Episode 90 - Vaccines and Acne - a podcast by Rio Bravo Family Medicine Residency Program

Episode 90: Vaccines and Acne. 

Updates on pneumococcal and COVID-19 vaccines. Sarah explains the treatment of acne.

New Pneumococcal Vaccine Recommendations. 
Written by Harkiran Bhattal, MS4, Ross University School of Medicine; Timiiye Yomi, MD; and Hector Arreaza, MD.

During the recording, we used brand names because they are easier to use. We are not sponsored by the manufacturers of these vaccines. 

Terminology of pneumococcal vaccines: 

PCV13: Prevnar13®

PPSV23: Pneumovax23®

PCV15: Vaxneuvance® 

PCV20: Prevnar20®

Tips about pneumococcal vaccines:

-Prevnar13 is no longer used in adults. 

-Pneumovax23 is still being used in adults.

-The two newer members of the pneumococcal vaccines are: Prevnar20® (PCV20) and Vaxneuvance® (PCV15).

 

The following groups of patients are all adults 19-64 with underlying conditions OR >65 years old.

 

Group A: Unknown or no prior doses of Prevnar13 or Pneumovax 23

Option 1: Prevnar20 given as a single dose

Option 2: Vaxneuvance followed by a dose of Pneumovax23 at least a year later (Consider >8 weeks in patients >19 at the highest risk)

Group B: Previously received Pneumovax 23

Give Prevnar20 or Vaxneuvance (at least 1 year since the last Pneumovax 23)

Group C: Previously Received Prevnar13

Give Pneumovax23 or Prevnar20 (if Pneumovax 23 is not available) >1 year since last dose of Prevnar13

Group D: Previously completed series of Prevnar13 and Pneumovax23 in any order

No additional doses are needed.

 

Scenario 1: 68 yo M who has not previously received PCV or whose previous vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by a dose of Pneumovax23.

 

Scenario 2: 25 yo F with HIV not previously received PCV or whose vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by

a dose of Pneumovax 23 given 8 weeks later. This patient is in the highest risk group.

 

Scenario 3: 50 yo M with chronic alcoholism who has not received any vaccine or unknown status (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by Pneumovax 23 one year later.

 

Scenario 4: 43 yo M with previous Pneumovax 23 only (Group B). This patient should receive either: a single dose of Prevnar20 or Vaxneuvance and be done with either vaccine. Give either vaccine at least 1 year after Pneumovax 23.

 

Scenario 5: 25 yo F with CSF leak and previously received Prevnar13 (Group C). This patient should 

receive Pneumovax23 or Prevnar 20 (if Pneumovax 23 is unavailable) at least one year after her las Pneumovax dose.

 

Scenario 6: 35 yo M who previously completed Prevnar13 and Pneumovax in any order because he has a cochlear implant (Group D). This patient should NOT receive any additional dose.

 

Research and Monitoring

CDC and ACIP will continue to assess the safety of Vaxneuvance and Prevnar20 vaccines (the new kids on the block), monitor the impact of the implementation of new recommendations, and assess post-implementation effectiveness and recommendations as appropriate.

 

Examples of risk factors to consider administration of pneumococcal vaccines: Chronic renal failure, HIV infection, alcoholism, cigarette smoking, chronic heart, liver, and lung disease. For a complete list of conditions, visit CDC.gov.

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A second booster shot of COVID-19 vaccines. 
By Hector Arreaza, MD.

On March 29 and 30, 2022, CDC announced that a second booster dose of any mRNA COVID-19 vaccine may be given to certain individuals who are at risk of severe outcomes from COVID-19(1). 

Individuals who may choose to receive a second booster are: 

1. People older than 12 years of age who have a moderate to severe immunocompromising condition. Remember, use Pfizer for older than 12 yo, and Moderna for older than 18 yo.

