Module:3. 44 P a g e. Identifying Medications

Module:3 44 P a g e Identifying Medications

This module is all about different medications and treatments that are used to fight acne. In the first section, you ll learn about oral medications, with a particular focus on isotrenoin, oral antibiotics, and birth control. Following on from that, we ll explore topical medications and treatments, with sections on creams, gels and oils, chemical peels, and other types of therapy. Next, you ll learn about alternatives, such as vitamins and other supplements. In the final section, you ll discover the side effects of all the treatments covered throughout the module, so you can weight the risks against the benefits of each treatment. 3.1 Oral 3.2 Topical 3.3 Alternatives 3.4 Side effects 3.1 Oral Many people who suffer from acne choose to take medication and treatment in an oral form. In this section, we give you an overview of the oral medications available, and their features. You will learn about any side effects in section 3.4. 45 P a g e

3.1.1 Isotretinoin This drug was widely known by the name Accutane or Roaccutane which is a brand name, but is now available as isotretinoin, though it is the same product. Isotretinoin contains a strong dosage of a vitamin A derivative, which is taken for 15-20 weeks in pill form. This treatment is most often prescribed for those who suffer from severe nodular acne, and will not be prescribed until various other measures have been tried, such as oral antibiotics and topical creams. Nodules are generally 5mm in diameter, and severely inflamed. You will remember from Module 1 that acne occurs when excess sebum is produced by the oil glands in the skin. The sebum mixes with dead skin and blocks the follicle, preventing oil from flowing out, instead allowing the sebum to accumulate under the skin. Acne-related bacteria feed on the sebum, and release fatty acids and waste products that irritate the oil glands and inflaming the area under the skin. Isotretinoin reduces the size of the oil glands by 35-58%m and decreases the activity of the oil glands, so that 80% less sebum is produced. This prevents the glands from becoming blocked, and prevents bacteria from thriving. This leads to less inflammation in the skin. When people begin to take isotretinoin, many find that their acne gets worse. This usually improves after a week to 10 days of continuing the treatment. A single course of isotretinoin may be enough to completely clear the skin of acne and prevent it reoccurring, with 95% of people seeing a strong improvement in their acne. Up to 33% of patients will relapse, however. Repeat courses are not usually 46 P a g e

recommended, and should be started at least eight weeks after the first treatment. Overall, this drug has a cure rate of 66%. Taking isotretinoin varies from person to person, as the dose prescribed and how often it is to be taken can be altered by a doctor. It is important to follow the instructions issued by the doctor. Isotretinoin pills should be swallowed whole or on a full stomach. Isotretinoin has serious side effects, particularly in pregnancy, and these are discussed in more detail in section 3.4. 3.1.2 Oral antibiotics There are a number of oral antibiotics on the market, which doctors might choose to prescribe to someone suffering from acne. These include: Cotrimoxazole, under the brand names of Deprim and Trisul Erythromycin, under the brand names of E-mycin and ERA Tetracyclines, under the brand names of Doxine, Doxy, Tetralysal, Mino-tabs and Minomycin Trimethroprim, under the brand name of TMP 47 P a g e

Oral antibiotics work by helping to halt the growth of acne bacteria known as P. Acnes, and producing an anti-inflammatory effect. About 50% of patients respond to antibiotics to some degree, though it is rare that their acne is totally clear. Antibiotics seem to work better on mild to moderate cases of acne. These are in pill form, and usually taken once a day. They should only be taken for six months or less. 3.1.3 Birth control Birth control is another method often advised for women who want to clear their acne. Clinical trials have illustrated that taking combination (estrogen and progesterone) pills, can result in less severe acne, 30-60% fewer lesions, less inflammation, and fewer flare ups. When high levels of androgens are produced by a woman s ovaries and adrenal glands, this can lead to too much sebum, which leads to acne. Birth control pills that contain both progesterone and estrogen can lower the androgen levels in the body, thereby lessening sebum and acne. 48 P a g e

The FDA has approved three birth control pills for the treatment of moderate acne, for women who are age 14-15 or above, need contraception, and have started menstruating. These are: Estrostep Ortho Tri-Cyclen YAZ (though the FDA has advised that the form of progestin used, drospirenone, increases the risk of blood clots. Other brands that include drospirenone include Zarah, Safyral, Syeda, Loryna, Yasmin, Gianvi, Beyaz and Ocella. In practice, doctors will prescribe a wider range of birth control products that have been shown to improve acne, such Alesse and Yasmin, and will do so for mild to severe acne. Women taking birth control pills for acne treatment may experience a flare up at the beginning of treatment, and it may take a few months before the skin begins to clear. As birth control pills only decrease sebum, other acne fighting treatments might be prescribed alongside them. These can include topical medications and antibiotics. It is important to note that some antibiotics can interfere with the oral contraceptive s effectiveness, and could lead to pregnancy. For example, antibiotic tetracycline can affect the effectiveness of some types of oral contraceptive. 49 P a g e

