Acne vulgaris treatment

Acne vulgaris treatment

INTRODUCTION

Although acne is not physically disabling, its psychological impact can be striking, contributing to low self-esteem, depression, and anxiety . As a result, there is a significant demand for effective acne therapies (table 1). The lack of standardization for grading acne severity and measuring treatment outcomes has made systematic interpretation of the literature difficult . However, quality evidence-based literature in the field of acne is increasing .Medical therapies for acne and therapeutic principles that support the selection of treatments will be discussed here. A table summarizing treatment recommendations for patients with acne vulgaris is provided (algorithm 1). Procedural therapies for acne, oral isotretinoin therapy for severe acne, hormonal therapy for women with acne, and interventions for acne scars are reviewed in detail separately. (See "Light-based, adjunctive, and other therapies for acne vulgaris" and "Oral isotretinoin therapy for acne vulgaris" and "Hormonal therapy for women with acne vulgaris" and "Management of acne scars".)PRETREATMENT ASSESSMENTDeciding on the appropriate course of treatment for acne requires a comprehensive assessment that includes:●Clinical type and severity of acne (eg, comedonal, papulopustular, mixed, nodular)
Medical therapies for acne and therapeutic principles that support the selection of treatments will be discussed here. A table summarizing treatment recommendations for patients with acne vulgaris is provided (algorithm 1). Procedural therapies for acne, oral isotretinoin therapy for severe acne, hormonal therapy for women with acne, and interventions for acne scars are reviewed in detail separately. (See "Light-based, adjunctive, and other therapies for acne vulgaris" and "Oral isotretinoin therapy for acne vulgaris" and "Hormonal therapy for women with acne vulgaris" and "Management of acne scars".)
Acne Treatment Services in Chennai
Systemic TherapySystemic antibiotics 0Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. The following agents should not be used in acne due to lack of efficacy and safety consideration such as cephalosporins, sulphonamide, and gyrase inhibitors.Tetracycline (500 mg–1 g/day), doxycycline (50–200 mg/day), minocycline (50–200 mg/day), lymecycline (150–300 mg/day), erythromycin (500 mg–1 g/day), co-trimoxazole, trimethoprim, and recently azithromycin (500 mg thrice weekly) are being used successfully in acne. Minocycline and doxycycline are more effective than tetracycline and erythromycin. Recently, doxycycline in subantimicrobial dose (20 mg twice daily) and an extended-release minocycline tablet (1 mg/kg/day) were used and found to be effective, but further controlled trials are needed.Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.Long-term therapy with oral antibiotic not only threat to resistant of P. acne, but also to coagulase negative staphylococci on the skin, Staphylococcus aureus in the nares, and streptococci in the oral cavity. There is a significant association between antibiotic used in acne and the incidence of upper respiratory tract infection.Optimizing antibiotic therapy: Research has demonstrated that problem of antibiotic-resistant P. acne is increasing, and it is most common with erythromycin. Therefore there is need to consider for antibiotic prescribing policies and to advocate the use of nonantibiotic preparations wherever possible. Antibiotic monotherapy is to be avoided and it can be combined with topical retinoid or benzoyl peroxide as per need.Wherever possible the duration of therapy should be limited. The usual minimum duration of therapy is 6–8 weeks but can be given up to 12–18 weeks and more.It is advisable to use the same antibiotic if retreatment is necessary and use benzoyl peroxide for a minimum of 5–7 days between antibiotic courses to reduce resistant organism.Concomitant use of oral and topical therapy with chemically dissimilar antibiotics is to be avoided. Hormonal therapy It may be needed in female patients with severe seborrhoea, clinically apparent androgenetic alopecia, seborrhoea/acne/hirsuitism/alopecia (SAHA) syndrome, late-onset acne (acne tarda), and with proven ovarian or adrenal hyperandrogenism.The main approach of hormonal therapy in acne is to prevent the effects of androgens on the sebaceous gland and probably follicular keratinocytes as well. It is wiser to take