2021 NCNP Virtual Conference
Transcript of 2021 NCNP Virtual Conference
2021 NCNP Virtual Conference
M A R G A R E T A . B O B O N I C H , D N P , F N P - C , D C N P , F A A N P
A s s i s t a n t P r o f e s s o r , C a s e W e s t e r n R e s e r v e
S c h o o l s o f N u r s i n g a n d M e d i c i n e
U n i v e r s i t y H o s p i t a l s C l e v e l a n d M e d i c a l C e n t e r
D e p a r t m e n t o f D e r m a t o l o g y , D i r e c t o r o f N P R e s i d e n c y
Things that go bump! Assessment and management of
acneiform skin eruptions
This Photo by Unknown Author is licensed under CC BY
Objectives
Attendees will:
1. Identify the pathogenesis and hormonal influences of acne.
2. Review other acneiform eruptions for an accurate diagnosis and management.
3. Discuss the tradition treatment approach and new advanced therapies for patients with acneiform eruptions.
4. Review the pharmacodynamics of therapeutic in the management of acne, rosacea and hidradenitis.
2©Bobonich 2020
Disclosures
Speaker’s bureau: Lilly USA and Abbvie; Advisory Board: Novartis, UCB, Bristol Myers Squibb, Dermavant, Biofrontera, Boehringer Ingelheim; Royalties: Wolters Kluwer; Partnership: Center for Advanced Practice Dermatology.
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Acneiform eruptions
•Acne (and beyond)
•Rosacea
•Perioral dermatitis
•Hidradenitis suppurativa
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Acne•THE most common skin condition•Primary care and dermatology • Impact•Hormonal influences on women•Treatment options•Referral•Mimickers
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Acne Vulgaris
Age
▪ Onset and duration
Lesions
▪ Comedones, pustules, cysts, nodules, scars
Severity
▪ Based on presence of inflammation, cysts, scarring and body involvement
Gender
▪Onset, severity and duration
Skin of Color
• Comedones and cystic lesions
• Post-inflammatory hyperpigmentation
©Bobonich 2020 ©Bobonich 2021
Acne Treatment
Goals
• Resolve without scarring
• Individualized care plan: type and severity
• Clinician-patient understand medications
• Adolescent and parental approaches
• Referral in timely manner
• Recognition of endocrinopathies
• Exacerbating factors (Iodides/bromides, steroids, lithium, phenytoin)
• Psychosocial assessment
• Realistic expectations
©Bobonich 2020 ©Bobonich 2021
Pathogenesis of Acne
Abnormal keratinization (comedones)
Propionibacterium acnes
Now Cutibacterium acnes (C. acnes)
Inflammation
Sebum production
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*Synergist effects also present between some agents ; **Available over the counter: Differin 0.1% (adapalene); ***OTC numerous wash and leave on preparations and strengths
TARGETS THERAPIES*Decrease sebum Normalize
keratinizationDecreaseC. acnes
Decrease inflammation
Topical therapies
Antimicrobial X X
Retinoids X X
Benzoyl peroxide X X X
Azelaic acid X X X
Anti-androgen X
Systemic therapies
Oral antibiotics X X
Isotretinoin X X X X
OCPs X
Spironolactone X9
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MILD ACNE
Open and closed comedones
First-line topical therapies only:• Benzoyl peroxide (BPO)• Retinoid• BPO and retinoid• BPO and antimicrobial• BPO, antimicrobial and retinoid
Re-evaluate: • Response to tx /adherence in 6 to 12 wksConsider: • Add/change retinoid• Add azelaic acid or dapsone
No/little response:• Increase to moderate acne therapy, acne
surgery, photodynamic therapy, chemical peels
10Zaenglein, A.G. et al. JAAD.. 74(5):945-73. 2015©Bobonich 2021
Classes of topicals
11NUMEROUS combination products available !
Cleansers Mild Cleansers
Salicylic Acid
• Use mild cleansers if skin is dry/sensitive or becomes
dry with treatment; Oil control astringents
Antimicrobials Sulfacetamide sulfur • Keratolytic, anti-bacterial and anti-yeast
• QD or BID, available as wash and leave-on
Azaleic Acid 15%, 20% • Antimicrobial & comedolytic, good for skin of color,
lightening properties for hyperpigmentation
Benzoyl peroxide 2.5-10% • Once daily, decreases bacterial resistance,
Clindamycin 1%
Erythromycin 2%
• Always use with BPO
Minocycline 4% foam (new) • Severe acne for ≥ 9yrs
Dapsone 5%, 7.5% • Great for inflammatory lesions; Do NOT use w/BPO
Retinoids Tretinoin , retin A, adapalene • Anti-inflammatory, minimizes dyskeratosis
Tazarotene • Category X, consider pregnancy testing
Trifarotene 0.005% • New category of retinoid
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What’s new?
