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Live Blog: Acne and Rosacea: New Therapies and Strategies for Management, Part One – Abby Jacobson, MS, PA-C

In this live blog from the 12th Annual SDPA conference in Indianapolis, Abby A. Jacobson, MS, PA?C, lectured on “Acne and Rosacea: New Therapies and Strategies for Management.” Here are some of the highlights from part one: Acne. Here is part two.

Ms. Jacobson began her lecture by reiterating that, in her mind, “Severity is in the eye of the beholder,” when it comes to patient perception and experience of their acne problems.

First: Acne Treatment Options

Topical monotherapy
Topical combination therapy
Systemic therapy
Combination of topical and systemic therapy
Chemical peels
Light and laser therapy
Photodynamic therapy
Corticosteroid injections
Retinoids
Antimicrobials
Salicylic acid
Keratolytic activity

Combination Products

Jacobson briefly discussed various topical combination products such as Adapalene and BPO (epiduo), BPO and clindamycin (acanya, benzaclin, generic), Erythromycin 3%/ benzoyl peroxide 5% gel (such as Benzamycin and Benzamycin), and Clindamycin and tretinoin (Ziana). She stated that, “retinoid and antibiotic combo is helpful, but it’s hard to get this product with changes in insurance.”

Antibiotic

Jacobson discussed antibiotic treatments and the increasing awareness and emergence of antibiotic resistance and talked about dermatology providers needing to limit courses of oral antibiotics. Systemic antibiotics include: Tetracycline (though Jacobson mentioned that she, personally, cannot obtain tetracycline anymore), doxycycline, minocycline, sulfa (bactrim), amoxicillin, and erythromycin. There was an audience participation question about PAs first choice of oral antibiotic and most audience members chose generic doxycycline.

Systemic Retinoids

Jacobson discussed systemic retinoids such as oral isotretinoin. Isotretinoin is indicated for severe, recalcitrant acne. Jacobson reminded the audience to tell their patients that isotretinoin must be taken with a high fat meal in order to be effectively absorbed. Guidelines for “high fat” meal is 50 grams of fat. That is the equivalent of 2 fried eggs in butter, two strips of bacon, two slices of toast with butter, 4 ounces of hash brown potatoes, and 8 ounces of whole milk.

iPLEDGE

As Jacobson said, “We can’t talk about isotretinoin without talking about iPledge.” And she asked the question: “What to do IF there is a pregnancy?”

1.     Don’t panic
2.     Contact your supervising physician and document the discussion
3.     Contact the patient
4.     Contact iPLEDGE program
5.     Counsel on birth defects and options and see OB-GYN to discuss options

Jacobson reassured the audience that, “If you play by the rules and the program will not punish you.”

Chemical Peels

Jacobson also discussed chemical peels are good for improving inflammatory and comedonal acne. However they have minimal effect on nodular acne. Are also good for people with scars, PIH, large pores, or sensitive skin. Chemical peels often appeal to cash paying or non-insured patients, since a lot of patients can pay for chemical peels and they may be more desirable than figuring out a long term topical routine. Chemical peels are also good for patients who are unwilling to do a routine at home (For example, if the parent is the one bothered by the acne and the teenager doesn’t care and won’t comply.) Superficial peels include: glycolic acid, salicylic acid, and pyruvic acid.

An Oldie But A Goodie

Jacobson discussed an “oldie but a goodie” medication: Spironolactone for women. It was first developed in 1957 as an aldosterone antagonist that was used initially as a potassium-sparing diuretic in the treatment of HTN and CHF. Jacobson said it’s a great treatment option for patients with PCOS and hirsutism.

Special Considerations For Spironolactone

It is safe to use with birth control, and actually both Yaz and Yasmin contain drospirenone (3 mg is equivalent to 25 mg of spironolactone). Women must prevent pregnancy because if pregnancy with a boy it could cause feminization of the baby. High dose side effects include hyperkalemia, menstrual irregularities (metrorrhagia, amenorrhea, breakthrough bleeding), breast tenderness and enlargement, orthostatic hypotension, and reduced libido.

Take Home Pearls

  • Remember acne is the bread and butter of dermatology.
  • Don’t rush these patients (although tempting because we are all busy). These patients want you to exam and talk to them.
  • Patients want to feel “heard” and “sympathy.”
  • Evaluate who/if and how much the acne bothers them: “Is today an average, best, or worst day that your acne has looked?” “How much does your acne bother you?”
  • Try to evaluate compliance (have the patient bring their medications in with them).
  • Ask patients to bring in everything they are using (like loofahs, etc., and realize you still may not be getting it all).
  • Do your best to not get stuck in a rut.

 

Image: Thomas Leth-Olsen

 

 




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