3.2 Topical Topical treatments are for use on the skin. They may come in cream, gel or oil form. Other treatments used on the skin include chemical peels, and various types of light and laser therapy. In this section, you ll learn about the features of various topical treatments. 3.2.1 Creams, gels and oils Differin gel This gel prevents skin cells shedding too fast inside the follicle, preventing pores from becoming blocked. It also has an anti-inflammatory effect. Azelex This cream contains 20% active ingredient azelaic acid. This is a naturally occurring acid, found in animal products and wholegrain cereals. It prevents the build up of cells that block pores. It also kills acne bacteria, and has an anti-inflammatory effect. 50 P a g e

Benzoyl peroxide This is available in cream, gel and wash form, both over-the-counter and by prescription. Its main function is to bring oxygen under the surface of the skin. Bacteria cannot survive in oxygen, and when benzoyl peroxide is used in the proper dosage, it eliminates 99.9% of bacteria. Using benzoyl peroxide also has a mild peeling and drying effect, minimizing oil on the skin and helping to prevent breakouts. It has anti-inflammatory effects. Clindamycin This is available in lotion, foam, solution or gel, and is a topical antibiotic. Applied twice daily, it kills acne bacteria. 51 P a g e

Dapsone This is a topical gel with 5% concentration, which is sold under the brand name Aczone. It has anti-inflammatory, antioxidant and antibacterial properties. It has been found to reduce acne lesions by 30-45%, and has been found as more effective in women. Erythromycin This comes in solutions, gels, ointments and packets. Often combined with products of benzoyl peroxide, this is usually applied twice a day. It is an antibiotic which kills acne bacteria. It is important to talk to a doctor about using this in conjunction with other medicines, or products such as make up, perfumes or cleansers, as it may cause irritation. Sodium sulfacetamide This is an antibacterial product, used on the skin to stop the growth of acne bacteria. Tazarotene This is a retinoid gel containing a derivative of vitamin A. This is applied to the skin once per day, and is used for both acne and psoriasis. It reduces inflammation and prevents pores from becoming clogged. It is effective, with a 50% reduction in lesions after 12 weeks. 52 P a g e

3.2.2 Chemical peels Chemical peels are acids, applied to the skin around once every 14 days. This is done to exfoliate the skin at its top layers. This signals for the cells inside the skin to produce more rapidly. This prevents pores from becoming clogged, as it increases skin turnover. A chemical peel can be administered by a doctor, or by an esthetician in a salon or spa. Doctors are allowed to administer chemical peels with up to 70% strength, while estheticians can administer up to 30%. Chemical peels are reasonably effective. Studies show that after four to six peels, acne lesions can be reduced by 45-50% on average. These results last for one to two months. 53 P a g e

Laser therapy Laser therapy is recommended for papules and pustules, rather than cysts, nodules, whiteheads or blackheads. Doctors offer laser treatments, and often recommend three treatments at one month intervals. There are a variety of laser types doctors might use, including vacuum lasers, fractional lasers, diode lasers, infrared lasers and pulsed dye lasers. These lasers are meant to excite compounds that live inside acne bacteria, which are called porphyrins. When the lasers excite them, they damage the wall of the bacteria, which kills the bacteria. This should reduce acne. Though this has not been widely studied, results are promising, with an improvement between 36 to 83%. However, these results do not last long because the acne bacteria do not take long to grow back. 3.3 Alternatives Many people also consider using alternatives, such as vitamins and supplements, to help them clear their acne and get clear skin. In this section, we ll examine some of the common choices. 54 P a g e

3.3.1 Vitamins Vitamin A Retinoids, which are forms of retinol also known as preformed vitamin A, help release dead skin, reduce the oil produced by the oil glands, suppress the production of androgen, and protect fats from oxidation, which helps avoid inflammation. Retinoids are found in eggs, dairy products, liver and animal foods, while carotenoids, another form of vitamin A are found in carrots, sweet potatoes, dark green vegetables and orange and yellow fruits and vegetables. Unfortunately, the body absorbs vitamin A from carotenoids at a low rate, so it is not enough to get vitamin A from vegetables. Acne is an inflammatory condition, and the liver releases vitamin A to help rebalance the inflammation, which can lead to vitamin A deficiency. People who suffer from acne may choose to take a vitamin A supplement of between 5,000 IU per day (recommended on U.S. nutritional labels) and 10,000 IU per day (though if vitamins D3 and K2 levels are low in the body, vitamin A toxicity is a potential problem with this dosage). 55 P a g e