consultation with gynecologist before starting therapy.a) Oral contraceptivesEstrogen is commonly combined with progestin to avoid the risk of endometrial cancer. Anti-acne effect of oral contraceptive governed by decreasing level of circulatory androgens through inhibition of luteinizing hormones (LH) and follicle stimulating hormone (FSH). The currently FDA approved agents include norgestimate with ethinyl estradiol, and norethindrone acetate with ethinyl estradiol.b) SpironolactoneThey functions primarily as a steroidal androgen receptor blocker. It may cause hyperkalemia (when higher doses are prescribed or when there is cardiac or renal compromise), menstrual irregularities.c) Cyproterone acetateIt is the first androgen receptor blocking agent to be well studied and found to effective in acne in females. Higher doses have been found to be more effective than lower dose. It is also combined (2 mg) with ethinyl estradiol (35 or 50 μg) as an oral contraceptive formulation to treat acne.d) FlutamideIt is useful in acne when given in females with hirsuitism.Oral isotretinoin Oral retinoid is indicated in severe, moderate-to-severe acne or lesser degree of acne producing physical or psychological scarring, unresponsive to adequate conventional therapy. It is the only drug that affects all four pathogenic factors implicated in the etiology of acne.Although there are many studies, but very large evidence-based study is lacking to confirm the dosing schedule. The approved dose is 0.5–2 mg/kg/day, which is usually given for 20 weeks. Alternatively, lower dose can be used for longer period, with a total cumulative dose of 120 mg/kg. New developments and future trends are low-dose long-term isotretinoin regimens and new isotretinoin formulations (micronized isotretinoin).Side effects include those of musculoskeletal, mucocutaneous, and ophthalmic systems, as well as headache, and central nervous system effects. Most of the side effects are temporary and resolves after the drug is discontinued. Oral isotretinoin is a potent teratogen. Therefore women of child-bearing age require negative pregnancy test before treatment, strict contraceptive measures essential before, during and even 6 weeks posttherapy. Due to this, in United States, a new risk management programme (iPLEDGE) has been developed where all the patients receiving this drug have to register.
Put Your Best Face Forward: Treatment of Acne Vulgaris


Conclusion
Various topical and systemic drugs are available to treat acne, which may sometimes confuse the treating dermatologist. To overcome this situation a panel of physicians and researchers worked together as a “Global Alliance” and “Task Force” to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne, mostly evidence-based and inputs from various countries. Similar alliance has also been formed in India recently with their recommendations.Topical retinoid It should be primary treatment for most forms of acne vulgaris.To be applied to entire affected area.Antimicrobial to be added for inflammatory lesions.Essential part of maintenance therapy. Combination therapy It works better and clearing of lesion is faster.Stop antibiotic if inflammatory lesion subsides.If withdrawal is not possible, switch to benzoyl peroxide plus an antibiotic.Topical retinoid can be continued to prevent remission. Antibiotics Oral and topical antibiotics not to be used as monotherapy to prevent bacterial resistance.Helpful in moderate-to-severe acne.Generally oral antibiotics are well tolerated, sometimes associated with severe adverse events.Always use the same antibiotic if it was effective previously.Doxycycline and minocyclines are more effective than tetracycline.Do not use chemically dissimilar oral and topical antibiotic together. Hormonal therapy It is an excellent choice in women requiring oral contraceptive (estrogen containing) for other reason and having moderate-to-severe acne with SAHA symptoms. Oral antiandrogen like spironolactone and cyproterone acetate can be useful in the treatment of acne.Oral isotretinoin It is approved in severe recalcitrant nodulocystic acne. It can also be used in moderate-to-severe acne vulgaris resistant to conventional therapy, frequently relapsing, with severe psychological and physical scarring due to acne. Pre-treatment counselling, patient selection, and monitoring are critical due to its side effects like teratogenicity, and adverse psychiatric events.