Clascoterone 1% cream
• FDA approved for females and males ≥ 12 years
• BID dosing
• Localized androgen inhibitor
• Phase 2 and 3 clinical trials
• significant reduction in inflammatory and noninflammatory lesions
• significant reduction in mild erythema
• Well-tolerated. Mild erythema most common AEs
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Dhillon S. (2020). Clascoterone: First Approval. Drugs, 80(16), 1745–1750. https://doi.org/10.1007/s40265-020-01417-6; Kalabalik-Hoganson, J., Frey, K. M., Ozdener-Poyraz, A. E., & Slugocki, M. (2021). Clascoterone: A Novel Topical Androgen Receptor Inhibitor for the Treatment of Acne. The Annals of pharmacotherapy, 55(10), 1290–1296. https://doi.org/10.1177/1060028021992053;
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MODERATE ACNEOpen/closed comedones, inflammatory papules & pustules, involves face, chest
+/or trunk
First-line therapies:
Topicals: • Same as for Mild acne PLUSSystemics: • Topical BPO and retinoid plus oral antibiotic• Oral antibiotics should not be used as monotherapy
Re-evaluate: • Response to tx and adherence in 6 to 12 wks• Oral antibiotic therapy shortest duration• Usu. 3 month trial before seeing improvement
Consider: • Add/change topical retinoid• Add/change topical or oral antibiotic• Females- OCPs if appropriate and spironolactone
No/little response:• Increase to severe acne therapy• Assess for possible endocrine disorder
13Zaenglein, A.G. et al. JAAD.. 74(5):945-73. 2015©Bobonich 2020
Oral Antibiotics
Tetracyclines
Doxycycline• Sub-antimicrobial dose 40mg• Antimicrobial dose 100mg daily or BID• Has greatest anti-inflammatory property• Esophagitis, photosensitivity, dietary restrictions
Minocycline• Dosing is 50-100mg daily or BID• Extended-release formulation• Dietary restrictions• Dizziness, drug induced pigmentation, lupus, SJS
Sarecycline (new molecule)• Narrow spectrum against Gm positive C. Acnes• Low risk for antibiotic resistance• Age ≥ 9yrs, limited pregnancy date
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SEVERE ACNE
Open/closed comedones, inflammatory papules or pustules, cysts, nodules involving the face or trunk. Scarring
First-line therapy:
• If there is any evidence of scarring, the therapy is escalated to severe.
• Initiate therapy noted in Moderate acne until the patient is seen by referral
REFER to Dermatology:
• Topical combinations and oral antibiotics• Oral contraceptives• Spironolactone (females only)• Isotretinoin (registered Ipledge prescriber)
15Zaenglein, A.G. et al. JAAD.. 74(5):945-73. 2015©Bobonich 2020
Other Systemic Agents
• Other antimicrobials▪ Amoxicillin, Bactrim DS, Azithromycin,
Erythromycin▪ Oral dapsone (off-label)
• Nicotinamide• Hormonal agents
▪ OCPs▪ Spironolactone (off-label)
• Steroids▪ Prednisone, dexamethasone
• Isotretinoin• Other
▪ Intralesional steroids, Laser, PDT, Chemical peels, SSRIs for excoriee
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Isotretinoin therapy
Ipledge Program• Federally regulated
✓ no change pregnancy rate ✓ not all dermatology providers
• Laboratory and pregnancy test monitoring• Monthly visits for 6-7 months• Usually 5 months of drug or more• Females- 2 forms of birth control method• May need concomitant prednisone taper for
severe cases to prevent initial flare 17
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Isotretinoin therapy18
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Acne subtypes
Vulgaris, mechanica, excoriee, chloracne, cosmetic, drug-related, conglobata &
fulminans
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Hormonal Treatment
• Most acne patients do NOT have associated endocrinopathy
• May be hormonal influence
▪ Lower 1/3 face, pre-menstrual flaring
• Birth-control pills (risk assessment & counseling)
▪ Amount/cycle of estrogen and type of progestin
• Spironolactone
▪ Blocks androgen receptors
▪ Side effect: metrorrhagia, breast tenderness, hypotension
▪ Hyperkalemia
▪ Pregnancy prevention 20
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Special Considerations
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PEDIATRICS
Approved for ≥9 yrs:Epiduo®
Approved for ≥ 12 yrs:Epiduo Forte®Benzamycin® gelZiana®, Veltin®Acanya®, BenzaClin®, Duac®, Onexton®
Winlevi®
Adapalene 0.1%/BPO 2.5%
Adapalene 0.3%/BPO 2.5%Erythromycin 3%/BPO 5%Clindamycin 1%/tretinoin 0.025 %Clindamycin 1%-1.2%/BPO (2.5%-5%)Clascoterone 1%
