- Email: [email protected]
Topical Antibiotic Therapy for Acne
Topical Antibiotic Therapy for Acne By NICHOLAS G. POPOVICH
Some 70% of all American teenagers have acne. At one time or another, most of them will seek the help of a pharmacist for relief of their condition. While many of these patients may effectively treat their acne with one or more of the scores of nonprescription acne preparations on the market, the Food and Drug Administration has not yet ruled on which ingredients in these products are effective. That ruling is expected sometime next year, when FDA will publish its monograph for these products. For patients with acne vulgaris and other forms of severe acne, the best advice is to visit their physician or dermatologist. There are several prescription products now in use that have been proven safe and effective. Among these are prescription topical antibiotics, which first received FDA approval for acne treatment about four years ago.
unerican Pharmacy Vol. NS21, No. 5, May 1981/303
55
In the early 1970s, innovative dermatologists began to prescribe topscribe topical antibiotic preparations for their patients with inflammatory acne. This was done to circumvent the problems associated with oral antibiotics such as patient noncompliance, the possibility of deleterious side effects and bioavailability. Although the topical preparations worked well and avoided these complications, new problems emerged. Pharmacists had to prepare these prescriptions, a complete reversal of the trend of the prior 70 years toward prepackaged topical preparations. There was little information about the best compounding technique, shelflife or the most advantageous form of the drug to use (e.g., clindamycin phosphate vs. clindamycin hydrochloride). That these preparations were being prescribed for what was technically an unapproved use further complicated the situation. Eventually, controlled trials demonstrated that topical antibiotics were useful in the control of acne for many patients. There were limitations to their use, however, as in the rare acne conglobata, where oral antibiotic therapy remains most effective. In the past four years, FDA has approved several prescription antibiotic products for the topical control of acne vulgaris. The first was tetracycline hydrochloride. More recently, that agent has been joined by meclocycline sulfosalicylate, erythromycin base and clindamycin phosphate. They remain available for acne treatment by prescription only.
Topical Antibiotic Therapy Patients with noninflammatory acne, characterized by closed and open comedones (whiteheads and blackheads) may be treated with OTC medications. However, those with more severe acne, with papules, pustules and inflammation
Nicholas G. Popovich, PhD, RPh, is associate professor of clinical pharmacy at Purdue University School of Pharmacy & Pharmacal Sciences, West Lafayette, IN 47907.
56
around the comedones, should consult a physician. The goal of therapy is to control the disease process until it spontaneously heals while preventing permanent damage to the skin. A complementary aim is promoting the comfort of the patient by reducing the soreness, burning and/or itching of the condition. The mechanism of action of topical antibiotics does not seem to be solely dependent on either a decrease in the percentage of free fatty acids produced or a suppression of bacterial flora. One group of investigators1 propose that these antibiotics may produce a partial or selective suppression of bacterial metabolic activity that prevents organisms in the follicles from becoming comedogenic. They also suggest, however, that it may be the anti-inflammatory rather than the antimicrobial effect that is important in acne treatment. To date, the reported incidence of allergic reactions to topical application of these antibiotics has been low. As with virtually all topical acne therapy, these products can produce some skin reddening and scaling. There are four prescription antibiotics available in topical form for acne treatment. Only these will be considered here. (There are, however, other topical antibiotics-including other forms of these drugs, chloramphenicol and lincomycinbut they all must be compounded by the pharmacist and are prescribed less frequently. In a recent survey, 74% of 538 U.S. dermatologists said they prescribed clindamycin, 50% used erythromycin, 8% used tetracycline, and 5% used lincomycin topically to treat acne. 2)
Tetracycline Hydrochloride To maintain an effective concentration of tetracycline hydrochloride and prevent its rapid degradation, this agent is mixed with a sufficient amount of its degradation product, 4-epitetracycline hydrochloride. Since the formulation is still relatively unstable, however, it is reconstituted at the time of dispensing and has a shelflife at room temper-
ature of two months. Its vehicle i! n -decylmethyl sulfoxide, an analo1 of dimethyl sulfoxide (DMSO), anc sucrose esters in aqueous ethanol. This DMSO analog is promoted tc increase the ability of the active in· gredient to penetrate into the se· baceous glands and hair follicles. Aside from the problem of limited shelflife, inherent problems asso· dated with the use of tetracycline hydrochloride include temporary yellowing of the skin. This effect may be particularly bothersome to light-complexioned patients, but it is immediately reversible by wash· ing the product off the skin. If skin yellowing is a problem and the drug is prescribed for twice daily use, the patient should be advised to apply the medication after school or work and again at bedtime. In addition, tetracycline is fluorescent, and an unsuspecting discotheque patron who has applied it and enjoys life under a blacklight might take on a "glowing" appearance. Thus, pa· tient education is necessary to en· hance compliance.