Put Your Best Face Forward: Treatment of Acne Vulgaris
Physical TreatmentA. Lesion removal a) ComedonesBoth open and closed comedones can be removed mechanically with comedone extractor and a fine needle or a pointed blade. Preprocedure topical retinoid application makes the procedure easier. Gentle cautery and laser puncture of macrocomedones are also useful procedure. The limitations of comedo extraction include incomplete extraction, refilling, and the risk of tissue damage.b) Active deep inflammatory lesionsAspiration of deep inflamed lesion may be needed in few cases which are followed by IL steroid injection in cysts and sinus tract.B. Phototherapy a) Visible lightThey are indicated for mild-to-moderate inflammatory acne. In vitro and in vivo exposure of acne bacteria to 405–420 nm of ultraviolet free blue light results in the photo-destruction through the effect on the porphyrin produced naturally by P. acne. Use of limited spectrum wavelength, such as blue light (peak at 415 nm), and mixed blue and red light (peak at 415 and 660 nm) have been found to be effective in reducing acne lesions after 4–12 weeks.b) Photodynamic therapy(with addition of δ-aminolevulinic acid) and pulsed dye laser (585 nm) were also effective in acne, but further trials are needed to confirm the same.Physical treatment of scars Acne scar can be broadly divided into two groups, those involving tissue losses (Ice pick scar, Box scar, Rolling scar, and Follicular macular atrophy) and those involving tissue excess (hypertrophic scars or keloids). Currently available treatment for scars include simple excision, and suturing, either alone or combined with punch grafting and laser resurfacing, dermabrasion, various type of lasers, chemical peels, and fillers. For hypertrophic scars, treatment includes pressure therapy, IL corticosteroid, 5-fluorouracil and bleomycin injections, surgical excision, radiotherapy, laser therapy and cryotherapy.All the procedures have their own merits and demerits; to be chosen carefully seeing the merit.Acne and diet Dietary restriction has not been demonstrated to be benefit in the treatment of acne. The myth that diet affects acne is widespread, but previous studies are not supporting it. Of late, various authors again claiming that there is the definite role of diet in acne but to conclude that further controlled trials are needed. It has been shown that the prevalence of acne is lower in rural, nonindustrialized societies than in modernized western populations may be due to lower glycemic index diet, claims one trial. Although not currently recognized within our dermatology standard of care, but due to “consistent and good quality patient oriented evidence”, dietary management of acne appears to be accumulating.The benefit of dietary management in the treatment of acne has been neither demonstrated nor disproved.

Acne Vulgaris Treatment | Acne Xplained

Topical retinoid It should be primary treatment for most forms of acne vulgaris.To be applied to entire affected area.Antimicrobial to be added for inflammatory lesions.Essential part of maintenance therapy. Combination therapy It works better and clearing of lesion is faster.Stop antibiotic if inflammatory lesion subsides.If withdrawal is not possible, switch to benzoyl peroxide plus an antibiotic.Topical retinoid can be continued to prevent remission. Antibiotics Oral and topical antibiotics not to be used as monotherapy to prevent bacterial resistance.Helpful in moderate-to-severe acne.Generally oral antibiotics are well tolerated, sometimes associated with severe adverse events.Always use the same antibiotic if it was effective previously.Doxycycline and minocyclines are more effective than tetracycline.Do not use chemically dissimilar oral and topical antibiotic together. Hormonal therapy It is an excellent choice in women requiring oral contraceptive (estrogen containing) for other reason and having moderate-to-severe acne with SAHA symptoms. Oral antiandrogen like spironolactone and cyproterone acetate can be useful in the treatment of acne.Oral isotretinoin It is approved in severe recalcitrant nodulocystic acne. It can also be used in moderate-to-severe acne vulgaris resistant to conventional therapy, frequently relapsing, with severe psychological and physical scarring due to acne. Pre-treatment counselling, patient selection, and monitoring are critical due to its side effects like teratogenicity, and adverse psychiatric events.