PREGNANCYTopicals: azelaic acid, clindamycin, erythromycin
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Skin of Color
• Characteristics are no equal across all Fitzpatrick skin types
• Racial and ethnic influences• Clinical characteristics• Attitudes• Behaviors• Patient satisfaction
• Darker skin types > greater risk for post-inflammatory hyperpigmentation (PIH)
• Emotional impact of PIH• Quality of life• Anxiety• Depression
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Impact of PIH from acne
White/Caucasian women
• 57.9% reported lesion clearance most important measure of success
• 41.6% focused on PIH clearance
Non-White/Caucasian
(black/AA, Hispanic/Latino, Asian, other) women
• 31.7% reported lesion clearance most important measure of success
• 8.4% focused on PIH clearance
CONCLUSION: race and ethnicity should inform clinicians in the assessment of acne and guide treatment recommendations.
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Acne inpregnancy
Topical therapies
Category B- first lineAzelaic acid
Erythromycin
Clindamycin
Category CBenzoyl Peroxide considered safe in pregnancy and needed for decrease of bacterial resistance when used in conjunction with oral antibiotics
Not recommendedTopical- salicylic acid, dapsone, retinoids, zinc
Oral- prednisone only if fulminans after first trimester 24
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Acne inpregnancy
Systemictherapies
For severe inflammatory acne:
1. Discuss with obstetrician or midwife
2. Combine BPO with oral antibiotic
3. Limit to the shortest duration
4. Avoid antibiotics for maintenance treatment
Category B
Erythromycin < 6 weeks (not erythromycin estolate)
Azithromycin (less safety data)
Amoxicillin-if resistant & avoid in early pregnancy
Cephalosporins – poor data, growing resistance25
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Beyond acne….
Suspicion for hormonal endocrinopathies when:
1. Sudden onset acne
2. Associated hirsutism
3. Irregular menstrual cycles
4. Signs of hyperandrogenism
▪ Etiology of androgen excess:
Adrenal tumor, congenital adrenal hyperplasia, ovarian tumor or PCOS
▪ Laboratories:
DHEAS, lutenizing hormone (LH), follicle stimulating hormone (FSH), testosterone total & free. 26
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Hormones
• No evidence to favor hormonal over acne tx
• Goal: to minimize androgens
• Lower androgenic activity• 2nd gen. Norgestrel and levonorgestrel
• 3rd generation desogestrel and norgestimate
• No intrinsic androgen effect• Drospirenone, cyproterone acetate, dinogest
• IUDs- debated evidence
• Subdermal implants- scant evidence
• Combination oral contraceptives• 2017 Retrospective study (n=2147)
• Most helpful: Drospirenone, norgestimate and desogestrel
• Least helpful: levonorgestrel and norethindrone
• COCs with triphasic progestin most benefit
• COCs with estrogen variation not helpful
27Lortscher et al. Drugs in Dermatol 2016, 15(6):670-674; Irowojolu et al. Cochrane Database Syst Rev. 2012(7):CD004425; Shahnazi et al. Iran J Nurs Midwifery Res. 2015, 20(1):47-55; Trivedi et al. Int J Womens Dermatol.2017, 3(1): 44-52©Bobonich 2020
Spironolactone
Spironolactone for treatment of acne
• 25-100mg/d usually divided BID
• 100-200mg/d more effective alopecia and hirsutism
• Usually clinically significant improvement in 3 months
• Recommend contraception▪ Feminization of male fetuses
• Well tolerated
• No need for monitoring of hyperkalemia in healthy females
• Side effects usu. transient (menstrual irreg, breast tenderness, nausea, dizziness)
• Postulated risk of breast and gynecologic cancer28
Barros & Thiboutot, Clinics in Dermatol (2017) 35(2):168-172; Bigger et al. 2013, Cancer Epidem. 2013, 3(37):870-875.©Bobonich 2020
Key recommendations for acne in females
• Consider hormonal influences• Monotherapy antibiotics NOT
RECOMMENDED• Concomitant use of OCPs w/acne meds
helpful• Limit antibiotics to 3 months, then re-evaluate• SEVERE acne: refer to dermatology early• Microcomedones! Don’t forget topical
retinoids• If you suspect endocrinopathy, screen for
possible sources of excess androgens Hold OCPs for 4-6 wks before performing labs
• Preadolescents-adapalene and BPO are a great start
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30Case Study©Bobonich 2020
Rosacea
• Unknown etiology (multifactorial)
• Chronic
• SE from topical steroid use
• “Flushing” disorder
• Middle age, F>M
