From Dermatology Nursing
Janet Selway
Posted: 03/30/2010; Dermatology Nursing. 2010;22(1) © 2010 Jannetti Publications, Inc.
Abstract
The management of pediatric and adolescent acne requires multifaceted considerations revolving around the patient, parents, and appropriate treatment. The following case report represents a typical scenario exemplifying the key role of the dermatology nurse practitioner in optimizing successful acne management outcomes.
Introduction
Acne vulgaris is common among adolescents; most, if not all, personally experience its impact or are directly involved with individuals who have the condition. Effects of acne may extend beyond the physical lesions; psychological and social implications associated with the condition can be equally severe. The management of acne is multifactorial and, fortunately, a number of therapeutic options are available. Nevertheless, careful consideration must be made, particularly among adolescents, to properly align appropriate treatment to optimize outcomes.
The role of nurse practitioners (NP) is particularly important, as the need for continual patient education, motivation, and followup can sometimes lapse in a typically busy clinical practice. Addressing patient concerns, evaluating treatment efficacy and tolerability, and monitoring adherence to treatment are critical components of acne management. The following case study represents a characteristic scenario where all of the aforementioned components play a considerable role in the NP's contributions to successful management.
Treatment Options
The key to successful acne treatment is matching an effective, manageable, and affordable plan with an individual. This is especially important for preteens and adolescents, who have the most difficulty complying with long-term plans (Eichenfield, Fried, Taylor, Paller, & Theos, 2005). Treatment possibilities for acne vulgaris include topical agents, systemic antibiotics, hormonal agents, and isotretinoin (Strauss et al., 2007).
Topical Treatment
Topical treatments target mild-to-moderate acne, which includes inflammatory and noninflammatory forms (Berson et al., 2003). According to American Academy of Dermatology guidelines, effective topical treatments include, among others, retinoids, BP alone, and combinations of BP with clindamycin or erythromycin (Strauss et al., 2007). Topical antibiotics alone are also effective treatments but, like systemic antibiotics, are associated with resistance. Less-effective options include salicylic acid, azelaic acid, sulfur, resorcinol, sodium sulfacetamide, aluminum chloride, and zinc. Simultaneous application of multiple topical agents can be effective, but agents should not be applied simultaneously unless compatible (Strauss et al., 2007). BP oxidizes and sunlight degrades topical retinoids; however, this is not true of adapalene (a second-generation topical retinoid) or microsphere formulations of tretinoin (Martin, Meunier, Montels, & Watts, 1998; Nyirady, Lucas, Yusuf, Mignone, & Wisniewski, 2002). Products with topical or oral clindamycin are contraindicated in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis (sanofi-aventis U.S. LLC, 2007).
Topical retinoids (tretinoin, adapalene, and tazarotene) reverse abnormal desquamation and interfere with microcomedone formation (Berson et al., 2003). Topical retinoids alone are indicated for noninflammatory acne because of their anti-inflammatory properties (Strauss et al., 2007). Adapalene is a less-irritating alternative to topical tretinoin (Bershad, 2008). Tazarotene, a second-line retinoid, is a teratogen (Pregnancy Category X) and prohibited for use in women of child-bearing potential (Bershad, 2008).
Benzoyl peroxide, a topical bactericidal agent available in a wide variety of formulations and concentrations, is a potent inhibitor of P. acnes and a weak keratolytic. Its oxidizing properties can bleach hair and colored fabrics (Berson et al., 2003).
Another topical antibacterial is dapsone (Aczone®). Topical antibiotics have the benefit of minimal side effects. However, because of potential resistance to P. acnes, they are more useful when used in combination with BP, since BP has been shown to minimize antibiotic resistance (Berson et al., 2003; Strauss et al., 2007).
Systemic Treatment
Systemic antibiotics are indicated for moderate-to-severe cases and treatment-resistant forms of inflammatory acne (Leyden, Del Rosso, & Webster, 2007). The most commonly prescribed antibiotics for acne are tetracycline, erythromycin, clindamycin, doxycycline, and minocycline (Tan & Tan, 2005). Systemic antibiotics are increasingly associated with bacterial resistance (Leyden et al., 2007; Strauss et al., 2007). Treatment guidelines indicate that minocycline is more effective than doxycycline (Strauss et al., 2007). Both are more efficacious than tetracycline. Oral erythromycin should be used only when tetracyclines cannot be used, such as in pregnancy or with allergies. When other antibiotics cannot be used, trimethoprim-sulfamethoxazole can be an effective alternative (Strauss et al., 2007).
Use of oral antibiotics (e.g., tetracycline, doxycycline, erythromycin, azithromycin) is typically associated with gastrointestinal irritation; long-term use of oral antibiotics may also induce vaginal candidiasis in women (Katsambas & Papakonstantinou, 2004). Doxycycline is more likely to induce photosensitivity reactions than the other commonly prescribed antibiotics (Strauss et al., 2007). Minocycline is more likely than doxycycline to induce hypersensitivity reactions, although these are rare. Long-term use of minocycline may cause cosmetically displeasing skin hyperpigmentation (Geria, Tajirian, Kihiczak, & Schwartz, 2009).
Hormonal agents are an alternative for females with acne and include estrogen-containing oral contraceptives and the oral anti-androgens spironolactone and cyproterone acetate. Hormonal therapy reduces sebum production caused by androgenic overstimulation and decreases androgen responsiveness of sebaceous glands (Berson et al., 2003).
Short-term, low-dose, oral corticosteroid therapy may provide temporary benefit for severe inflammatory acne and adrenal hyperandrogenism (Strauss et al., 2007).
Isotretinoin is indicated for severe recalcitrant nodular acne and in some patients with treatment-resistant acne resulting in physical scarring (Jones, 2007; Yan, 2006). Isotretinoin is the only systemic agent that has anti-inflammatory action, inhibits sebum production, and impacts follicular desquamation (Yan, 2006). Persons taking isotretinoin have been reported to experience mood disorders, depression, suicidal ideation, and suicide attempts, but no causal link has been established (Hull & D'Arcy, 2005; Strauss et al., 2007). Because isotretinoin is a teratogen, female patients of child-bearing potential may be treated with isotretinoin only if they are participating in the approved pregnancy prevention and management program known as iPLEDGETM (https://www.ipledgeprogram.com) (Jones, 2007; Strauss et al., 2007). Both male and female patients receiving isotretinoin must register with this program. The iPLEDGE program is a computer-based risk management program designed to eliminate fetal exposure to isotretinoin through a specially restricted distribution program approved by the U.S. Food and Drug Administration (FDA). The program's purpose is to ensure that no female patient starts isotretinoin therapy if pregnant or becomes pregnant while receiving isotretinoin therapy (Jones, 2007).
Other treatments include intralesional corticosteroid injections (Levine & Rasmussen, 1983). Data are limited regarding use of chemical peels, comedone removal, and herbal agents, and dietary restriction has no confirmed treatment benefit (Strauss et al., 2007).
http://www.medscape.com/viewarticle/718696
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