Children s Hospital Of Wisconsin

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1 Children s Hospital Of Wisconsin Co-Management Guidelines To support collaborative care, we have developed guidelines for our community providers to utilize when referring to, and managing patients with, the pediatric specialists at Children s Hospital of Wisconsin. These guidelines provide protocols for jointly managing patient cases between community providers and our pediatric specialists. Acne Vulgaris Diagnosis/symptom Suggested Workup/Initial Management When to initiate referral/ consider refer to Dermatology Clinic: What can referring provider send to Dermatology Clinic? Specialist s workup will likely include: Acne vulgaris is the most common skin problem in the U.S., affecting approximately 80% of the population. Most commonly affects the adolescent population, but can be seen in infants, preadolescent children, and adults. It s a multi factorial condition of the pilo sebaceous unit. Signs and symptoms of acne include recurrent or persistent blackheads and whiteheads (comedones), *Refer to table on pages 4-5 for specific categories of acne medications. History and physical exam. If suspected, evaluation and management of hormonal abnormalities (PCOS, more examples needed, etc.). Over-the-counter treatments: salicylic acid preparations Many over-the-counter products contain salicylic acid as the active ingredient (strength ranges between 0.5-2%). These products typically come in the form of washes, wipes, or moisturizers. These are best tolerated when used in wash form. Any patient with deep cystic lesions or acne scarring should be referred to dermatology. Patients that are unable to tolerate topical medication and patients that do not respond to 6-8 weeks of highest recommended formulations or dosage of topical agents should also be referred to dermatology. 1. Using Epic Please complete the external referral order In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order: Urgency of the referral What is the key question you would like answered? Note: Our office will call to schedule the appointment with the patient. 2. Not using Epic external referral order: In order to help triage our patients maximize the visit time, please fax the above information to ( ) It would also be helpful to include: Chief complaint, onset, A complete medical history. A full body skin exam at the initial visit. Lab work may be recommended if there are signs of underlying hormonal abnormalities or if necessary for medication monitoring.

2 inflamed papules, and/or painful inflamed nodules or cysts over the face and upper body. Over-the-counter treatments: benzoyl peroxide preparations There are several products available overthe-counter that contain benzoyl peroxide as the active ingredient (strength ranges between 2-10%). These typically come in the form of washes, gels, or wipes. Benzoyl peroxide products are usually more effective than salicylic acid containing products. Patients should be aware that benzoyl peroxide can bleach fabrics including washcloths, towels, shirt collars and pillow cases. Prescription treatment: Retinoids Topical retinoids (tretinoin, adapalene, and tazorotene) should be considered for the initial prescription management of acne. These tend to help most with comedonal acne. It is important to start with a low potency retinoid to determine tolerability. Creams are generally better tolerated for patients with sensitive skin and gels for those with oily or more severe symptoms. Differin (adapalene) 0.1% gel is now available as an over-the-counter medication. frequency Recent progress notes Labs and imaging results Other Diagnoses Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient s problems.

3 A 45 gram tube retails for approximately $30. Still available as a generic prescription A non-comedogenic sunscreen should be used on the face and all exposed skin in the morning because most acne medications increase photosensitivity. Prescription treatment: topical antibacterial agents Topical antibacterial agents help most with the inflammatory component of acne. Clindamycin is the most commonly used topical antibiotic. It is available in gel, solution, lotion, foam and pledget. Monotherapy with topical clindamycin can lead to resistance and combination treatment with benzoyl peroxide will decrease that risk. Prescription treatment: combination products Combination products can be more convenient for the patient and can be more effective for the treatment of acne than single agents. These are often more expensive than single agent products. Some topical retinoids come combined with benzoyl peroxide. This can increase efficacy but can also increase irritation risk. Examples include Epiduo (adapalene 0.1% gel-benzoyl peroxide 2.5% gel) and Epiduo

4 Forte (adapalene 0.3% gel-benzoyl peroxide 2.5% gel). There are some combination products with benzoyl peroxide and clindamycin gel. This decreases resistance to clindamycin and improves efficacy. Examples include Duac and BenzaClin; both 5% benzoyl peroxide gel and 1% Clindamycin gel.

5 Table 1: Retinoids