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                                                                      V O L U M E      8

                                                                      N U M B E R      8

                                                                      S U M M E R     2 0 0 5

  I N T E R V I E W

  Getting the Word Out about E ective Treatments: A Hurdle to
  Treating Acne
  Jasper Lovoi, PharmD
  Lovoi and Sons Pharmacy
  Beaumont, Texas
  One of the problems with treating acne is,       pares with Benzaclin (the proprietary
  quite simply, getting the word out. Market-      name for a topical preparation combin-
  ing of medications is now an important           ing clindamycin 1% and benzoyl
  aspect of health care, and compounding           peroxide 5%). Unlike the antibacterial
  pharmacists, who are typically on the cusp       Benzaclin, niacinamide induces no
  of current medical research, are still way       bacterial resistance. A double-blind
  behind in getting the word out to prescrib-      study cited in the International Journal
  ers about how effective compounded               of Dermatology concluded that
  treatments can be. In fact, many physicians      “[n]icotinamide gel provides potent
  first hear about compounding from their          anti-inflammatory activity without the
  patients who have heard from a family            risk of inducing bacterial resistance.” 1
  member or friend about the effectiveness
  of a compounded preparation.
                                                        “One of the problems with
   Niacinamide is a good example of this.             treating acne is, quite simply,
   Many doctors are unaware of niacinamide                getting the word out.”
   (also called nicotinamide) and how it com-
                                                                           Continued on reverse

  C A S E    R E P O R T

Severe Acne and Excess Facial Hair in a 35-year-old Woman
Jasper Lovoi, PharmD                               mone, one of the causes of acne. The test
Lovoi and Sons Pharmacy                            did, however, measure levels of testoster-
Beaumont, Texas                                    one and dihydroepiandosterone (DHEAS),
                                                   which both correlate with DHT level. The
In February 2004, a 35-year-old woman with         results of her saliva tests showed that her
severe acne and excessive facial hair came         testosterone level was sky high at 90
into our pharmacy. She had heard from a            pg/mL when the normal range is 20-50.
speaker at a skincare clinic that I was having
                                                   Her DHEAS level
very good results in treating acne. Having had
                                                   was 21.1 H ng/mL,
acne since her teenage years, the patient said
                                                   (normal range
she had tried “everything,” which included
                                                   3-10). Her cortisol
oral and topical antibiotics as well as Retin A.
                                                   morning score was
None of those treatments, she said, helped her
                                                   8.7 H ng/mL
acne or facial hair. She also reported symp-
                                                   (normal range, 3-8),
toms of weight gain around her waste and
                                                   and her cortisol
hips and loss of scalp hair. Although I have
                                                   night level was
recently found a lab that can measure a
                                                   within range at 1.2.
patient’s dihydrotestosterone (DHT) level
specifically, the saliva test tha t I gave this
patient did not measure the level of this hor-
   ACNE: E ective Treatments                                                                                                                            COMPOUNDED MEDICATIONS
   INTERVIEW CONTINUED                                                                                                                                  USED IN TREATING ACNE
   Since February 2004, I have been using
   niacinamide 4% topical gel to treat acne                                                                                                                Erythromycin 3% and benzoyl
   with remarkable success. Of the 15 patients                                                                                                             peroxide 10% gel: Apply daily
   who have tried my niacinamide prepara-
   tion, each has raved about it and refilled it,

