The BPO 5 per cent wash is useful for treating acne over large surface areas such as the back and chest.10 The lowest strength should only be considered for patients with sensitive or dry skin or a history of atopic dermatitis.10 Patients can gradually increase the amount used and strength as they become more tolerant of the side effects of the product.17 According to the Australian Medicines Handbook and the Therapeutic Guidelines, no evidence supports the use of the 10 per cent gel, as it is more irritating without additional benefit over other strengths.10,19,21 This is substantiated by an early randomised control trial that found all strengths to be comparable for reducing lesions, but the 10 per cent strength resulted in more adverse effects of burning and peeling.22 If a patient has attempted using BPO and not achieved adequate control of their acne symptoms, pharmacists should recommend the patient discuss their acne with a medical practitioner. Treatment options should be determined if the acne appears more inflammatory or more dominantly affected by comedones (commonly known as whiteheads and blackheads).2,10 Topical antibiotics are preferred for acne presenting with more inflammation.10 TO PAGE 42 RETAIL PHARMACY • JUN 2021 CPD ACTIVITY 41 2 CPD CREDITS