2. People older than 50 years of age who are NOT moderately or severely immunocompromised.

3. People 18-49 years of age who are NOT immunocompromised but received the J&J COVID-19 vaccine as both the primary and booster dose. 

When can you receive the second booster shot? At least 4 months after the first booster dose.

Who is considered up to date? A person is considered up to date when he/she has received all recommended doses in their primary vaccine series, and a booster dose when eligible. A second booster dose is not required to be considered up to date at this time.

Underlying medical conditions associated with higher risk for severe COVID-19 include: Cancer, obesity, cerebrovascular disease, diabetes mellitus, HIV, obesity, COPD, smokers, and chronic liver disease.

Comment: Remember to give the second booster to your patients. 

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Acne Treatment.  
By Sarah Park, MS3, University of California Los Angeles. Discussed with Hector Arreaza, MD.  

Definition: Acne vulgaris is a common inflammatory disorder of the pilosebaceous unit, which includes the hair follicle and sebaceous gland. It is characterized by chronic or recurrent development of papules, pustules, or nodules commonly on the face, chest, or upper back.(1,2) Acne affects nearly 50 million people in the U.S. per year and can cause significant psychological distress in those who are affected. It primarily begins at puberty when the production of androgens and/or sensitivity of androgen receptors increase, thereby commonly affecting adolescents and young adults.(2) 

Pathophysiology: The pathophysiology of acne involves four main processes: 1) sebum overproduction, 2) hyperkeratinization of the follicle, 3) bacterial colonization by Cutibacterium acnes, and 4) inflammation.(2,3) It can be classified as mild, moderate, or severe based on the extent and types of lesions.3

Treatment: Treatment is selected based on the severity of the condition, patient preference, and tolerability. Acne treatment often requires long-term, consistent use of one or more medications.(3) The main objective of treatment is to decrease sebum production, get rid of extra keratin, treat infection and decrease inflammation. You can warn your patients that their skin may feel dryer and more scaly than usual, but that’s part of the treatment. 

For mild and exclusively comedonal acne, topical retinoids like tretinoin are the treatment of choice(4), but topical retinoids can be used in any level of severity for maintenance. Examples: Adapelene, tazarotene, and tretinoin, 

For mild inflammatory papulopustular acne or mild mixed comedonal and papulopustular acne, topical retinoids may be used in combination with antimicrobial therapy (either combined with benzoyl peroxide or combined with benzoyl peroxide plus clindamycin or erythromycin). If patients cannot tolerate a topical retinoid, alternatives include salicylic acid and azelaic acid. Of note, oral or topical antibiotics should only be used in combination with benzoyl peroxide and retinoids for a maximum of 12 weeks. 

If unresponsive to these topical therapies, namely retinoids, benzoyl peroxide, and/or clindamycin, alternative therapies may be initiated. These include topical dapsone, minocycline, and clascosterone.

Topical dapsone is an effective treatment for both inflammatory papulopustular and comedonal acne lesions. 

Topical minocycline is an alternative topical antibiotic used for specifically moderate to severe acne. 

And last but not least is topical clascosterone, a relatively new topical (specifically an androgen receptor inhibitor) approved by the FDA in 2020.(4)

Treatment for moderate to severe acne: For moderate to severe acne vulgaris, management is systemic therapy. This includes oral antibiotics or hormonal therapies, often used in conjunction with topical therapy, or monotherapy with oral isotretinoin. 

1. Oral antibiotics for acne vulgaris include doxycycline, minocycline, and sarecycline. Treatment should be limited to three to four months.(5)

2. For female patients, hormonal therapy with oral contraceptives and/or spironolactone is also an option. A meta-analysis comparing oral contraceptive therapy and oral antibiotic therapy suggests similar efficacy for the treatment of acne. OCP treatment is often the first-line choice for hormonal therapy, especially for patients who desire the added benefit of contraception. Spironolactone is often used for patients who have contraindications to OCP therapy or prefer to avoid OCPs. Both methods work to inhibit acne by reducing the effects of androgen on the pilosebaceous unit.5

