Pharmacology Case Study: Acne Vulgaris

Alyssa Matulich

University of Tennessee Chattanooga

PHARMACOLOGY CASE STUDY 1: ACNE VULGARIS

Pharmacology Case Study 1: Acne Vulgaris

For the purpose of this case study, the pharmacological intervention for acne vulgaris will

be examined. Forty to fifty million Americans are affected by acne and it is one of the most

common skin conditions in the United States (Woo & Robinson, 2016, p. 659). The

pathophysiology of acne vulgaris includes plugging of the folliculosebaceous unit by keratin

plugs, sebum production, overgrowth of the bacteria Propionibacterium acnes within the plugged

follicle and a secondary inflammatory response (Hammer & Mcphee, 2014, p. 208).

Pharmacotherapeutic Selection

Medications used to treat acne vulgaris can either be topical or systemic. The

pharmacological intervention for acne is typically based on the severity of the skin condition.

The topical agents are either retinoid or antibiotics while the systemic agents are oral antibiotics,

hormonal therapy, and isotretinoin which is an oral retinoid (Woo & Robinson, 2016, p. 659).

Topical agents are used in mild to moderate acne, oral antibiotics are used in moderate to severe

acne, and isotretinoin is prescribed for severe nodulosystic acne (Woo & Robinson, 2016).

Topical Agents

There are many topical agents to choose from when treating acne vulgaris. The first line

therapy to be considered alone or in combination is a retinoid (Woo & Robinson, 2016).

Tretinoin is recommended first and as retinoid it enhances the penetration of other topical agents

(Woo & Robinson, 2016). Other topical retinoid options include adapalene, tazarotene,

isotretinoin, metretinide, retinaldehyde, and β-retinol glucuronide (Rathi, 2011). Benzoyl

peroxide which is available in washes, lotions, creams, and gel is a broad spectrum bactericidal

agent and another option for acne treatment (Rathi, 2011). Topical antibiotic agents that inhibit

the growth of P. acnes and reduce inflammation to be considered for use are erythromycin and
PHARMACOLOGY CASE STUDY 1: ACNE VULGARIS

clindamycin (Rathi, 2011). Topical antibiotics should not be used as monotherapy but rather in

combination with a retinoid or benzoyl peroxide (Graber, 2017). Other topical agents that may be

used for the treatment for mild to moderate acne include salicylic acid, azelaic acid, lactic

acid/lactate lotion, tea tree oil, picolinic acid gel, and dapsone gel (Rathi, 2011).

Systemic Agents

Oral antibiotics are indicated for treatment of moderate to severe acne vulgaris. First

choice oral antibiotics are tetracyclines (Rathi, 2011). Alternatives for tetracyclines are

macrolides, co-trimoxazole, and trimethoprim (Keri, 2017). Hormonal therapy may be needed in

female patients to prevent the effects of androgens on the sebaceous glands (Rathi, 2011). Oral

contraceptives, spironolactone, cyproterone acetate and flutamide are a few options of hormonal

therapy in the treatment of acne vulgaris (Rathi, 2011). Oral isotretinoin is an oral retinoid that is

indicated in moderate to severe acne and when oral antibiotics are not successful (Keri, 2017).

Adjunctive therapies

Light/Laser therapies have been used in the treatment of acne. The phototherapy is used

in combination with aminolaevulinic acid or methyl aminolaevulinic acid prior to exposure to a

light or laser (Dover & Batra, 2017). The efficacy to laser or light therapy still remains under

investigation (Dover & Batra, 2017). Chemical peels, microdermabrasion, comodone extraction,

intralesional and glucocorticoid injections are other clinical treatments that may be considered in

the treatment of acne vulgaris (Dover & Batra, 2017). Chemical peels are the only adjunctive

therapy with any support for efficacy (Dover & Batra, 2017). Dietary modifications may be

considered but more research is needed to support this recommendation (Dover & Batra, 2017).