• Types▪ Erythematotelangiectatic
▪ Papulopustular
▪ Phymatous
▪ Ocular 31
Erythematotelangiectaticrosacea
• Avoid triggers
• Sensitive skin care
• Topical anti-inflammatories
• Herbals
• Topical vasoconstrictors- brimonidine and
oxymetazoline
• Systemic- doxycycline, propranolol or
clonidine (off-label)
• Laser or impulse-light therapy
• Make-up for camouflage (green-tinted)
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Papulopustular rosacea
Mild- topicals• Ivermectin 1% • Metronidazole 0.75% or 1 % • Azelaic acid 15% or 20%• Phase 3 Clinical trials new BPO
Off-label• Sulfacetamide sulfur 10/5%
wash/lotion; Clindamycin 1%; Permethrin 5%; Dapsone 5%, 7.5%
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Moderate to Severe• Doxycycline 40mg anti-inflammatory• Doxycycline 50 – 100mg daily or BID• Erythromycin if doxycycline is
contraindicated• Azithromycin 2 to 3 times consideredSevere or granulomatous
Off-label• Oral isotretinoin• Oral dapsone
Stein, L.L. et al. Journal of drugs in dermatology. 2015, 14(6): 546-547; DelRosso, J.Q. et al.. Cutis. 2014 March;93(3):134-138; van Zuuren EJ et al. Cochrane Database of Systematic Reviews 2015, (4). ©Bobonich 2020
Other Rosacea
Subtypes
• Phymatous (rhinophyma)
▪ Refer to dermatology
▪Mild- antibiotics and retinoids
▪ Severe- CO2 laser vs surgical excision
• Ocular
• Moisturizers & eyelid hygiene
• Ocular moisturizers (not redness relief or antihistamine medications)
• Oral doxycycline
• Severe- refer to ophthalmology
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CO2 Laser
Before After35
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Differential diagnosis
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Lupus erythematosus
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Case study©Bobonich 2020
Demodex Folliculitis
▪ Clinically looks like rosacea
▪ Therapeutics (off-label)Ivermectin (Soolantra®)
Permethrin
▪ Skin care
▪ Prevention
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©2017 Bobonich39©Bobonich 2020
Hidradenitis Suppurativa (HS)
• Chronic and recurrent inflammatory disorder of the follicular epithelium. • Apocrine gland rich areas (esp. areas repetitive mechanical
stress)• Nodules, abscesses, sinus tracts, scaring• Occurs in areas exposed to repetitive mechanical stress• Risk factors: obesity and smoking• Genetics• Higher in African Americans and females• Secondary bacterial infections
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Saunte et al. BJD. 2016; Ingram et al. BJD. 2016; Zouboulis et al. JEADV. 2015; Prens & Deckers. JAAD. 2015; Wang et al. Adv Skin & Wound Care. 2015; Canoui-Poitrine et al. JAAD. 2009©Bobonich 2020
41©Bobonich 2016
Hidradenitis suppurativa©Bobonich 2020
42Hidradenitis suppurativa
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Hidradenitis suppurativaAcne conglobataDissecting cellulitis of scalpPilonidal sinus
Follicular Occlusion Tetrad
Follicular Occlusion Tetrad
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Treatment of HSManagement of Comorbidities:
• PCOS
• Metabolic syndrome
• Depression/Suicidal Ideation
• Autoimmune disorders
https://www.cdc.gov/drugresistance/biggest-threats.html
Hurley
Stage 1
Hurley
Stage 2
Hurley
Stage 3
All Stages
• Antiseptic
wash
QD- BID
• Topical
Clindamycin
BID x2-3
months
• Intralesional
triamcinolon
e injections
• Oral
Antibiotics
• Adalimumab
• Metformin
• May
consider
surgical
excision
• Oral
Antibiotics
• Adalimumab
• Metformin
• Surgical
Intervention
• Weight loss
• Smoking
Cessation
• Avoid
restrictive
clothing
• Hygiene
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Case Study
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Periorificial Dermatitis
▪ Self-limiting inflammatory papules, pustules
▪ Similar features to rosacea and seborrheic dermatosis
▪ Perioral but spares vermillion border
▪ Can be perinasal and periorbital or granulomatous
▪ Onset usually 15 -45 yrs and F>M
Causative factors:• Topical, systemic or intranasal steroids (or connubial)
• Chewing gum, fluorinated or tarter control toothpastes
• Heavy make up or creams, sunscreens, environmental (UVR, aromatherapy/aerosolized )
• Candida, demodex, fusobacteria
• Oral contraceptives46
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Management
Skin care:
• Avoid toothpaste containing fluoride, anti-tarter or whitening agents
• Stop use of foundation, moisturizer or night cream until problem has resolved.