Meclocycline Sulfosalicylate Meclocycline sulfosalicylate is a tetracycline analog. Like the other topical antibiotics, this drug reduces the risk of adverse systemic effects. It is not absorbed through the skin in quantities sufficient to be de· tected systemically, even when ap· plied at 40 times the average dose. Although some cases of skin irri tation have been reported, the dru and its cream vehicle are well toler ated. Temporary follicular stainin may occur with meclocycline sulfo· salicylate, especially with excessive application. Like tetracycline hydro· chloride, this agent also causes ski to fluoresce under blacklight. This drug, in a cream dosage form, has a shelflife of two years.
Erythromycin Base Clinical studies have demon strated that the optimal concentra tion of topical erythromycin for acne is 1-2%. Erythromycin base is pre· ferred for topical application over other forms of the drug because o its high partition coefficient (i.e., oil water ratio), which gives it a Jipo·
American Pharmacy Vol. NS21, No. 5, May 1981
philic character that favors skin penetration. This antibiotic exhibits good stability in nonaqueous alcohol/propylene glycol formulations so shelflife of marketed formulations is 24 months when stored at room temperature. Since the drug can be applied with the fingertip, it is especially important that patients wash their hands after application. Otherwise, inadvertent transmittal of residual product into the eyes or onto mucous membranes could cause irritation. An advantage of erythromycin to date remains its low degree of sensitization and systemic adverse effects.
Clindamycin Phosphate Both the phosphate and the hydrochloride forms of clindamycin
are effective in reducing acne lesions. 3.4 Clindamycin phosphate is a stable antibiotic and has a shelflife of 24 months in its available solution dosage form . Topical concentrations of 1-2% are optimal for the control of acne . A concern with clindamycin is the possibility of percutaneous absorption . There have been no detectable serum levels of clindamycin when it has been applied in a 1% hydroalcoholic solution, although substantial urinary concentrations have been demonstrated. 5•6 To date, there have been no published reports of antibiotic-associated colitis, known to be associated with the overgrowth of Clostridium difficile. However, patients should stop using topical clindamycin if diarrhea occurs.
An unusual side effect has been reported with the use of the hydrochloride salt in an extemporaneous ethyl alcohol preparation .7 Six patients complained of a bad taste after application to facial skin. Apparently, the topical clindamycin was either licked off or carried by perspiration to the mouth. Some of these patients were so troubled by the bad taste that they discontinued use of the product. This does not appear to be a problem with the phosphate ester, so the rational approach to avoid noncompliance would be to switch the patient to this form.
Patient Consultation Patient education from the pharmacist on the use of these products is vital, since acne is a continuous,
Pathogenesis of Acne Vulgaris The pathogenesis of acne is complex. But in simple terms, it is a condition in which the products of large sebaceous glands irritate the lining of the follicular ducts, particularly in the skin of the head, neck and shoulder region, and induce plugged and obstructed ducts .1 These glands are under endocrine control, especially from androgens. Patients with acne probably have sebaceous glands which are over-responsive to the effects of androgens.2 Complicating the situation is that these ducts have large numbers of Propionibacterium acnes which under optimal conditions produce lipolytic enzymes that convert esterified fatty acids of sebum to free fatty acids which can change noninflamed lesions into inflamed ones (inflammatory acne) . Thus, topical antibiotic acne therapy is directed toward modification of bacteria-induced inflammation and/or a lessening of the inflammatory response.