AbstractAcne Vulgaris is one of the most common skin disorders which dermatologists have to treat. It mainly affect adolescent, though may present at any age. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities and various permutation and combinations have been designed. In topical agents; benzoyl peroxide, antibiotics, retinoids, etc are the mainstay of treatment; can be given in combinations. While systemic therapy includes oral antibiotics, hormonal therapy, and isotretinoin, depending upon the need of patients it has to be selected. Physical treatment in the form of lesion removal, photo-therapy is also helpful in few of them. Since various old and new topical and systemic agents are available to treat acne, it sometime confuse treating dermatologist. To overcome this, panel of physicians and researchers worked together as a global alliance and task force to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs.Keywords: Acne, treatment, consensus recommendation
Acne Vulgaris is one of the most common skin disorders which dermatologists have to treat. It mainly affect adolescent, though may present at any age. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities and various permutation and combinations have been designed. In topical agents; benzoyl peroxide, antibiotics, retinoids, etc are the mainstay of treatment; can be given in combinations. While systemic therapy includes oral antibiotics, hormonal therapy, and isotretinoin, depending upon the need of patients it has to be selected. Physical treatment in the form of lesion removal, photo-therapy is also helpful in few of them. Since various old and new topical and systemic agents are available to treat acne, it sometime confuse treating dermatologist. To overcome this, panel of physicians and researchers worked together as a global alliance and task force to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs.
Systemic antibiotics 0Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. The following agents should not be used in acne due to lack of efficacy and safety consideration such as cephalosporins, sulphonamide, and gyrase inhibitors.Tetracycline (500 mg–1 g/day), doxycycline (50–200 mg/day), minocycline (50–200 mg/day), lymecycline (150–300 mg/day), erythromycin (500 mg–1 g/day), co-trimoxazole, trimethoprim, and recently azithromycin (500 mg thrice weekly) are being used successfully in acne. Minocycline and doxycycline are more effective than tetracycline and erythromycin. Recently, doxycycline in subantimicrobial dose (20 mg twice daily) and an extended-release minocycline tablet (1 mg/kg/day) were used and found to be effective, but further controlled trials are needed.Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.Long-term therapy with oral antibiotic not only threat to resistant of P. acne, but also to coagulase negative staphylococci on the skin, Staphylococcus aureus in the nares, and streptococci in the oral cavity. There is a significant association between antibiotic used in acne and the incidence of upper respiratory tract infection.Optimizing antibiotic therapy: Research has demonstrated that problem of antibiotic-resistant P. acne is increasing, and it is most common with erythromycin. Therefore there is need to consider for antibiotic prescribing policies and to advocate the use of nonantibiotic preparations wherever possible. Antibiotic monotherapy is to be avoided and it can be combined with topical retinoid or benzoyl peroxide as per need.Wherever possible the duration of therapy should be limited. The usual minimum duration of therapy is 6–8 weeks but can be given up to 12–18 weeks and more.It is advisable to use the same antibiotic if retreatment is necessary and use benzoyl peroxide for a minimum of 5–7 days between antibiotic courses to reduce resistant organism.Concomitant use of oral and topical therapy with chemically dissimilar antibiotics is to be avoided. Hormonal therapy It may be needed in female patients with severe seborrhoea, clinically apparent androgenetic alopecia, seborrhoea/acne/hirsuitism/alopecia (SAHA) syndrome, late-onset acne (acne tarda), and with proven ovarian or adrenal hyperandrogenism.The main approach of hormonal therapy in acne is to prevent the effects of androgens on the sebaceous gland and probably follicular keratinocytes as well. It is wiser to take consultation with gynecologist before starting therapy.
Physical treatment of scars Acne scar can be broadly divided into two groups, those involving tissue losses (Ice pick scar, Box scar, Rolling scar, and Follicular macular atrophy) and those involving tissue excess (hypertrophic scars or keloids). Currently available treatment for scars include simple excision, and suturing, either alone or combined with punch grafting and laser resurfacing, dermabrasion, various type of lasers, chemical peels, and fillers. For hypertrophic scars, treatment includes pressure therapy, IL corticosteroid, 5-fluorouracil and bleomycin injections, surgical excision, radiotherapy, laser therapy and cryotherapy.All the procedures have their own merits and demerits; to be chosen carefully seeing the merit.Acne and diet Dietary restriction has not been demonstrated to be benefit in the treatment of acne. The myth that diet affects acne is widespread, but previous studies are not supporting it. Of late, various authors again claiming that there is the definite role of diet in acne but to conclude that further controlled trials are needed. It has been shown that the prevalence of acne is lower in rural, nonindustrialized societies than in modernized western populations may be due to lower glycemic index diet, claims one trial. Although not currently recognized within our dermatology standard of care, but due to “consistent and good quality patient oriented evidence”, dietary management of acne appears to be accumulating.The benefit of dietary management in the treatment of acne has been neither demonstrated nor disproved.