Doxycycline
PHARMACOLOGY CASE STUDY 1: ACNE VULGARIS

Doxycycline, a tetracycline, is a first line drug in the treatment of acne vulgaris (Keri,

2017). Tetracyclines are bacteriostatic and may be bactericidal by inhibiting the protein

synthesis through reversibly binding to the 30S subunit of the bacterial ribosome and prevents

the addition of amino acids to growing peptides (Woo & Robinson, 2016). The main mechanism

of action is to prevent the bacterial protein synthesis which gives it antibacterial properties (Woo

& Robinson, 2016). The antibacterial properties of tetracyclines as well as their anti-

inflammatory mechanisms makes doxycycline useful in the treatment in of acne vulgaris (Woo

& Robinson, 2016). Doxycycline is best absorbed in a fasting state and is highly lipid soluble

(Woo & Robinson, 2016). The percentage of doxycycline absorbed is 95-100% (Woo &

Robinson, 2016). Because it is highly lipid soluble, doxycycline readily penetrates body tissues

and fluids (Woo & Robinson, 2016). Polyvalent cations like calcium, magnesium zinc, iron and

aluminum can decrease absorption (Woo & Robinson, 2016). Doxycycline is excreted by the

kidneys via glomerular filtrations after being metabolized by the liver (Woo & Robinson, 2016).

There are some patient populations that should not be prescribed doxycycline or should

be prescribed doxycycline with extreme caution. Doxycycline is pregnancy category D and

therefore should not be prescribed to pregnancy patients (Hamilton, 2018). Doxycycline is

excreted in breastmilk, but the levels are low, and absorption is inhibited by calcium so short

course treatment with doxycycline is considered safe (Woo & Robinson, 2016). Doxycycline

should not be prescribed to children 8 years and younger because of the risk of decrease bone

growth and tooth discoloration (Hamilton, 2018). Renal adjustment doses are not necessary with

doxycycline (Hamilton, 2018). Hepatic impairment does cause reason for caution and monitoring

with doxycycline (Woo & Robinson, 2016). Long term use of doxycycline requires periodic

hematopoietic, hepatic, and renal function tests (Woo & Robinson, 2016).
PHARMACOLOGY CASE STUDY 1: ACNE VULGARIS

The most common adverse drug reactions associated with doxycycline are GI side effects

such as anorexia, nausea, vomiting, and diarrhea (Woo & Robinson, 2016). Taking doxycycline

with food or reducing the dose can relieve GI side effects (Hamilton, 2018). Esophageal ulcers

are another adverse reaction and can be prevented by taking doxycycline with a full glass of

water and remaining upright after the dose (Hamilton, 2018). Light headedness, dizziness,

vertigo, pseudo tremor cerebri, headache, and blurred vision may occur in some patients and

resolve when the doxycycline is discontinued (Woo & Robinson, 2016). Photosensitivity and

severe skin reactions are an adverse reaction reported with tetracyclines like doxycycline

(Hamilton, 2018). Doxycycline should not be taken within two hours of antacids or calcium

supplements (Hamilton, 2018). Barbiturates, carbamazepine, rifampin, and phenytoin decrease

doxycycline levels Hamilton, 2018). Tetracyclines like doxycycline may affect oral

contraceptive use and barrier contraceptive methods should be considered with doxycycline use

(Woo & Robinson, 2016).

There are no ethical or legal considerations when prescribing doxycycline.

Doxycycline is usually prescribed as 50 to 100mg PO one to two times per day and it is limited

to three months to prevent bacterial resistance (Hamilton, 2018). It is important for the patient to

take the entire prescription and should be told of all adverse side effects and how to avoid them.
PHARMACOLOGY CASE STUDY 1: ACNE VULGARIS

References

Dover, J. S., & Batra, P. (2017). Light-based, adjunctive, and other therapies for acne vulgaris.

Retrieved from

Graber, E. (2017). Treatment of acne vulgaris. Up to Date.

Hamilton, R. J. (2018). Tarascon Pocket Pharmacopoeia (19th ed.). Burlington, MA: Jones &

Bartlett Learning.

Hammer, G. D., & Mcphee, S. J. (2014). Pathophysiology of disease: An introduction to clinical

medicine (7th ed.).: McGraw-Hill Education.

Keri, J. E. (2017). Acne vulgaris. Retrieved from www.merckmanuals.com

Rathi, S. K. (2011). Acne vulgaris treatment: The current scenario. Indian Journal of

Dermatology, . http://dx.doi.org/10.4103/0019-5154.77543

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse

prescribers (4th ed.). Philadelphia, PA: F.A. Davis Company.