Predisposing Factors The course of acne differs according to sex. In boys, the course is rnuch more severe and common. Usually, it will spontaneously heal
lrnerican Pharmacy Vol. NS21, No. 5, May 1981/305
and become clinically insignificant by age 25 .3 In girls, however, the acne condition may be only marginal well into maturity. It may be that after escaping unscathed during adolescence a young woman develops acne in her early 20s. This type of acne differs from classical acne and may be acne cosmetica, encouraged by oleaginous substances in cosmetics. The diminutive nature of this disease is characteristic, occurring only on the face and remaining essentially noninflammatory. Although individual susceptibility is different among women, those who have a history of adolescent acne seem to be at higher risk for its development. There is no known association between diet and the development of acne. Dietary manipulations other than severe caloric restrictions have little effect upon the secretion of the sebaceous glands. Emotional or psychological stress, · often accompanied by an increase in seborrhea, can exacerbate the acne condition, however. Premenstrual tension has been implicated. Mechanical factors, such as manipulation, friction, occlusion, and rubbing of acne le-
sions may induce new lesions or delay the resolution of older ones . Certain drugs administered orally and topically can induce acneiform lesions.4 These include: • Androgens-danazol, fluoxymesterone, methandrostenolone, methyltestosterone, oxymetholone and testosterone. • Anticonvulsants--mephenytoin, phenytoin and trimethadione. • Antimanic agent-lithium. • Antituberculosis agent-isoniazid (INH). • Corticosteroids--cortisone, dexamethasone, hydrocortisone, prednisone, and triamcinolone . • Expectorants--iodine products (e.g., SSKI) and iodinated glycerol. • Progestins--ethynodiol diacetate, norethindrone, norethindrone acetate, and norgestrel.
References I. W .j . Cunliffe, British Medical fau rnal, 280, 1394. 2. G. Sansone and R.M. Reisner, Journal of Inves tigative Dermatology, 56, 366. 3. A .M . Kligman and O .H . Mills Jr., Archives of Dermatology. 106, 843. 4. j .W . Melski and K.A. Arndt, New England Journal of Medicine, 302, 503.
57
nagging affliction that may go on for several years. Pharmacists should advise patients not to expect overnight remission of the acne condition. The onset of symptomatic and visual relief may take several months because therapy is a gradual process. Patients should be advised of the need for continual, conscientious use of the medication. The apparent effectiveness during the first month of oral antibiotic therapy is due to the placebo effect of the medication, but it takes at least two or three months before the impact of the antibiotic is realized. 8 Some dermatologists suggest treatment for six months. This finding appears consistent with reports of early success of topical antibiotic therapy where vehicle effects and a good skin cleansing program contributed to improvement in the first month of treatment. At the time patients are given the topical antibiotic solution, the pharmacist can be helpful. It is important for patients to realize that topical products must be used together with a conscientious and consistent cleansing program. The skin should be thoroughly washed with warm water and soap, rinsed and patted dry. The product should then be applied to the whole acne-bearing area to prevent the formation of new lesions. Patients should also be in-
Emulsia..:
Wax,N~F~ COIIIact Crocla. 51 Madison Ave. New York, N.Y. 10010 Tel. (212) 683-3089
*XIV, 1975.
58
formed of any precautions to take when using the drug and should be informed about the expiration date of the medication, especially when using tetracycline, because some patients are inclined to save the medication over the summer when acne "seems to get better with the sun."
