Teaching and Treating Your Acne Patients
Live blog coverage of Douglas DiRuggiero, PA-C lecturing on treating acne based upon severity at the 2014 SDPA Fall conference in San Diego.
Douglas DiRuggiero, PA-C lectured on presentation and treatment of acne at the 2014 SDPA Fall conference in San Diego. He began by noting that the facial skin is unique. It is the most medicated and cleansed area of the body, it is constantly exposed to the elements and microorganisms, and it has a great supply of oil and blood.
Once acne has been diagnosed, DiRuggiero has a few questions for his patient before naming the treatment: How does your acne affect you socially/emotionally?; What kinds of treatments have you tried?; Is your acne worse at certain times?; Is there a history of melanoma? Explaining that last question, DiRuggiero pointed out that, although melanoma is not linked to acne, missing a melanoma in your office can get you in trouble.
After patients have provided these answers, the following treatment options can be discussed.
Benzoyl peroxide (BPO)
BPO + Antibiotics
The first line of treatment for acne depends on the severity:
Comedonal: Topical Retinoid
Mild Papular/Pustular: Topical Retinoid + Topical Antibiotic
Moderate Papular/Pustular: Topical Retinoid + Oral Antibiotic +/- BPO
Moderate Nodular: Topical Retinoid + Oral Antibiotic +/- BPO
Severe Nodular: Oral Isotretinoin
Educate your patients on the factors that can cause and exacerbate acne:
- Family history of acne is associated with earlier occurrence of acne,
increased acne severity, and poor response to treatment
- Increased production of androgens during puberty leads to greater
production of sebum
- Stress is associated with acne severity
- Corticotropin-releaseing horomone upregulates sebocyte conversion of androgren precursors to testosterone
- Substance P, a neuropeptide produced during stress, stimulates proliferation of sebaceous glands
- Evidence suggests that stress decreases proinflammatory cytokine production and can slow wound healing, leading to slower repair of acne lesions
Dialogue Between Matthew Zirwas, MD and Douglas DiRuggiero PA-C on Isotretinoin
Z: If it was your kid, would you put them on an oral antibiotic or isotretinoin?
D: I would try an oral antibiotic first before going through the rigmarole of isotretinoin.
Z: What are the main side effects you really make sure you cover in an isotretinoin discussion?
D: I say this is an excellent medicine. Things will change. Research shows that 82% have a lifetime cure. Why could it fail? If you’re a woman, if you’re 14 or less, or if you don’t get the recommended dose. I also tell them that it’s known to possibly effect mood. Don’t over-read depression, but don’t over-look it either.
I’ve put more than 4,000 people on isotretinoin. Out of those, two young women had mood issues. Some 20-year-old men experienced a fog. I also ask patients if they have history of gastro-issues. When I document, I list all of the history so there are notes that show we went over it. I tell them, if anything happens to your stomach, if you get a headache, then I want to hear about it.
Z: Another thing that I do for those who are nervous about inflammatory bowel disease… I tell them the risk without meds is 1 in 5000. Start this treatment, and those numbers change to 1 to 4999.
Audience: Concerns with Bipolar and accutane?
Z: Anyone with a psychiatric history, I need a letter from their psych. And I tell mom to watch for change in mood and behavior.
Audience: What if they aren’t with a psychologist but getting SSRIs from a primary care physician?
Z: If you’re on a psych med managed by your primary care doc, I’d be ok with a letter from primary care doc. But I don’t have the liability issues in my practice that some have so…
D: It’s also important in that case to check with your supervising Doc.