The social and economic costs of treating acne vulgaris are substantial. In the United States, acne vulgaris is responsible for more than 5 million doctor visits and costs over $2.5 billion each year in direct costs. Similarly, acne vulgaris is responsible for 3.5 million doctor visits each year in the United Kingdom.
Acne and diet Dietary restriction has not been demonstrated to be benefit in the treatment of acne. The myth that diet affects acne is widespread, but previous studies are not supporting it. Of late, various authors again claiming that there is the definite role of diet in acne but to conclude that further controlled trials are needed. It has been shown that the prevalence of acne is lower in rural, nonindustrialized societies than in modernized western populations may be due to lower glycemic index diet, claims one trial. Although not currently recognized within our dermatology standard of care, but due to “consistent and good quality patient oriented evidence”, dietary management of acne appears to be accumulating.The benefit of dietary management in the treatment of acne has been neither demonstrated nor disproved.
Cigarette smoking is known to increase the risk of developing acne. Additionally, acne severity worsens as the number of cigarettes a person smokes increases. The relationship between diet and acne is unclear as there is no high-quality evidence. However, a high glycemic load diet is associated with worsening acne. There is weak evidence of a positive association between the consumption of milk and a greater rate and severity of acne. Other associations such as chocolate and salt are not supported by the evidence. Chocolate does contain a varying amount of sugar that can lead to a high glycemic load and it can be made with or without milk. There may be a relationship between acne and insulin metabolism and one trial found a relationship between acne and obesity. Vitamin B12 may trigger acneiform eruptions, or exacerbate existing acne, when taken in doses exceeding the recommended daily intake.
In women, acne can be improved with the use of any combined oral contraceptive. The combinations that contain third or fourth generation progestins such as desogestrel, norgestimate, or drospirenone may theoretically be more beneficial. Antiandrogens such as cyproterone acetate and spironolactone have also been used successfully to treat acne. The aldosterone antagonist spironolactone is an effective treatment for acne in adult women, but unlike combination oral contraceptives, is not approved by the United States' Food and Drug Administration for this purpose. Spironolactone is thought to be a useful acne treatment due to its ability to block the androgen receptor at higher doses. It may be used with or without an oral contraceptive. Hormonal therapies should not be used to treat acne during pregnancy or lactation as they have been associated with certain birth defects such as hypospadias and feminization of the male fetus. Finasteride is also likely to be an effective treatment for acne.
Acne of any severity usually remits spontaneously by the early to mid 20s, but a substantial minority of patients, usually women, may have acne into their 40s; options for treatment may be limited because of childbearing. Many adults occasionally develop mild, isolated acne lesions. Noninflammatory and mild inflammatory acne usually heals without scars. Moderate to severe inflammatory acne heals but often leaves scarring. Scarring is not only physical; acne may be a huge emotional stressor for adolescents who may withdraw, using the acne as an excuse to avoid difficult personal adjustments. Supportive counseling for patients and parents may be indicated in severe cases.
Acne vulgaris is one of the commonest skin disorders which dermatologists have to treat, mainly affect adolescents, though it may present at any age. Acne by definition is multifactorial chronic inflammatory disease of pilosebaceous units. Various clinical presentations include seborrhoea, comedones, erythematous papules and pustules, less frequently nodules, deep pustules or pseudocysts, and ultimate scarring in few of them. Acne has four main pathogenetic mechanism—increased sebum productions, follicular hyperkeratinization, Propionibacterium acne (P. acne) colonization, and the products of inflammation.