Treatment Failure When topical antibiotic therapy fails, the dermatologist must determine the cause of the problem. The possibility does exist that a number of patients will fail to respond to these topical antibiotics because of the emergence of Propionibacterium acnes resistant to these drugs. Additional considerations might be the development of persistent deep nodular lesions, formation of sinus tracts that require surgical intervention, emotional or psychological stress, and Gram-negative folliculitis. There are other factors, however, that the pharmacist might first be in a position to question. Usually, the patient complains to the pharmacist that the medication is not working. Questions to the patient might include: • Are you using the medication sufficiently and in a conscientious manner? • Are you using the cleansing program the physician has suggested? • Are you rubbing or manipulating your face in such a way as to cause further irritation? • Are you using any oily cosmetics, such as some facial soaps, emollients or skin cleansers? • Are you routinely exposed enyironmentally to agents such as tars, chlorinated hydrocarbons or industrial cutting oils used for cooling and lubrication? • What other prescription drugs are you taking (if the patient medication profile is not available)? If the patient profile is available, the pharmacist should check it to see if the patient is taking any hormonal or other systemic medication that could induce acneiform eruptions. Topical medications, such as corticosteroids, can also cause these lesions. The pharmacist must also be cog-
nizant of patient complaints about side effects. Any patient who ex· periences excessive reddening and scaling of the skin should be told to discontinue the use of the medica· tion and consult the physician. The I mere application of a medication on· I to the face does not ensure that the drug will not be absorbed system· ically. Urinary concentrations ol clindamycin have demonstrated this. Thus, the pharmacist must be sensitive to patient complaints about systemic toxicity and ade· I quately counsel the patient. .
1
Long-Term Therapy Acne vulgaris is a treatable dis· ease. Since it is a chronic condition, continuous treatment is usually nee· essary until the time it spontane· ously disappears. The pharmacist can add immeasurably to the edu· cation of the patient and at the same time provide the patient the oppor· tunity to maximize the benefit of the prescribed medications. By a con cerned, enthusiastic and know edgeable attitude the pharmaci can brighten the otherwise ble outlook a patient might have and in a position to shape the eventu outcome of therapy. o
References 1. R. J. Thomsen, A. Stranieri, D. Knutson, eta/. , Archires~ Dermatology, 116, 1031. 2. R. B. Stoughton, Archives of Dermatology, 115, 486. 3. J. D. Guin, International Journal of Dermatology, 18, 164. 4. M .W. McKenzie, D. C. BeckandN . G. Popovich,Archit!! of Dermatology, in press. 5. R. ] . Algra, T. Rosen and M. Waisman, Archives of matology, 113 , 1390. 6. R. B. Stoughton and W. Resh, Cutis, 17, 551. 7. L. Slazinski and F. W. Flowers, Archives of Dermatolo 116, 383. 8. R. G. Crounse, Journal of the American Medical Associatio 193 , 906.
American Pharmacy Vol. NS21, No. 5, May 1981
e
Some 70% of all American teenagers have acne. At one time or another, most of them will seek the help of a pharmacist for relief of their condition. While many of these patients may effectively treat their acne with one or more of the scores of nonprescription acne preparations on the market, the Food and Drug Administration has not yet ruled on which ingredients in these products are effective. That ruling is expected sometime next year, when FDA will publish its monograph for these products. For patients with acne vulgaris and other forms of severe acne, the best advice is to visit their physician or dermatologist. There are several prescription products now in use that have been proven safe and effective. Among these are prescription topical antibiotics, which first received FDA approval for acne treatment about four years ago.
unerican Pharmacy Vol. NS21, No. 5, May 1981/303
55
In the early 1970s, innovative dermatologists began to prescribe topscribe topical antibiotic preparations for their patients with inflammatory acne. This was done to circumvent the problems associated with oral antibiotics such as patient noncompliance, the possibility of deleterious side effects and bioavailability. Although the topical preparations worked well and avoided these complications, new problems emerged. Pharmacists had to prepare these prescriptions, a complete reversal of the trend of the prior 70 years toward prepackaged topical preparations. There was little information about the best compounding technique, shelflife or the most advantageous form of the drug to use (e.g., clindamycin phosphate vs. clindamycin hydrochloride). That these preparations were being prescribed for what was technically an unapproved use further complicated the situation. Eventually, controlled trials demonstrated that topical antibiotics were useful in the control of acne for many patients. There were limitations to their use, however, as in the rare acne conglobata, where oral antibiotic therapy remains most effective. In the past four years, FDA has approved several prescription antibiotic products for the topical control of acne vulgaris. The first was tetracycline hydrochloride. More recently, that agent has been joined by meclocycline sulfosalicylate, erythromycin base and clindamycin phosphate. They remain available for acne treatment by prescription only.