Getting vitamin A from food sources, such as livers of beef, lamb, chicken, goat, pork and fish, is advised. A ¼ to ½ pound of animal liver once per week is sufficient, as vitamin A stores within the body for when it is needed. An alternative source of retinol is fermented cod liver oil. Alternatively, you might choose to take vitamin A supplements of 5000 IU.0 Vitamin E Studies have shown that vitamin E supplements taken in oral form can help to relieve acne. A study in 2006 of 100 acne sufferers found those with the worst acne had low levels of both vitamins A and E. Supplementations of both these vitamins improved the acne by removing their deficiency. 15mg per day is the recommended amount, though this may vary according to age and gender. Women who are pregnant and/or breastfeeding may require a different dosage. In addition, make sure you get vitamin E through your diet. Foods rich in this vitamin include asparagus, green leafy vegetables, and nuts, wheat germ, and seeds. Vegetable oils, olives and olive oil are also good sources of vitamin E. 56 P a g e

3.3.2 Other supplements Zinc Zinc is known to decrease oil production in the oil glands, and also has antibacterial and antiinflammatory properties. The RDA for adults is a dose of 8-10mg. Some evidence says that 30mg is a relatively safe dose and can assist in the treatment of acne. Milk thistle Milk contains two medicinal active ingredients, silymarin and silbinin. In 2012, a study found that a group taking 210mg of silymarin from milk thistle had a decrease of 50% in acne lesions. It is so effective because it boosts the natural antioxidant glutathione by 35-270%. This antioxidant detoxifies the liver and can help with acne. However, milk thistle does have side effects, which are explored in section 3.4. Selenium A study found that taking 200mcg of selenium per day could decrease acne lesions by 40%. Selenium deficiency is common in acne sufferers, so taking a supplement can help boost selenium back to optimal levels and prevent acne breakouts. Selenium also improves the efficiency of zinc, so they are often taken together. Some people choose to take supplements, while others consume brazil nuts, which contain high levels of selenium. It is important not to overdose on selenium, and we cover this in section 3.4. 57 P a g e

3.4 Side effects 58 P a g e

3.4.1 Side effects of isotrenoin Upwards of 80% of patients on isotretinoin experience side effects. There are a huge range of side effects that can be experienced when using this drug, ranging from mild to severe. Some of the most common include: Dry lips 92% of users Dry skin 57% of users Muscle pain 15-50% of users Joint pain 15-30% of users Lower back pain 30% of users Nosebleed 30% of users Neurological symptoms, such as dizziness, insomnia, lethargy, nervousness, tingling, numbness, seizures, weakness 16-29% of users Headaches 10-28% of users Elevated liver enzymes 15% of users Overgrowth of bone 10% of users 59 P a g e

Some rare, but more serious, side effects of isotretinoin include: Acute, long lasting arthritis Anemia Life threatening blood disease Depression Long term hearing impairment Low white blood cell count Respiratory symptoms Rapid breakdown of muscle tissue Reduced blood flow to the brain Severe allergy Ulcerative collitis It is important to remember that isotretinoin is the drug that causes the most birth defects in the USA. If a woman is already pregnant, or if she gets pregnant while taking isotretinoin, there is an extremely high risk that the infant will be deformed. It causes a developing fetus to suffer from serious malformations as it grows. This is true even if she only takes a small amount of the drug for a short time. 60 P a g e

To prevent this happening, there are strict rules, known as the Pregnancy Prevention Program, for women who want to take isotretinoin: One, or preferably two, methods of contraception must be used at all times to prevent pregnancy. This contraception must be started at least four weeks before treatment begins, be used throughout treatment, and until four weeks afterward. Doctors are not allowed to prescribe the drug until this contraception has been used for at least a month and a pregnancy test is taken, which must come back negative. Doctors can only prescribe isotretinoin for 30 days. Women must return to the doctor for a follow up visit every 30 days, and will be required to take another pregnancy test before prescription can be continued. While using the medicine, neither men nor women should donate blood. Five weeks after treatment is finished, another pregnancy test must be taken. All unused medicine must be returned to the pharmacist when treatment is finished. There is no evidence to indicate that men who take this medicine should not father children during this time. There does not appear to be a connection between a father taking isotrenoin and a fetus becoming deformed. 61 P a g e