Oral isotretinoin is the best treatment for patients with moderate acne in whom antibiotics are unsuccessful and for those with severe inflammatory acne. Dosage of isotretinoin is usually 1 mg/kg once/day for 16 to 20 wk, but the dosage may be increased to 2 mg/kg once/day. If adverse effects make this dosage intolerable, it may be reduced to 0.5 mg/kg once/day. After therapy, acne may continue to improve. Most patients do not require a 2nd course of treatment; when needed, it should be resumed only after the drug has been stopped for 4 mo. Retreatment is required more often if the initial dosage is low (0.5 mg/kg). With this dosage (which is very popular in Europe), fewer adverse effects occur, but prolonged therapy is usually required. Isotretinoin is nearly always effective, but use is limited by adverse effects, including dryness of conjunctivae and mucosae of the genitals, chapped lips, arthralgias, depression, elevated lipid levels, and the risk of birth defects if treatment occurs during pregnancy. Hydration with water followed by petrolatum application usually alleviates mucosal and cutaneous dryness. Arthralgias (mostly of large joints or the lower back) occur in about 15% of patients. Increased risk of depression and suicide is much publicized but probably rare. It is not clear whether risk of new or worsened inflammatory bowel disease (Crohn disease and ulcerative colitis) is increased. CBC, liver function, and fasting glucose, triglyceride, and cholesterol levels should be determined before treatment. Each should be reassessed at 4 wk and, unless abnormalities are noted, need not be repeated until the end of treatment. Triglycerides rarely increase to a level at which the drug should be stopped. Liver function is seldom affected. Because isotretinoin is teratogenic, women of childbearing age are told that they are required to use 2 methods of contraception for 1 mo before treatment, during treatment, and for at least 1 mo after stopping treatment. Pregnancy tests should be done before beginning therapy and monthly until 1 mo after therapy stops.
Systemic antibiotics 0Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. The following agents should not be used in acne due to lack of efficacy and safety consideration such as cephalosporins, sulphonamide, and gyrase inhibitors.Tetracycline (500 mg–1 g/day), doxycycline (50–200 mg/day), minocycline (50–200 mg/day), lymecycline (150–300 mg/day), erythromycin (500 mg–1 g/day), co-trimoxazole, trimethoprim, and recently azithromycin (500 mg thrice weekly) are being used successfully in acne. Minocycline and doxycycline are more effective than tetracycline and erythromycin. Recently, doxycycline in subantimicrobial dose (20 mg twice daily) and an extended-release minocycline tablet (1 mg/kg/day) were used and found to be effective, but further controlled trials are needed.Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.Long-term therapy with oral antibiotic not only threat to resistant of P. acne, but also to coagulase negative staphylococci on the skin, Staphylococcus aureus in the nares, and streptococci in the oral cavity. There is a significant association between antibiotic used in acne and the incidence of upper respiratory tract infection.Optimizing antibiotic therapy: Research has demonstrated that problem of antibiotic-resistant P. acne is increasing, and it is most common with erythromycin. Therefore there is need to consider for antibiotic prescribing policies and to advocate the use of nonantibiotic preparations wherever possible. Antibiotic monotherapy is to be avoided and it can be combined with topical retinoid or benzoyl peroxide as per need.Wherever possible the duration of therapy should be limited. The usual minimum duration of therapy is 6–8 weeks but can be given up to 12–18 weeks and more.It is advisable to use the same antibiotic if retreatment is necessary and use benzoyl peroxide for a minimum of 5–7 days between antibiotic courses to reduce resistant organism.Concomitant use of oral and topical therapy with chemically dissimilar antibiotics is to be avoided.
If noninflammatory, acne is characterized by comedones and, if inflammatory, by papules, pustules, nodules, and cysts. Mild and moderate acne usually heals without scarring by the mid 20s. Recommend that patients avoid triggers (eg, occlusive cosmetics and clothing, cleansers, lotions, high humidity, some drugs and chemicals, possibly a high intake of milk or a high-glycemic diet). Consider the psychologic as well as the physical effects of acne. Prescribe a topical comedolytic (eg, tretinoin) plus, for inflammatory acne, benzoyl peroxide, a topical antibiotic, or both. Prescribe an oral antibiotic for moderate acne and oral isotretinoin for severe acne. Treat cystic acne with intralesional triamcinolone.
