Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 16:

Acne Vulgaris and Rosacea

Acne Vulgaris

Causes: exact cause remains unknown; exacerbating factors include foods, stress, dirt, oily agents, medications, friction

Pathophysiology

Excess androgen causes increased sebum production. For unknown reasons, abnormal keratinization causes retention of sebum in the pilosebaceous follicle.

This produces open comedones (blackheads) and closed comedones (whiteheads).

Medications That Cause Acneiform Rash and Underlying Conditions

Corticosteroids: chronic inflammatory conditions

Isoniazid: tuberculosis

Lithium: depression

Phenytoin: seizure disorder

Trimethadione: seizure disorder

Classifications of Acne Vulgaris

Comedonal acne: open comedones (blackheads), closed comedones (whiteheads)

Mild inflammatory acne: papules

Moderate inflammatory acne: pustules, cysts

Severe cystic acne: cysts, nodules “ice-pick” scarring

Question

A patient presents with a case of acne manifesting pustules and cysts. What classification of acne vulgaris would the practitioner document?

Comedonal acne

Mild inflammatory acne: papules

Moderate inflammatory acne

Severe cystic acne

Answer

C. Moderate inflammatory acne

Rationale: Moderate inflammatory acne presents as pustules and cysts. Comedonal acne manifests open comedones (blackheads) and closed comedones (whiteheads). Mild inflammatory acne manifests as papules, and “ice-pick” scarring occurs with severe cystic acne.

Nonpharmacologic Therapy for Acne

Wash the face gently two or three times a day with mild soap.

Avoid harsh, drying cleansers.

Avoid manipulating acne with fingers.

Use moisturizers and cosmetics that are water based, noncomedogenic, and fragrance free.

Question

A practitioner is teaching a teenage patient how to care for acne. Which teaching point describes a recommended guideline?

Avoid using drying cleansers on the skin.

Wash the face vigorously twice a day.

Gently squeeze pustules using a tissue.

Use moisturizers with an oily base.

Answer

A. Avoid using drying cleansers on the skin.

Rationale: Recommended guidelines for acne care are avoid harsh, drying cleansers; wash the face gently two or three times a day with mild soap; avoid manipulating acne with fingers; and use moisturizers and cosmetics that are water based, noncomedogenic, and fragrance free.

Goals of Drug Therapy for Acne

Minimize the number and severity of new lesions

Prevent scarring

Improve the patient’s appearance

Topical Preparations to Treat Acne: Tretinoin

Tretinoin (Retin-A, Avita) 0.025%, 0.05% cream, gel 0.04%, 0.1% microspheres; apply once daily; increase strength as tolerated; pregnancy C category

Adverse events: erythema, local skin irritation, photosensitivity

Contraindications: eczema, sunburn

Considerations: apply to dry skin for short periods or on alternate nights until better tolerated; avoid products with high concentrations of alcohol, astringents, spices, lime

Topical Preparations to Treat Acne: Benzoyl Peroxide

Dosage: benzoyl peroxide (many) 2.5% to 5.0% once a day; increase to two or three times daily.

Adverse event: irritation.

Contraindication: sunscreens containing para-aminobenzoic acid (PABA) may cause transient skin discoloration.

Considerations: product may bleach fabrics. Apply at different time from other topical medications.

Topical Preparations to Treat Acne: Azelaic Acid

Azelaic acid (Azelex) 20% cream apply twice a day.

Adverse events: pruritus, irritation.

Considerations: darker-pigmented people may have hypopigmentation; exacerbation of asthma.

Topical Preparations to Treat Acne: Clindamycin

Clindamycin (Cleocin T) apply to the skin twice a day

Adverse events: burning; stinging of eyes; possibly pseudomembranous colitis

Considerations: discontinue use if diarrhea develops; pseudomembranous colitis may develop; drug may potentiate neuromuscular blocking

Topical Preparations to Treat Acne: Erythromycin and Tazarolene

Erythromycin (many) 2% to 3% topical apply twice daily

Adverse event: irritation

Contraindication: allergy to erythromycin

Tazarolene (Tazorac) 0.05%, 0.1% gel, cream apply once daily

Adverse events: irritation, photosensitivity

Considerations: pregnancy category X; obtain negative pregnancy test; use contraceptives

Oral Medications to Treat Acne: Tetracycline

Dosage: tetracycline (many); 500 to 1,000 mg daily divided bid/qid; taper to 250 mg/d after improvement; attempt to discontinue after 4 to 6 months of therapy.

Adverse events: photosensitivity, gastric irritation, decreased effectiveness of oral contraceptives.

Contraindications: age younger than 12 years pregnancy category D.

Considerations: drug may increase serum digoxin levels; drug absorption is reduced if taken with antacids, iron, zinc, dairy products.