   reporting no side effects.
   Before trying the niacinamide treatment,                                                                                                                Niacinamide 4% acne gel, 30 mL:
   many of my acne patients had tried                                                                                                                      Apply daily
   Benzaclin and said that it worked for a little
   while but then showed no results. Several
   of these acne patients said they did not                                                                                                                Niacinamide 4% in Vanicream:
   want to take Acutane because of side                                                    Reference:                                                      Apply daily
   effects, such as scarring. Niacinamide has                                              1. Shalita AR, Smith JG, Parish LC et al. Topical nicotin-
   made all of my clients with acne very happy,                                               amide compared with clindamycin gel in the treat-
   especially those whose acne showed                                                         ment of inflammatory acne vulgaris. Int J Dermatol
   resistance to antibiotics.                                                                 1995; 34(6): 434–437.                                        Spironolactone 5% cream, 30 g:
                                                                                                                                                           Apply twice daily
    What is Nicotinamide 4%                                                                                                        t
                                                                                               When exposed to air and light, it may
                                                                                             turn brown and, at temperatures lower
    Topical Gel?
                                                                                             than 15C, it may stratify (this can bean
    Also known as niacinamide (or nicotinic                                                                                                                Tretinoin .025% and erythro-
                                                                                             corrected by warming and mixing). It
    acid amide), nicotinamide in a g e l form                                                                           tight     tainers
                                                                                             should be stored in airtight containers
                                                                                                                                                           mycin 4% gel: Apply daily
    has been reported to provide potent                                                      protected from light, in a cool place.
    anti-inflammatory activity in acne
    without inducing bacterial resistance. In
    one study, 76 patients with moderately                                                    References:
    severe inflammatory acne vulgaris were
                                                                                              1. Allen LV Jr. Formulation: Nicotinamide
                                                                                                              Formula                                   What Is Acne?
    divided into two groups; 38 received 4%
    nicotinamide gel and the other 38                                                                                 1998;
                                                                                                 4% Topical Gel. IJPC 1998 2(4): 302.                   According to the American Academy of
    received 1% clindamycin twice daily.                                                                                Pa
                                                                                              2. Shalita AR, Smith JG, Parish, LC et al.                Dermatology, “acne” is the term for
    After 8 weeks, both treatments produced                                                                              com
                                                                                                 Topical Nicotinamide compared with                     plugged pores (blackheads and white-
    beneficial results, as follows: 82% of the                                                   cli         n             t
                                                                                                 clindamycin gel in the treatment of                    heads), pimples, and even deeper lumps
    patients treated with nicotinamide gel     l                                                                                        -
                                                                                                 inflammatory acne vulgaris. Int J Derma-               (cysts or nodules) that occur on the face,
    and 68% treated with clindamycin had n                                                                      34–437.
                                                                                                 tol 1995; 34: 434–437.                                                    ,
                                                                                                                                                        neck, chest, bac k shoulders, and even
    improvement in their acne. The authorsthors                                                                                                         the upper arms. Acne a ects most
                                                                                              3. McEvoy GK. AHFS Drug Information-98.
    concluded that 4% nicotinamide gel is                                                                                                               teenagers to some extent, but is not
                                                                                                 Bethesda, MD: American Society of
    comparable to 1% clindamycin gel in                                                          Health-System Pharmacists; 1998: 3002-
                                                                                                                                                        restricted to that age group; adults in
    efficacy and that nicotinamide gel had                                                       -3003.                                                 their 20s--even their 40s--can get acne.
    the advantage of not inducing bacterial                                                                                                             While not a life-threatening condition,
                                                                                              4. Goskonda SR, Lee JC. Triethanolamine. In
    resistance. Nicotinamide is a water                                                                                                                 acne can be upsetting and dis guring.
                                                                                                 Kibbe AH, ed. Handbook of Pharmaceuti- -
    soluble, B-complex vitamin that occurs as                                                                                                           When severe, acne can lead to serious
                                                                                                 cal Excipients, 3rd ed. Washington, DC:
    a white, odorless or practically odorless, ,                                                 American Pharmaceutical Association
                                                                                                                                                        and permanent scarring. Even less
    crystalline powder. It has a bitter taste                                                    2000: 572–57
                                                                                                       572–573.                                         severe acne can lead to scarring.
    and is freely soluble in water and alcohol.                                                                                                         References:
                                                                                                                                                        1. American Academy of Dermatology.
    Regulatory Update                                                Over-the-Counter Medications: DID YOU KNOW?
                                                                                                                                                           AcneNet. Available at: www.derminfo
   Pharmacists can compound over-the-counter (OTC) products for in-store sales as long                                                                     March 4, 2005.
   as their state boards allow such practices. Since the state boards have primary
                                       ctices.                             prim
                                      d                     pharmacis
   jurisdiction over compounding and state laws do vary, pharmacists should make
   sure that OTC compounding is allowed in their state. If so, pharmacists can com-
                                     owed                                                                                                               Allen LV Jr. Estriol solution for iontophoresis
   pound nonprescription drugs as OTC products.                                                                                                         for acne scars. IJPC 1997; 1(6): 411.
                                                                                                                                                        Allen LV Jr. Formulation: Niacinamide 4% acne
CASE REPORT CONTINUED                                                                                                                                   gel. IJPC 2001; 5(1): 49.
We recommended that her doctor                                                                                                                           Chu CY. The use of 1% pimecrolimus cream
prescribe niacinamide 4% gel to be                                                                                                                       for the treatment of steroid-induced rosacea.
applied to her affected skin twice daily. We                                                                                                             Br J Dermatol 2005; 152(2): 396–399.
recommended that he prescribe spirono-
lactone 5% cream and spironolactone 25                                                                                                                   Dreno B, Nocera T, Verriere F et al. Topical
mg orally once daily to help slow down                                                                                                                   retinaldehyde with glycolic acid: Study of
hair growth on her face. When the woman                                                                                                                  tolerance and acceptability in association
                                                                                                                                                         with anti-acne treatments in 1,709 patients.
returned to us 2 months later, her acne
                                                                                                                                                         Dermatology 2005; 210(Suppl 1): 22–29.
was almost completely gone. She was
flabbergasted that finally she had found                                                                                                                Shalita AR, Berson DS, Thiboutot DM et al, and
an acne treatment that worked. She had                                                                                                                  the Acne Clinical Study Investigator Group.
undergone facial laser treatment during                                                                                                                 Effects of tazarotene 0.1% cream in the
that time, and her facial hair had dimin-                                                                                                               treatment of facial acne vulgaris: Pooled
ished substantially. Although spironolac-                                                                                                               results from two multicenter, double-blind,
tone binds immediately to the receptors,                                                                                                                randomized, vehicle-controlled, parallel-group
the slowing of facial hair growth takes                                                                                                                 trials. Clin Ther 2004; 26(11): 1865–1873.
some time and therefore would not be
observable after 2 months. Spironolac-                                                                                                                   Shalita AR, Myers JA, Krochmal L et al. The
tone does not lower testosterone levels                                                                                                                  safety and efficacy of clindamycin phosphate
but stops testosterone from binding to
                                                                                          Suggested Reading:                                             foam 1% versus clindamycin phosphate
                                                                                                                                                         topical gel 1% for the treatment of acne
the receptors that lead to hair loss on the                                                                Spieg             by
                                                                                          Adebamowo CA, Spiegelman D, Danby FW et                        vulgaris. J Drugs Dermatol 2005; 4(1): 48–56.
scalp and rapid hair growth on the face.                                                                     d              take
                                                                                          al. High school dietary diary intake and
Spironolactone for excess facial hair                                                     teenage acne. J Am Acad Dermatol 2005; 52(2):
                                                                                                      .                                                  [No author listed]. Treatment for severe acne
should not be recommended unless                                                          207–214.                                                       vulgaris. IJPC RxTriad 2002; 5(1):1.
hormone levels are accurately tested.
RxTriad - A publication of the International Journal of Pharmaceutical Compounding. © 2005 IJPC. All rights reserved.

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