3.4.2 Side effects of oral antibiotics Some common side effects of oral antibiotics include upset to the digestive system and discoloration of the teeth. The yellowing of the teeth is particularly prevalent with tetracycline use, along with an effect on bone formation. For this reason, tetracycline is not recommended to be prescribed to children under 14 or to pregnant women. The antibiotic minocycline is associated with more serious effects such as irreversible hyperpigmentation, autoimmune liver damage and autimmune disease lupus erythematosus. In this condition, the immune system becomes hyperactive and begins to attack healthy body tissue. 3.4.3 Side effects of birth control Women taking oral contraceptives have a higher risk of blood clots, particularly in the leg and lungs, heart attacks, and strokes. Other potential side effects include high blood pressure, gallbladder and liver disease, depression, and migraine headaches. Less serious side effects include mild headaches, breast tenderness, temporary acne flare ups and breakthrough bleeding. Women with the following conditions or family health histories are advised against taking oral contraceptives: 62 P a g e

Those with a history of heart disease Those with a history of hypertension A blood clotting disorder or previous blood clots in the lungs or the legs A history of uterine, breast or liver cancer Migraine headaches Liver disease Diabetes Obesity Smokers aged over 35 Pregnant or breastfeeding 3.4.3 Side effects of topical treatments Topical gels, creams, oils, washes - Potential side effects of topical gels, creams and washes include more sensitivity to sunlight, redness, drying, burning, itchiness, scaling, stinging and tingling. It is important that people with dark complexions are careful with the use of Azelax (azelaic acid). This is because lightening of the skin has been reported, and the treatment has not been studied enough in people with darker complexions. Benzoyl peroxide Itchiness, redness and dryness is expected in the first few weeks of using the product. This is known as the hardening effect and is normal. However, 1-3% of people have an allergic reaction to benzoyl peroxide, which can manifest in severe crusting or inflammation of the skin. These people should discontinue use. Benzoyl peroxide might also have a bleaching effect on fabric and hair. 63 P a g e

Clindamycin Along with skin irritation, inflammation of the colon, diarrhoea, and bloody diarrhoea have been reported with use of this product. Chemical peels In the days after the first peel, most people take on a sub burnt look with redness and peeling. This is consistent after every peel, but is less severe each time. Some people with dark complexions have experienced skin lightening which could be permanent, while lighter skinned people have reported their skin tone darkening. People who are prone to keloid scarring need to consult a dermatologist before getting a chemical peel, to find out how it might affect them. After a chemical peel, the skin is more sensitive to sunlight. Sodium sulfacetamide Some people can have a severe reaction to sulfonamides, which can result in death. This is very rare. Tazarotene This should not be used by pregnant women, as it may cause harm to the fetus. 64 P a g e

Photodynamic therapy Pain is felt during treatment, and this can be severe. A week or so after treatment, side effects such as redness, itching, peeling, crusting and swelling might be experienced. Many people prefer not to leave their homes for several days after receiving the therapy. Patients are not permitted to go in the sun for two days after treatment, because the skin is extremely sensitive to light. Laser therapy Pain or discomfort during laser therapy is common. Some people experience crusting, blistering, inflammation and/or redness after treatment. 3.4.3 Side effects of alternatives Vitamin A If you decide to take retinol as a pill, only do so under the careful supervision of a doctor. Vitamin A overdose can lead to toxicity, which is a very serious medical matter. Vitamin A is stored in the liver, but when there is too much vitamin A coming in for the liver to store, some of the storage cells burst and release vitamin A into the blood stream. This can cause birth defects and miscarriages for pregnant women, abnormalities in the liver, and osteoporosis. If vitamin A toxicity is severe or long term, this could lead to coma or death. Zinc Excessive zinc can lead to a copper deficiency. Zinc toxicity can cause vomiting, diarrhoea, headaches, loss of appetite, abdominal cramping and nausea. In the long term, it may cause kidney failure and urinary tract infections. Milk thistle Side effects of milk thistle can include loss of appetite, nausea, abdominal cramping and bloating. Insomnia is another frequently reported side effect, as well as changes in libido. Selenium Overdosing on selenium (taking over 400mcg a day) can lead to discoloration of the skin, baldness, tooth decay, mental fatigue, and weak hair, nails and skin. In addition, excessive selenium can disrupt the healing process of acne, because it slows down the formation of collagen. 65 P a g e