Oral Medications to Treat Acne: Erythromycin

Dosage: erythromycin (many) 500 to 1,000 mg/d divided bid/qid

Adverse events: nausea, vomiting, diarrhea, rash, allergic reactions, fungal infection, hepatitis, ototoxicity

Contraindications: allergy to erythromycin or macrolide; not recommended for children younger than age 2 months

Considerations: take on an empty stomach for better absorption 1 hour before or 2 hours after a meal; enteric-coated form can be taken with or without food

Oral Medications to Treat Acne: Isotretinoin (Accutane)

Dosage: 0.5 to 1.0 mg/kg bid

Adverse events: increased cholesterol and triglyceride levels; dry skin and mucous membranes; depression; aggressive/violent behaviors; back pain; arthralgias in pediatric patients

Contraindications: adolescents before cessation of growth; pregnancy category X

Considerations: prescriber SMART program; females pregnancy tests; monitor cholesterol and triglyceride levels, CBC, liver function test

Oral Medications to Treat Acne: Ethinyl Estradiol with Norgestimate

Dosage: ethinyl estradiol with norgestimate (Ortho Tri-Cyclen, Tri-Sprintec) one tablet daily

Adverse events: none known

Contraindications: premenarchal girls, male patients

Considerations: women who smoke should avoid use of oral contraceptives

Question

A practitioner routinely prescribes isotretinoin (Accutane) for patients with acne. For which patient would this drug be contraindicated?

Any male patient

A patient who is allergic to macrolide

A patient who has eczema

An adolescent prior to cessation of growth

Answer

D. An adolescent prior to cessation of growth

Rationale: Isotretinoin should not be prescribed for adolescents before cessation of growth or pregnant women. Ethinyl estradiol with norgestimate should not be prescribed for male patients. Erythromycin should not be prescribed for patients with an allergy to macrolide. Tretinoin (Retin-A, Avita) 0.025%, 0.05% cream, gel 0.04%, 0.1% microspheres should not be prescribed for patients who have eczema.

Recommended Order of Treatment for Acne

Special Population Considerations

Pediatric: tetracycline: dental enamel defects and bone growth retardation seen in children under 12; isotretinoin: growth retardation in children not at adult height; arthralgias and back pain in children.

Women of childbearing age: isotretinoin or tazarotene gel are teratogenic; tetracycline is also teratogenic and may decrease effectiveness of oral contraceptives; retinoic acid is pregnancy category C.

Ethnic: azelaic acid may cause hypopigmentation in patients with dark skin.

Patient Education

Drug information

Applying topical drugs

Not using excessive amounts of topical drugs

Nutrition

Patience with regimen: 4 to 6 weeks are required for resolution of acne

Follow-up and encouragement

Rosacea

Causes: not a clear cause; theories suggest bacterial infection, fungal infection, hair follicle mite infestation, menopausal changes, and Helicobacter pylori infection.

Diagnostic criteria: fixed telangiectasia is hallmark; acne, systemic lupus erythematosus, Staphylococcus aureus folliculitis, D. folliculorum infestation, and gram-negative folliculitis should be ruled out.

Pathophysiology of Rosacea

Early stage: simple erythema in response to cold exposure; extravascular fluid accumulates, blood flow to superficial dermis increases, and persistent telangiectasia occurs; oral involvement may develop

Second stage: represents lymphatic failure, epidermal epithelial hyperplasia and pilosebaceous gland hyperplasia with fibrosis, inflammation, and telangiectasia; persistent erythema, telangiectases, papules, and pustules occur

Late stage: deep erythema, dense telangiectases, papules, pustules, nodules, and persistent edema of the central part of the face

Topical Antibacterials Used for Rosacea

Metronidazole 0.75% gel, cream, lotion (MetroGel, etc.) 1.0% cream (Noritate)

Events: burning sensation, irritation, erythema (transient), mild dryness, pruritus

Contraindications: children; breast-feeding mother

Considerations: avoid eyes, with anticoagulant therapy, monitor closely for enhanced anticoagulation

Topical Antibacterials Used for Rosacea (cont.)

Sodium sulfacetamide 10% with sulfa 5% (Sulfacet-R, Novacet)

Events: local irritation, allergic dermatitis

Contraindications: kidney disease, breast-feeding mothers, sulfa allergy

Considerations: avoid eyes and denuded skin. Pregnancy category C

Sodium sulfacetamide 10% with sulfa 5% and urea 10% (Rosula) one to three times a day in thin layer

Topical Antibacterials Used for Rosacea (cont.)

Azelaic acid 15% (Finacea); apply thin film two times daily

Events: burning, stinging, pruritus

Contraindications: children

Considerations: hypopigmentation may occur in patients with dark complexions

Recommended Order of Treatment for Rosacea

Patient Education for Rosacea

Recognize triggers.

Sun exposure, strong winds, cold weather, warm environment, strenuous exercise, alcoholic beverages, spicy foods, hot foods and beverages, and stress

Use broad-spectrum UVA/UVB sunscreen.

Avoid harsh cleansers, rough washcloths, and pulling or tugging at the skin.

Use cosmetic with green tint.

Summary

Acne vulgaris is viewed by many as a rite of passage during the adolescent years. Up to 90% of all teenagers report having some form of acne. Adults suffer from the effects of acne as well: between 30% and 50% of adult women report experiencing acne.

The practitioner should ask patients if they are concerned about their acne and whether they would like treatment.

Patients with rosacea need to recognize what triggers the condition. The goal of management is to avoid flare-ups.