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

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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

4©Bobonich 2021

Acne•THE most common skin condition•Primary care and dermatology • Impact•Hormonal influences on women•Treatment options•Referral•Mimickers

5©Bobonich 2021

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


Pathogenesis of Acne

Abnormal keratinization (comedones)

Propionibacterium acnes

Now Cutibacterium acnes (C. acnes)

Inflammation

Sebum production

8©Bobonich 2020

*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


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

©Bobonich 2020

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

12

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;

©Bobonich 2021

https://doi.org/10.1007/s40265-020-01417-6

https://doi.org/10.1177/1060028021992053

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


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


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)


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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©Bobonich 2020

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

©Bobonich 2020

©Bobonich 2016

Isotretinoin therapy18

©Bobonich 2020

Acne subtypes

Vulgaris, mechanica, excoriee, chloracne, cosmetic, drug-related, conglobata &

fulminans

©Bobonich 2020

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

©Bobonich 2020

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

©Bobonich 2021

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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©Bobonich 2021

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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©Bobonich 2021

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

©Bobonich 2020

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

©Bobonich 2020

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

©Bobonich 2020

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

©Bobonich 2020

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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©Bobonich 2020

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

©Bobonich 2020

CO2 Laser

Before After35

©Bobonich 2020

Demodex Folliculitis

▪ Clinically looks like rosacea

▪ Therapeutics (off-label)Ivermectin (Soolantra®)

Permethrin

▪ Skin care

▪ Prevention

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©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

Hidradenitis suppurativaAcne conglobataDissecting cellulitis of scalpPilonidal sinus

Follicular Occlusion Tetrad

Follicular Occlusion Tetrad

©Bobonich 2020

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

©Bobonich 2020

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

©Bobonich 2020

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

https://www.aad.org/media/stats/conditions

Thank you!

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2021 NCNP Virtual Conference

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