TREATMENT

General Principles of Treatment

• Obtain a complete historical record of prior therapies, including all over-the-counter products

• Most common and important cause of failure of treatment is lack of compliance

• Topical application to the entire affected area rather than to specific lesions should be emphasized

• Oral and topical medications should be used daily as the treatment is preventive in nature

General Principles of Treatment

• Avoidance of specific foods is not necessary

• Scrubbing of the face will not only increase irritation but may worsen acne due to friction

• Non-comedogenic cosmetics are recommended and pressed powders and oil-based products should be avoided

• Preventive• Long term usage is the rule

A. Topical RetinoidsB. Benzoyl PeroxideC. Topical AntibacterialsD. Sulfur, Sodium Sulfacetamide, Resorcin, and

Salicylic AcidE. Azeleic Acid

Topical Retinoids

• Effective in promoting normal desquamation of the follicular epithelium

• Have marked anti-inflammatory effect

• Help in penetration of other active agents

• Preferred agents in maintenance therapy

• Use of moisturizers may lessen their irritancy

Application: Pregnancy Category:

Tretinoin - 0.025% and 0.05% in cream base- May take 8-12 weeks before improvement occurs

Should be applied at night C

Adapalene Well tolerated retinoid like compound

either in the morning or evening C

Tazarotene Strong in action, relatively irritating

once at night or every other night X

Benzoyl Peroxide

• Has a potent antibacterial effect; P. acne resistance doesn’t develop during use

• Concomitant use during antibiotic treatment will limit the development of resistance

• Wash formulations may be utilized for mild trunkal acne

• Usually used once or twice a day• May irritate skin and produce peeling• Pregnancy Category: C

Topical Antibacterials

• Clindamycin & Erythromycin

• Well tolerated; effective in mild-to-moderate inflammatory acne

• Pregnancy category: B

• Use of topical antibiotics alone is not recommended because of increasing resistance

Sulfur, Sodium Sulfacetamide, Resorcin, Salicyclic Acid

• Useful and helpful if newer medications are not tolerated

• Sulfacetamide-sulfur combination– Mildly effective in both acne and rosacea

Azeleic Acid

• Dicarboxylic acid

• Remarkably free from adverse actions and has mild efficacy in both inflammatory and comedonal acne

• Help to lighten post inflammatory hyperpigmentation

• Pregnancy Category: B

• Indications:– Moderate to severe acne– Patients with inflammatory disease in

whom topical combinations have failed/ not tolerated

– Treatment for chest, back or shoulder acne– Patients in whom absolute control is

deemed essential

• Takes 6-8 weeks to judge efficacy

• Safest and cheapest• Given usually at an initial dose of 250-

500mg, once to four time a day; best taken on an empty stomach

• Side effects:– Vaginitis or perianal itching– Nausea– Staining of growing teeth (not used in

pregnant women and children < 9 years of age)

• Avoided if renal function is impaired

Tetracycline

Dosage Side effects

Doxycycline 50-100 mg od or bid

Photosensitivity reactions

Minocycline Most effective oral antibiotic in treating acne vulgaris; absorption is less affected by food or milk

50-100 mg od or bid

Vertigo; pigmentation; lupus-like syndromes; serum sickness; pneumonitis; hepatitis

Erythromycin

• For those who cannot take tetracycline

• Low efficacy

• Side effects: gastrointestinal upset; vaginal itching (rare)

• Initial dosage: 250-500 mg bid or qid, reduced gradually after control is achieved

Clindamycin

• Initial dose is 150 mg tid, reduced gradually as control is achieved

• Excellent response in treatment of acne but the potential for development of pseudomembranous colitis and availability of retinoids has limited its use

Other Antibiotics

• Sulfonamides• Trimethoprim-sulfamethoxazole• Trimethoprim• Dapsone

• Good candidates for hormonal therapy:– Women with PCOS, adrenal hyperplasia– Women with late onset acne, severe acne,

acne that has not responded to other oral & topical therapies or acne that has relapsed quickly after isotretinoin treatment

– Women with acne primarily on the lower face and neck, deep seated nodules that are painful and lasting

• Oral Contraceptives– Block adrenal and ovarian androgens– Orthro Tri-Cyclin, Estrostep, Alesse, Yasmin– Adverse reactions: nausea, vomiting, abnormal

menses, melasma, weight gain, breast tenderness, thrombophlebitis, pulmonary embolism, HPN

• Spironolactone– Effective dose: 25-200 mg/day– Usually prescribed in combination w/ OC– Side effects: breast tenderness, headache,

dizziness, light headedness, irregular menses, diuresis

• Dexamethasone– Doses of 0.125-0.5 mg once at night reduced

androgen excess and alleviated cystic acne

• Prednisone– Generally only given to patients with severe

inflammatory acne during first few weeks of treatment w/ isotretinoin, for initial reduction of inflammation, and to reduce isotretinoin-induced flares.

• Others:– Finasteride, flutamide, GRH agonists,

estrogen, metformin

• Indications:– For severe acne

– Poorly responsive acne that improves by < 50% after 6 mos of therapy with combined oral and topical antibiotics

– Acne that relapses off oral treatment

– Scars or acne that induces psychological distress

– Gram negative folliculitis, inflammatory rosacea, pyoderma faciale, acne fulminans, hidradenitis suppurativa

• Dose: 0.5-1 mg/kg/day in one or two doses

• Major advantage: it is the only acne therapy that is not open ended

• Adverse effects: – Risk of severe damage to the fetus when given

during pregnancy

– Psychological effects

• Other side effects:– Dry skin, lips, eyes and nasal mucosa

– Arthralgias

– hypertriglyceridemia

Summary of Acne Treatment

Mild Moderate Severe

1. Comedonal- Topical retinoid +/-

physical extraction (first line)

- Alternate retinoid, salicylic acid, azelaic acid (2nd line)

2. Papular/pustular- Topical antimicrobial

combination + topical retinoid, benzoyl peroxide wash if mild trunkal lesions (1st line)

- Alternate antimicrobials + alternate topical retinoids, azelaic acid, sodium sulfacetamide-sulfur, salacylic acid (2nd line)

Papular/Pustular-Oral antibiotic + topical retinoid + benzoyl peroxide (1st line)- Alternate antibiotic, alternate topical retinoid, alternate benzoyl peroxide (2nd line)-In women, spirinolactone + OCP + topical retinoids +/- topical antibiotic and/or benzoyl peroxide-Isotretinoin if relapses quickly off oral antibiotics, does not clear or scars

Nodular/conglobate-Isotretinoin-Oral antibiotic + topical retinoid + benzoyl peroxide-In women, spironolactone + oral birth control pill + topical retinoid, +/- topical or oral antibiotics and/or benzoyl peroxide

Treatment of comedones Comedo extractionElectrocauteryChemical peels

Treatment of inflammatory nodules Intralesional corticosteroids

Treatment of inflammatory lesions PhotodynamicBlue light1450-nm laser

Treatment of scarring Chemical peelsDermabrassionExcisionLaser resurfacingFiller substances

• Pitted scarring and wide-mouthed depression and keloids

• Maybe prominent and often results from cystic type of acne

• Prominent residual hyperpigmentation, especially in darker-skinned patients

• Pyogenic granuloma formation – more common in acne fulminans and in patients treated with high-dose isotretinoin

• Osteoma cutis – small, firm papules resulting from long-standing acne vulgaris

• Facial edema - uncommon