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Medications used to treat acne vulgaris: Nursing Pharmacology

Notes

Notes

ACNE MEDICATIONS, PART 1/2
DRUG NAMEsalicylic acid, azelaic acid (Azelex, Finacea), benzoyl-peroxide
tretinoin (Retin-A, Avita), adapalene (Differin)
erythromycin (Ery, Erygel), clindamycin (Cleocin, Clindesse), tetracycline, doxycycline(Oracea)
CLASSKeratolytics
Vitamin A derivatives
Antibiotics
MECHANISM OF ACTION
Soften and shed stratum corneum → decrease skin thickness and improve skin moisture
Blunt inflammatory process, modulate keratinization → help eliminate comedones
Inhibit bacterial overgrowth → reduce inflammation
INDICATIONS
  • Acne
ROUTE(S) OF ADMINISTRATION
  • TOP
  • TOP 
  • PO
SIDE EFFECTS
  • Skin irritation, erythema, burning, itching, tingling sensation, photosensitivity



  • Skin irritation, erythema, burning, itching, tingling sensation, photosensitivity
  • GI disturbances (e.g., nausea, vomiting, diarrhea)
  • Hepatotoxicity
  • Headache, dizziness 
  • Conjunctivitis 
  • Epistaxis 
  • Hirsutism
  • Tetracyclines: bone accumulation in children < 8 yo
CONTRA-INDICATIONS AND CAUTIONS
  • Sun exposure
  • Sun exposure 
  • Hepatic or renal disease
  • Pregnancy
  • Breastfeeding
  • Children < 8 yo


ACNE MEDICATIONS PART 2/2
DRUG NAME
isotretinoin (Absorica, Accutane, Zenatane)
spironolactone (Aldactone, CaroSpir), estrogen with progestin Ortho-Cyclen, Yaz)
CLASS
Retinoids
Hormonal agents
MECHANISM OF ACTION
Decrease sebum formation and secretion, blunt inflammation, keratolytic effects
Decrease androgen levels → reduce sebum production
ROUTE OF
ADMIN.
  • PO
SIDE EFFECTS
  • Skin irritation, erythema, burning, itching, tingling sensation, photosensitivity, skin peeling
  • Dry eyes 
  • Dry mouth, chapped lips
  • GI disturbances (e.g., nausea, vomiting, diarrhea)
  • Hepatotoxicity
  • Headache, dizziness 
  • Conjunctivitis 
  • Epistaxis 
  • Hirsutism
  • Cheilitis 
  • Teratogenic
  • Skin irritation, erythema, burning, itching, tingling sensation, photosensitivity
  • GI disturbances (e.g., nausea, vomiting, diarrhea)
  • Hepatotoxicity
  • Headache, dizziness 
  • Conjunctivitis 
  • Epistaxis 
  • Hirsutism
  • Clot formation 
CONTRA-INDICATIONS AND CAUTIONS
  • Sun exposure
  • Hepatic or renal disease 
  • Boxed warning: Pregnancy, breastfeeding
  • Sun exposure 
  • Hepatic or renal disease 
NURSING CONSIDERATIONS: ACNE MEDICATIONS
ASSESSMENT AND MONITORING
Assessment and monitoring: isotretinoin 
Assess
  • Affected area: acne lesion characteristics, type location
  • Laboratory test results: CBC, blood glucose, renal and hepatic function, and lipid panel
  • For female clients of childbearing age
    • Two negative pregnancy tests
    • Registered with the iPLEDGE program
    • Confirm informed consent 

Monitor
  • Hepatic function, lipid panel, monthly pregnancy status, blood glucose level
  • Side effects
  • Desired therapeutic effects of the medication: decrease in size and number of lesions
CLIENT EDUCATION
  • Purpose of medication: treat severe acne
  • Take medication two times each day with food and a full glass of water
  • Maintain a well-balanced diet
  • Avoid alcohol
  • Avoid  supplements containing vitamin A
  • Wash skin gently twice a day with a mild cleanser; avoid the use of harsh soaps or chemicals
  • Side effects
    • Dry eyes, contact lens discomfort 
      • Lubricating eye drops
    • Decreased night vision
      • Caution at night; avoid night driving
    • Photosensitivity
      • Avoid sunlight; wear protective clothing, use sunscreen
    • Diabetic clients
      •  Check blood glucose levels more often; monitor themselves for symptoms of hyperglycemia
    • Report symptoms of altered mood and behavior, liver impairment, hearing problems 
  • Avoid skin resurfacing treatments during therapy and for six months afterwards

Transcript

Acne vulgaris is a common skin disorder characterized by raised, red bumps that occur when hair follicles get clogged by particles like dead skin cells or oil, and it primarily occurs on the face, neck, chest, and back.