Topical Antibiotic Therapy Patients with noninflammatory acne, characterized by closed and open comedones (whiteheads and blackheads) may be treated with OTC medications. However, those with more severe acne, with papules, pustules and inflammation
Nicholas G. Popovich, PhD, RPh, is associate professor of clinical pharmacy at Purdue University School of Pharmacy & Pharmacal Sciences, West Lafayette, IN 47907.
56
around the comedones, should consult a physician. The goal of therapy is to control the disease process until it spontaneously heals while preventing permanent damage to the skin. A complementary aim is promoting the comfort of the patient by reducing the soreness, burning and/or itching of the condition. The mechanism of action of topical antibiotics does not seem to be solely dependent on either a decrease in the percentage of free fatty acids produced or a suppression of bacterial flora. One group of investigators1 propose that these antibiotics may produce a partial or selective suppression of bacterial metabolic activity that prevents organisms in the follicles from becoming comedogenic. They also suggest, however, that it may be the anti-inflammatory rather than the antimicrobial effect that is important in acne treatment. To date, the reported incidence of allergic reactions to topical application of these antibiotics has been low. As with virtually all topical acne therapy, these products can produce some skin reddening and scaling. There are four prescription antibiotics available in topical form for acne treatment. Only these will be considered here. (There are, however, other topical antibiotics-including other forms of these drugs, chloramphenicol and lincomycinbut they all must be compounded by the pharmacist and are prescribed less frequently. In a recent survey, 74% of 538 U.S. dermatologists said they prescribed clindamycin, 50% used erythromycin, 8% used tetracycline, and 5% used lincomycin topically to treat acne. 2)
Tetracycline Hydrochloride To maintain an effective concentration of tetracycline hydrochloride and prevent its rapid degradation, this agent is mixed with a sufficient amount of its degradation product, 4-epitetracycline hydrochloride. Since the formulation is still relatively unstable, however, it is reconstituted at the time of dispensing and has a shelflife at room temper-
ature of two months. Its vehicle i! n -decylmethyl sulfoxide, an analo1 of dimethyl sulfoxide (DMSO), anc sucrose esters in aqueous ethanol. This DMSO analog is promoted tc increase the ability of the active in· gredient to penetrate into the se· baceous glands and hair follicles. Aside from the problem of limited shelflife, inherent problems asso· dated with the use of tetracycline hydrochloride include temporary yellowing of the skin. This effect may be particularly bothersome to light-complexioned patients, but it is immediately reversible by wash· ing the product off the skin. If skin yellowing is a problem and the drug is prescribed for twice daily use, the patient should be advised to apply the medication after school or work and again at bedtime. In addition, tetracycline is fluorescent, and an unsuspecting discotheque patron who has applied it and enjoys life under a blacklight might take on a "glowing" appearance. Thus, pa· tient education is necessary to en· hance compliance.
Meclocycline Sulfosalicylate Meclocycline sulfosalicylate is a tetracycline analog. Like the other topical antibiotics, this drug reduces the risk of adverse systemic effects. It is not absorbed through the skin in quantities sufficient to be de· tected systemically, even when ap· plied at 40 times the average dose. Although some cases of skin irri tation have been reported, the dru and its cream vehicle are well toler ated. Temporary follicular stainin may occur with meclocycline sulfo· salicylate, especially with excessive application. Like tetracycline hydro· chloride, this agent also causes ski to fluoresce under blacklight. This drug, in a cream dosage form, has a shelflife of two years.
Erythromycin Base Clinical studies have demon strated that the optimal concentra tion of topical erythromycin for acne is 1-2%. Erythromycin base is pre· ferred for topical application over other forms of the drug because o its high partition coefficient (i.e., oil water ratio), which gives it a Jipo·
American Pharmacy Vol. NS21, No. 5, May 1981
philic character that favors skin penetration. This antibiotic exhibits good stability in nonaqueous alcohol/propylene glycol formulations so shelflife of marketed formulations is 24 months when stored at room temperature. Since the drug can be applied with the fingertip, it is especially important that patients wash their hands after application. Otherwise, inadvertent transmittal of residual product into the eyes or onto mucous membranes could cause irritation. An advantage of erythromycin to date remains its low degree of sensitization and systemic adverse effects.