• Avoid moderate, potent or fluorinated topical corticosteroids
• TAPER but do not abruptly discontinue (can take 1-3 months)
• Decrease potency either % or frequency.• Allow a rescue twice a month• Severity of flare is usually directly correlated
with speed of taper• Can use oral doxycycline as anti-
inflammatory
Lee, G.L. & Zirwas, M.J. Derm Clinics, 2015, 33(3), 447-455.©Bobonich 2020
Therapeutic approach to perioral dermatitis
Topical• Metronidazole 1% cream or gel BID• Erythromycin 2% gel or ointment BID• Pimecrolimus 1% cream BID
Alternatives• Sulfacetamide w/ or w/o sulfur wash• Azelaic acid• Less evidence: clindamycin and tacrolimus
Oral• Doxycycline or minocycline 100mg BID• Erythromycin 250mg BID
TIPS:• Suggested minimum of 8 weeks of oral therapy
then taper off • Severe disease may require isotretinoin (off-label)
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Lee, G.L. & Zirwas, M.J. Derm Clinics, 2015, 33(3), 447-455.©Bobonich 2020
Take home points
• Most acne conditions can be treated by primary care
• Address the different components
• Individualize treatment plans with ethnic and racial considerations
• Many OTC products available
• Topical benzoyl peroxide & retinoids are fundamental for acne
• ALWAYS consider differential diagnoses for acneiform eruptions
• LOOK for open comedones
• If not responsive to therapy, assess adherence & reconsider diagnosis, and/or refer to dermatology
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©Bobonich 2020
Objectives
Attendees will:
1. Identify the pathogenesis and hormonal influences of acne.
2. Review other acneiform eruptions for an accurate diagnosis and management.
3. Discuss the tradition treatment approach and new advanced therapies for patients with acneiform eruptions.
4. Review the pharmacodynamics of therapeutic in the management of acne, rosacea and hidradenitis.
50©Bobonich 2020
Resources
• AAD https://www.aad.org/media/stats/conditions
• Bagatin, E., Freitas, T., Rivitti-Machado, M.C., Machado, M., Ribeiro, B.M., Nunes, S., & Rocha, M. (2019). Adult female acen: a guide to clinical practice. Anais brasileiros de dematologica, 94(1), 62-75.
• Bhate K, & Williams, H.C. (2013). Epidemiology of acne vulgaris. The British journal of dermatology, 168:474-85.
• Bobonich, M.A., Nolen, M., Honaker, J.S. & DiRuggerio, D. (2021). Dermatology for Advanced Practice Clinicians. 2 Ed., Philadelphia: Lippincott.
• Bosanac, S.S., Trivedi, M., Clark, A.K., Sivamani, R.K., & Larsen, L.N. (2018). Progestins and acne vulgaris: a revew. Dermatology online journal, 24(5), 13030/qt6wm945xf.
• Gupta, R., High, W. A., Butler, D., & Murase, J.E. (2013). Medicolegal aspects of prescribing dermatologic medications in pregnancy. Seminars in Cutaneous Medical Surgery, 32(4), 209-216
• Wolverton, S.E. (2020). Comprehensive Dermatologic Drug Therapy. 4rd Ed. London: Elsevier.
• Post laser therapy photo rhinophyma treatment courtesy of Jeffrey Scott, M.D. and Margaret Mann, M.D.
• All other photos copyright of Margaret Bobonich 51
Thank you!
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