3. For severe, extensive, nodular acne vulgaris, oral isotretinoin is the drug of choice. It is given as a monotherapy and is often used when all other treatment modalities fail.  Oral isotretinoin is the only medication that can permanently affect the natural course of acne by affecting all four factors in acne pathogenesis. Isotretinoin is most notably known for its teratogenic adverse effects and so is contraindicated in pregnant women and pregnancy must be avoided during therapy by using two forms of birth control.(5)

Comment about isotretinoin use: Although prescribing isotretinoin (brand name Accutane®) is within the scope of family medicine, many providers choose not to prescribe it because of lack of training, monitoring hassles, fear of side effects, especially due to concerns with teratogenicity. Isotretinoin is an effective treatment for a condition that can not only disfigure and scar the face but can also cause significant psychosocial dysfunction. Dr. Van Durme recommended when you prescribe isotretinoin, you should have a regular schedule of monthly laboratory tests (including pregnancy test), then office visit, and then prescription, in that order. This schedule will improve the likelihood that side effects are managed promptly and medication is taken appropriately(7). If you would like more information about prescribing isotretinoin, visit https://ipledgeprogram.com.

Conclusion: Use topical retinoids alone for mild cases of acne; topical retinoids combined with benzoyl peroxide or topical clindamycin or erythromycin for moderate cases; and topical retinoids combined with benzoyl peroxide and oral antibiotics in severe cases. Remember that isotretinoin is an oral treatment reserved for severe inflammatory papules and pustules with nodules. Treating acne effectively can certainly improve the quality of life of your patients. 

Now we conclude Episode 90 “Vaccines and Acne”. We gave you an update on pneumococcal and COVID-19 vaccines. Prevnar 20 seems to be the new star in the show. PCV15 is also useful but it needs to be followed by a shot of Pneumovax 23. Regarding COVID-19 vaccines, a second shot may be given to patients older than 12 who are immunocompromised or patients older than 50 who are NOT immunocompromised. Then we finished with a discussion about acne and we learned that topical is usually enough for mild cases, but oral therapy may be needed in moderate to severe cases of acne. Even without trying, every night you go to bed being a little wiser.

 

Thanks for listening to Rio Bravo qWeek. Send us your feedback by email to RioBravoqWeek@clinicasierravista.org, or in our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Timiiye Yomi, Amardeep Chetha and Sarah Park. Audio edition: Suraj Amrutia. See you next week! 

 

References:

Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109–117. DOI: http://dx.doi.org/10.15585/mmwr.mm7104a1

 

2. Pneumococcal Vaccination Timing for Adults, CDC. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, accessed on March 30, 2022.

 

Interim Clinical Considerations for Use of COVID-19 Vaccines, Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html#considerations-covid19-vax-booster, accessed April 5, 2022. 

 

Thiboutot, Diane, MD; and Andrea L Zaenglein, MD. Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-acne-vulgaris

 

Leung AK, Barankin B, Lam JM, Leong KF, Hon KL. Dermatology: how to manage acne vulgaris. Drugs Context. 2021 Oct 11;10:2021-8-6. doi: 10.7573/dic.2021-8-6. PMID: 34691199; PMCID: PMC8510514.

 

Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019 Oct 15;100(8):475-484. PMID: 31613567.

 

Graber, Emmy, MD, MBA. Acne vulgaris: Overview of management, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-overview-of-management

 

Harris C. Clascoterone (Winlevi) for the Treatment of Acne. Am Fam Physician. 2021 Jul 1;104(1):93-94. PMID: 34264597.

 

Acne vulgaris: Management of moderate to severe acne, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-management-of-moderate-to-severe-acne

 

Van Durme DJ. Family physicians and accutane. Am Fam Physician. 2000 Oct 15;62(8):1772, 1774, 1777. PMID: 11057835. https://www.aafp.org/afp/2000/1015/p1772.html

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