Although the exact cause of acne is not completely understood, there are a few main factors that are known to contribute to acne formation.

These include keratin plugs that block the opening of the hair follicle; increased sebum released by sebaceous glands, which sometimes occurs in response to increased androgen production during puberty; and overgrowth of bacteria like Cutibacterium acnes that trigger local inflammation.

Acne vulgaris can be categorized into different types based on specific characteristics. Mild acne usually consists of comedones, while moderate acne usually consists of pustules, and severe acne usually consists of cysts and nodules.

Depending on the severity and location of acne, there are various medications that can be used to treat acne.

These include topical medications, such as keratolytics like salicylic acid, azelaic acid, and benzoyl peroxide, vitamin A derivatives like tretinoin and adapalene, and topical antibiotics like erythromycin or clindamycin; as well as systemic medications, such as oral antibiotics like the tetracyclines tetracycline and doxycycline, oral retinoids like isotretinoin, and hormonal agents like spironolactone or oral contraceptives containing a combination of estrogen and progestin.

Okay, now let’s dive deeper into the different classes of medications, starting with topical agents.

Keratolytics include salicylic acid, azelaic acid, and benzoyl peroxide, and once administered, they primarily work by softening and shedding the stratum corneum, which is the outer layer of the skin.

As a result, keratolytics help decrease the skin’s thickness and improve its moisture. Next, vitamin A derivatives include tretinoin and adapalene, and they work by blunting the inflammatory process, modulating keratinization, and ultimately helping to eliminate comedones.

Lastly, the most commonly used topical antibiotic for acne is erythromycin, which works by limiting bacterial growth and proliferation and thus, reducing inflammation.

Now, let’s switch gears to systemic medications to treat acne. The most commonly used oral antibiotics include tetracycline and doxycycline, which also act by limiting bacterial growth and proliferation.

On the other hand, oral retinoids, like isotretinoin, have multiple effects. They can decrease sebum formation and secretion, blunt inflammation, and they also have keratolytic effects.

Finally, oral contraceptives, such as ethinylestradiol with levonorgestrel, can be used to treat acne because they decrease androgen levels and thus, they reduce sebum production.

The bad news is that these medications can cause side effects. Topical medications can cause local skin irritation, which can manifest as erythema, as well as a burning, itching, tingling sensation, and photosensitivity.

On the other hand, systemic medications can also lead to more widespread side effects, such as gastrointestinal disturbances like nausea, vomiting, and diarrhea.

Clients may also present with headaches, dizziness, conjunctivitis, epistaxis, and hirsutism.

In addition, these systemic medications can cause photosensitivity and hepatotoxicity. Tetracyclines can also accumulate in the bones, affecting bone growth in children under the age of 8.

Oral retinoids often cause dry eyes and mouth, chapped lips, and skin peeling; they can cause increased triglycerides, increase blood glucose levels, cause visual changes, and increase the risk of depression; they are also highly teratogenic. Finally, oral contraceptives can lead to formation of clots.

As far as contraindications go, these medications should be avoided before or after sun exposure or sunburn.

These medications are also contraindicated during pregnancy and breastfeeding, which is a boxed warning for systemic retinoids!

Additionally, tetracyclines are contraindicated for children younger than 8 years old. Finally, these medications should be used with caution in clients with hepatic or renal disease.

Okay, if your client with severe acne vulgaris is prescribed an oral retinoid like isotretinoin, first perform a baseline assessment of the affected area, making note of the acne lesion characteristics, including type and location.

Sources
  1. "Focus on Nursing Pharmacology" LWW (2019)
  2. "Pharmacology" Elsevier Health Sciences (2014)
  3. "Mosby's 2021 Nursing Drug Reference" Mosby (2020)
  4. "Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2016)
  5. "Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)
  6. "Davis's Drug Guide for Nurses"  (2020)
  7. "Vitamin A"  ()
  8. "Isotretinoin"  (2018)
  9. "The effect of isotretinoin on insulin resistance and adipocytokine levels in acne vulgaris patients" Turkish Journal of Medical Sciences (2018)
  10. "Acne Vulgaris" Merck and the Merck Manuals (2020)