Azelaic acid has been shown to be effective for mild-to-moderate acne when applied topically at a 20% concentration. Application twice daily for six months is necessary, and treatment is as effective as topical benzoyl peroxide 5%, isotretinoin 0.05%, and erythromycin 2%. Treatment of acne with azelaic acid is less effective and more expensive than treatment with retinoids. Azelaic acid is thought to be an effective acne treatment due to its antibacterial, anti-inflammatory, and antikeratinizing properties. Additionally, azelaic acid has a slight skin-lightening effect due to its ability to inhibit melanin synthesis and is therefore useful in treatment of individuals with acne who are also affected by postinflammatory hyperpigmentation. Azelaic acid may cause skin irritation but is otherwise very safe.
Acne is commonly classified by severity as mild, moderate, or severe. This type of categorization can be an important factor in determining the appropriate treatment regimen. Mild acne is classically defined as open (blackheads) and closed comedones (whiteheads) limited to the face with occasional inflammatory lesions. Acne may be considered to be of moderate severity when a higher number of inflammatory papules and pustules occur on the face compared to mild cases of acne and acne lesions also occur on the trunk of the body. Lastly, severe acne is said to occur when nodules and cysts are the characteristic facial lesions and involvement of the trunk is extensive.
Oral systemic therapy with antibiotics is the best way to treat moderate acne. Antibiotics effective for acne include tetracycline, minocycline, erythromycin, and doxycycline. Full benefit takes ≥ 12 wk. Topical therapy as for mild acne is usually used concomitantly with oral antibiotics. Tetracycline is usually a good first choice: 250 or 500 mg bid (between meals and at bedtime) for 4 wk or until lesions respond, after which it may be reduced to the lowest effective dose. Rarely, dosage must be increased to 500 mg qid. After control is achieved, it is reasonable to attempt to taper and discontinue the oral antibiotic and continue topical therapy for control. Because relapse often follows short-term treatment, therapy may need to be continued for months to years. For maintenance, tetracycline 250 or 500 mg once/day is often sufficient. Minocycline 50 or 100 mg bid causes fewer GI adverse effects, is easier to take, and is less likely to cause photosensitization, but it may have more adverse effects with chronic use, including drug-induced lupus and hyperpigmentation. Erythromycin and doxycycline are considered 2nd-line drugs because both can cause GI adverse effects, and doxycycline is a frequent photosensitizer. Subantimicrobial doses of doxycycline have also been proved effective for acne and rosacea. Long-term use of antibiotics may cause a gram-negative pustular folliculitis around the nose and in the center of the face. This uncommon superinfection may be difficult to clear and is best treated with oral isotretinoin after discontinuing the oral antibiotic. Ampicillin is an alternative treatment for gram-negative folliculitis. In women, prolonged antibiotic use can cause candidal vaginitis; if local and systemic therapy does not eradicate this problem, antibiotic therapy for acne must be stopped. If the patient is female and unresponsive to oral antibiotics, a trial of oral antiandrogens (oral contraceptives and/or spironolactone) may be considered.
It is approved in severe recalcitrant nodulocystic acne. It can also be used in moderate-to-severe acne vulgaris resistant to conventional therapy, frequently relapsing, with severe psychological and physical scarring due to acne. Pre-treatment counselling, patient selection, and monitoring are critical due to its side effects like teratogenicity, and adverse psychiatric events.
Oral isotretinoin It is approved in severe recalcitrant nodulocystic acne. It can also be used in moderate-to-severe acne vulgaris resistant to conventional therapy, frequently relapsing, with severe psychological and physical scarring due to acne. Pre-treatment counselling, patient selection, and monitoring are critical due to its side effects like teratogenicity, and adverse psychiatric events.
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