Clindamycin Phosphate Both the phosphate and the hydrochloride forms of clindamycin
are effective in reducing acne lesions. 3.4 Clindamycin phosphate is a stable antibiotic and has a shelflife of 24 months in its available solution dosage form . Topical concentrations of 1-2% are optimal for the control of acne . A concern with clindamycin is the possibility of percutaneous absorption . There have been no detectable serum levels of clindamycin when it has been applied in a 1% hydroalcoholic solution, although substantial urinary concentrations have been demonstrated. 5•6 To date, there have been no published reports of antibiotic-associated colitis, known to be associated with the overgrowth of Clostridium difficile. However, patients should stop using topical clindamycin if diarrhea occurs.
An unusual side effect has been reported with the use of the hydrochloride salt in an extemporaneous ethyl alcohol preparation .7 Six patients complained of a bad taste after application to facial skin. Apparently, the topical clindamycin was either licked off or carried by perspiration to the mouth. Some of these patients were so troubled by the bad taste that they discontinued use of the product. This does not appear to be a problem with the phosphate ester, so the rational approach to avoid noncompliance would be to switch the patient to this form.
Patient Consultation Patient education from the pharmacist on the use of these products is vital, since acne is a continuous,
Pathogenesis of Acne Vulgaris The pathogenesis of acne is complex. But in simple terms, it is a condition in which the products of large sebaceous glands irritate the lining of the follicular ducts, particularly in the skin of the head, neck and shoulder region, and induce plugged and obstructed ducts .1 These glands are under endocrine control, especially from androgens. Patients with acne probably have sebaceous glands which are over-responsive to the effects of androgens.2 Complicating the situation is that these ducts have large numbers of Propionibacterium acnes which under optimal conditions produce lipolytic enzymes that convert esterified fatty acids of sebum to free fatty acids which can change noninflamed lesions into inflamed ones (inflammatory acne) . Thus, topical antibiotic acne therapy is directed toward modification of bacteria-induced inflammation and/or a lessening of the inflammatory response.
Predisposing Factors The course of acne differs according to sex. In boys, the course is rnuch more severe and common. Usually, it will spontaneously heal
lrnerican Pharmacy Vol. NS21, No. 5, May 1981/305
and become clinically insignificant by age 25 .3 In girls, however, the acne condition may be only marginal well into maturity. It may be that after escaping unscathed during adolescence a young woman develops acne in her early 20s. This type of acne differs from classical acne and may be acne cosmetica, encouraged by oleaginous substances in cosmetics. The diminutive nature of this disease is characteristic, occurring only on the face and remaining essentially noninflammatory. Although individual susceptibility is different among women, those who have a history of adolescent acne seem to be at higher risk for its development. There is no known association between diet and the development of acne. Dietary manipulations other than severe caloric restrictions have little effect upon the secretion of the sebaceous glands. Emotional or psychological stress, · often accompanied by an increase in seborrhea, can exacerbate the acne condition, however. Premenstrual tension has been implicated. Mechanical factors, such as manipulation, friction, occlusion, and rubbing of acne le-
sions may induce new lesions or delay the resolution of older ones . Certain drugs administered orally and topically can induce acneiform lesions.4 These include: • Androgens-danazol, fluoxymesterone, methandrostenolone, methyltestosterone, oxymetholone and testosterone. • Anticonvulsants--mephenytoin, phenytoin and trimethadione. • Antimanic agent-lithium. • Antituberculosis agent-isoniazid (INH). • Corticosteroids--cortisone, dexamethasone, hydrocortisone, prednisone, and triamcinolone . • Expectorants--iodine products (e.g., SSKI) and iodinated glycerol. • Progestins--ethynodiol diacetate, norethindrone, norethindrone acetate, and norgestrel.
References I. W .j . Cunliffe, British Medical fau rnal, 280, 1394. 2. G. Sansone and R.M. Reisner, Journal of Inves tigative Dermatology, 56, 366. 3. A .M . Kligman and O .H . Mills Jr., Archives of Dermatology. 106, 843. 4. j .W . Melski and K.A. Arndt, New England Journal of Medicine, 302, 503.
