🧠 TLDR Primary Care - Test your Knowledge (#045)

In This Issue:

🦠 Ace the Acne

✅ Review workup and management of a common condition

📚 Key guideline review for the primary care provider

🧵 And more!

🧠 Test your Knowledge: Ace the Acne 🦠

Keep sharpening your clinical skills

A 23-year-old male presents to your clinic with complaints of persistent acne vulgaris over the past year. He reports multiple papules, pustules, and comedones on his face and chest. He has tried over-the-counter acne treatments without much improvement. He is otherwise healthy and takes no medications. On exam, you note numerous inflammatory and non-inflammatory lesions. There is no evidence of scarring, cysts, or nodules. Which of the following is the most appropriate initial management for this patient?

[A] Oral isotretinoin

[B] Topical retinoids and benzoyl peroxide

[C] Oral antibiotics

[D] Intralesional corticosteroid injections

Scroll down to find the answer at the end! 👇

Need to refresh your memory before answering this question? Head over to Pathway to review the latest guidelines on Acne Vulgaris, as well as some landmark trials. 

Case Conclusion

Keep your clinical skills sharp

Answer - B. Topical retinoids and benzoyl peroxide

Explanation - This patient's clinical presentation is consistent with acne vulgaris, which is a common dermatological condition characterized by the presence of inflammatory and non-inflammatory lesions such as papules, pustules, and comedones. It commonly affects the face, chest, and back. In this case, the patient has experienced persistent acne over the past year despite using over-the-counter acne treatments. Oral isotretinoin is a highly effective treatment for severe acne and is reserved for cases that are recalcitrant to other therapies or are associated with significant scarring or psychosocial distress. It is not typically indicated as the initial management option for patients with persistent acne vulgaris, especially when they have not tried other treatment modalities. Oral antibiotics may be considered in certain cases of moderate to severe acne when topical therapies alone are insufficient. However, they are generally not recommended as the initial management approach due to concerns about bacterial resistance and the potential for side effects.

Topical retinoids and benzoyl peroxide are considered first-line therapy for acne vulgaris. Retinoids, such as tretinoin, adapalene, or tazarotene, are known to normalize follicular epithelial desquamation and reduce the formation of microcomedones, leading to the resolution of both inflammatory and non-inflammatory acne lesions. Benzoyl peroxide has antibacterial properties and helps to reduce the population of Propionibacterium acnes, a bacterium involved in the pathogenesis of acne. The combination of topical retinoids and benzoyl peroxide has been shown to be effective in the treatment of mild to moderate acne and is well-tolerated.

What are the guideline recommendations for topical medical management of acne vulgaris?

• Offer benzoyl peroxide as monotherapy for mild acne, or in conjunction with a topical retinoid or systemic antibiotic therapy for moderate-to-severe acne. (B)
• Offer benzoyl peroxide for patients on topical or systemic antibiotic therapy, as it is effective for the prevention of bacterial resistance. (B)
• Do not use topical antibiotics (such as erythromycin and clindamycin) as monotherapy because of the risk of bacterial resistance. (D)
• Offer topical retinoids as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne lesions, as they are important in addressing the development and maintenance of acne. (B)
• Offer topical adapalene, tretinoin, and benzoyl peroxide for the management of preadolescent acne in pediatric patients. (B)
• Offer azelaic acid for the treatment of patients with postinflammatory dyspigmentation. (A)

What are the guideline recommendations for oral antibiotic management of acne vulgaris?

• Offer systemic antibiotics for the management of moderate and severe acne and forms of inflammatory acne that are resistant to topical treatments. (B)
• Use doxycycline and minocycline over tetracycline, but neither is superior to the other. (B)
• Offer oral erythromycin and azithromycin for patients who cannot use tetracyclines (pregnant patients, pediatric patients < 8 years old). Restrict erythromycin use because of its increased risk of bacterial resistance. (A)
• Avoid systemic antibiotics other than tetracyclines and macrolides because there are limited data for their use in acne. Reserve TMP-SMX and TMP for patients unable to tolerate tetracyclines or for treatment-resistant patients. (D)
• Use systemic antibiotics for the shortest possible duration. Reevaluate at 3-4 months to minimize the development of bacterial resistance. Do not use systemic antibiotics as monotherapy. (B)
• Offer concomitant topical therapy with benzoyl peroxide or a retinoid with systemic antibiotics and for maintenance after completion of systemic antibiotic therapy. (B)

What about oral isotretinoin for acne vulgaris?

• Offer oral isotretinoin for the treatment of patients with severe nodular acne. (B)
• Offer oral isotretinoin for the treatment of patients with moderate acne that is treatment-resistant or for the management of patients with acne that is producing physical scarring or psychosocial distress. (B)
• Conduct routine monitoring of LFTs, serum cholesterol, and triglycerides at baseline and again until response to treatment is established. (B)
• Counsel female patients of child-bearing potential taking isotretinoin regarding various contraceptive methods, including user-independent forms. (B)
• Offer oral isotretinoin monotherapy (at least 6 months, and longer in case of inadequate response) in patients with severe papulopustular, moderate-to-severe nodular, or conglobate acne at a dose of 0.3-0.5 mg/kg in severe papulopustular or moderate nodular acne and ≥ 0.5 mg/kg in conglobate acne. (A)

To learn more about the SAFA trial, head over to Pathway!

What are some other considerations for acne vulgaris?

• Offer estrogen-containing combined oral contraceptives for the treatment of inflammatory acne in female patients. (A)
• Consider offering spironolactone in the treatment of acne in select female patients. (C)
• Consider offering oral corticosteroid therapy in patients who have severe inflammatory acne while starting standard acne treatment, as it can provide temporary benefits. (C)
• Offer low-dose oral corticosteroids for the treatment of acne in patients who have well-documented adrenal hyperandrogenism. (B)
• Consider offering oral zinc in patients with mild-to-moderate papulopustular acne. (C)
• Consider advising patients that high glycemic index diets may be associated with acne. (C)
• Consider advising patients that some dairy, particularly skim milk, may influence acne. (C)

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