57
nagging affliction that may go on for several years. Pharmacists should advise patients not to expect overnight remission of the acne condition. The onset of symptomatic and visual relief may take several months because therapy is a gradual process. Patients should be advised of the need for continual, conscientious use of the medication. The apparent effectiveness during the first month of oral antibiotic therapy is due to the placebo effect of the medication, but it takes at least two or three months before the impact of the antibiotic is realized. 8 Some dermatologists suggest treatment for six months. This finding appears consistent with reports of early success of topical antibiotic therapy where vehicle effects and a good skin cleansing program contributed to improvement in the first month of treatment. At the time patients are given the topical antibiotic solution, the pharmacist can be helpful. It is important for patients to realize that topical products must be used together with a conscientious and consistent cleansing program. The skin should be thoroughly washed with warm water and soap, rinsed and patted dry. The product should then be applied to the whole acne-bearing area to prevent the formation of new lesions. Patients should also be in-
Emulsia..:
Wax,N~F~ COIIIact Crocla. 51 Madison Ave. New York, N.Y. 10010 Tel. (212) 683-3089
*XIV, 1975.
58
formed of any precautions to take when using the drug and should be informed about the expiration date of the medication, especially when using tetracycline, because some patients are inclined to save the medication over the summer when acne "seems to get better with the sun."
Treatment Failure When topical antibiotic therapy fails, the dermatologist must determine the cause of the problem. The possibility does exist that a number of patients will fail to respond to these topical antibiotics because of the emergence of Propionibacterium acnes resistant to these drugs. Additional considerations might be the development of persistent deep nodular lesions, formation of sinus tracts that require surgical intervention, emotional or psychological stress, and Gram-negative folliculitis. There are other factors, however, that the pharmacist might first be in a position to question. Usually, the patient complains to the pharmacist that the medication is not working. Questions to the patient might include: • Are you using the medication sufficiently and in a conscientious manner? • Are you using the cleansing program the physician has suggested? • Are you rubbing or manipulating your face in such a way as to cause further irritation? • Are you using any oily cosmetics, such as some facial soaps, emollients or skin cleansers? • Are you routinely exposed enyironmentally to agents such as tars, chlorinated hydrocarbons or industrial cutting oils used for cooling and lubrication? • What other prescription drugs are you taking (if the patient medication profile is not available)? If the patient profile is available, the pharmacist should check it to see if the patient is taking any hormonal or other systemic medication that could induce acneiform eruptions. Topical medications, such as corticosteroids, can also cause these lesions. The pharmacist must also be cog-
nizant of patient complaints about side effects. Any patient who ex· periences excessive reddening and scaling of the skin should be told to discontinue the use of the medica· tion and consult the physician. The I mere application of a medication on· I to the face does not ensure that the drug will not be absorbed system· ically. Urinary concentrations ol clindamycin have demonstrated this. Thus, the pharmacist must be sensitive to patient complaints about systemic toxicity and ade· I quately counsel the patient. .
1
Long-Term Therapy Acne vulgaris is a treatable dis· ease. Since it is a chronic condition, continuous treatment is usually nee· essary until the time it spontane· ously disappears. The pharmacist can add immeasurably to the edu· cation of the patient and at the same time provide the patient the oppor· tunity to maximize the benefit of the prescribed medications. By a con cerned, enthusiastic and know edgeable attitude the pharmaci can brighten the otherwise ble outlook a patient might have and in a position to shape the eventu outcome of therapy. o
References 1. R. J. Thomsen, A. Stranieri, D. Knutson, eta/. , Archires~ Dermatology, 116, 1031. 2. R. B. Stoughton, Archives of Dermatology, 115, 486. 3. J. D. Guin, International Journal of Dermatology, 18, 164. 4. M .W. McKenzie, D. C. BeckandN . G. Popovich,Archit!! of Dermatology, in press. 5. R. ] . Algra, T. Rosen and M. Waisman, Archives of matology, 113 , 1390. 6. R. B. Stoughton and W. Resh, Cutis, 17, 551. 7. L. Slazinski and F. W. Flowers, Archives of Dermatolo 116, 383. 8. R. G. Crounse, Journal of the American Medical Associatio 193 , 906.
American Pharmacy Vol. NS21, No. 5, May 1981
e