dermatologic disorders
Acne Vulgaris
Treatment of Acne Vulgaris
Comedones: Topicaltretinoin Mild inflammatory acne: Topical retinoid alone or with a topical antibiotic,benzoyl peroxide, or both Moderate acne: Oral antibiotic plus topical therapy as for mild acne Severe acne: Oralisotretinoin Cystic acne: Intralesionaltriamcinolone It is important to treat acne to reduce the extent of disease, scarring, and psychologic distress. Treatment of acne involves a variety of topical and systemic agents directed at reducing sebum production, comedone formation, inflammation, and bacterial counts and at normalizing keratinization ( see Figure: How various drugs work in treating acne ). Selection of treatment is generally based on severity; options are summarized in table Affected areas should be cleansed once or twice a day, but extra washing, use of antibacterial soaps, and scrubbing confer no added benefit. A lower glycemic diet and moderation of milk intake might be considered for treatment-resistant adolescent acne, but the effectiveness of these measures in treating acne remains controversial ( Treatment references ). Peeling agents such as sulfur,salicylic acid, glycolic acid, and resorcinol can be useful therapeutic adjuncts. Oral contraceptives are effective in treating inflammatory and noninflammatory acne, andspironolactone(beginning at 50 mg orally once a day, increased to 100 to 150 mg [maximum 200 mg] orally once a day after a few months if needed) is another antiandrogen that is occasionally useful in women. Various light therapies, with and without topical photosensitizers, have been used effectively, mostly for inflammatory acne. Treatment should involve educating the patient and tailoring the plan to one that is realistic for the patient. Treatment failure can frequently be attributed to lack of adherence to the plan and also to lack of follow-up. Consultation with a specialist may be necessary. Treatment of mild acne should be continued for 6 weeks or until lesions respond. Maintenance treatment may be necessary to maintain control. Single-agent therapyis generally sufficient for comedonal acne. A mainstay of treatment for comedones is daily topicaltretinoinas tolerated. Dailyadapalenegel,tazarotenecream or gel,azelaic acidcream, and glycolic orsalicylic acidare alternatives for patients who cannot tolerate topicaltretinoin. Adverse effects include erythema, burning, stinging, and peeling.Adapaleneandtazaroteneare retinoids; liketretinoin, they tend to be somewhat irritating and photosensitizing.Azelaic acidhas comedolytic and antibacterial properties by an unrelated mechanism and may be synergistic with retinoids. Dual therapy(eg, a combination oftretinoinwithbenzoyl peroxide, a topical antibiotic, or both) should be used to treat mild papulopustular (inflammatory) acne. The topical antibiotic is usuallyerythromycinorclindamycin. Combiningbenzoyl peroxidewith these antibiotics may help limit development of resistance. Glycolic acid may be used instead of or in addition totretinoinbut is no longer used commonly. Treatments have no significant adverse effects other than drying and irritation (and rare allergic reactions tobenzoyl peroxide). Physical extractionof comedones using a comedone extractor is an option for patients unresponsive to topical treatment. Comedone extraction may be done by a physician, nurse, or physician assistant. One end of the comedone extractor is like a blade or bayonet that punctures the closed comedone. The other end exerts pressure to extract the comedone. Oral antibiotics(eg,tetracycline,minocycline,doxycycline,erythromycin) can be used when wide distribution of lesions makes topical therapy impractical. 1% cream is applied 2 times a day. Adverse effects include redness, scaling or dryness, and itching;although hyperkalemia and hypothalamic-pituitary-adrenal axis suppression have been predicted based on its mechanism, these effects have not been noticed clinically ( Treatment references ). Oral systemic therapy with antibioticsis the best way to treat moderate acne. Antibiotics effective for acne includetetracycline,minocycline,erythromycin,doxycycline, andsarecycline. Full benefit takes≥12 weeks. Topical therapy as for mild acneis usually used concomitantly with oral antibiotics. Doxycyclineandminocyclineare first-line drugs; both can be taken with food.Tetracyclineis also a good first choice, but it cannot be taken with food and may have lower efficacy thandoxycyclineandminocycline.Doxycyclineandminocyclinedosage is 50 to 100 mg orally 2 times a day.Doxycyclinemay cause photosensitivity, andminocyclinemay have more adverse effects with chronic use, including drug-induced lupus and hyperpigmentation.Tetracyclinedosage is 250 or 500 mg orally 2 times a day between meals. To reduce the development of antibiotic resistance after control is achieved (usually 2 to 3 months), the dose is tapered as much as possible to maintain control.Sarecyclineis a newtetracyclineantibiotic. The dosages are weight-based: 33 to 54 kg, 60 mg orally once a day; 55 to 84 kg, 100 mg orally once a day; and 85 to 136 kg, 150 mg orally once a day. Antibiotics may be discontinued if topical therapy maintains control. Erythromycinandazithromycinare other options, but they can cause gastrointestinal adverse effects and antibiotic resistance develops more often. Some physicians also usetrimethoprim/sulfamethoxazole, but antibacterial resistance may develop and this combination can cause rare adverse drug reactions. 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 oralisotretinoinafter discontinuing the oral antibiotic.Ampicillinis 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/orspironolactone) may be considered. Oralisotretinoinis the best treatment for patients with moderate acne in whom antibiotics are unsuccessful and for those with severe inflammatory acne. Dosage ofisotretinoinis usually 1 mg/kg once a day for 16 to 20 weeks, but the dosage may be increased to 2 mg/kg once a day. If adverse effects make this dosage intolerable, it may be reduced to 0.5 mg/kg once a day. After therapy, acne may continue to improve. Many patients do not require a 2nd course of treatment; when needed, it is resumed only after the drug has been stopped for 4 months, except in severe cases when it may be resumed earlier. 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. Cumulative dosing has gained support; a total dosage of 120 to 150 mg/kg resulted in lower recurrence rates, and some experts suggest a higher cumulative dose of 220 mg/kg ( Treatment references ). , such an association now appears unlikely ( Treatment references ). Complete blood count, liver tests, triglyceride, and cholesterol levels should be determined before treatment. Each should be reassessed at 4 weeks 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. Becauseisotretinoinis teratogenic, women of childbearing age are told that they are required to use 2 methods of contraception for 1 month before treatment, during treatment, and for at least 1 month after stopping treatment. Pregnancy tests should be done before beginning therapy and monthly until 1 month after therapy stops. Intralesional injection of 0.1 mLtriamcinoloneacetonide suspension 2.5 mg/mL (the 10 mg/mL suspension must be diluted) is indicated for patients with firm (cystic) acne who seek quick clinical improvement with reduced scarring. Local atrophy may occur but is usually transient. For isolated, very boggy lesions, incision and drainage are often beneficial but may result in residual scarring. Pyoderma faciale is treated with oral corticosteroids andisotretinoin. Acne fulminans is commonly treated with oral corticosteroids and systemic antibiotics. Acne conglobata is treated with oralisotretinoinand systemic corticosteroids if severe and if systemic antibiotics fail. For acne caused by endocrine abnormalities (eg, polycystic ovary syndrome, virilizing adrenal tumors in females), antiandrogens are indicated.Spironolactone, which has some antiandrogen effects, is sometimes prescribed to treat acne at a dose of 50 to 150 mg (maximum 200 mg) orally once a day. Cyproterone acetate is used in Europe. When other measures fail, an estrogen/progesterone–containing contraceptive may be tried; therapy≥6 months is needed to evaluate effect. Small scars can be treated with chemical peels, laser resurfacing, or dermabrasion. Deeper, discrete scars can be excised. Wide, shallow depressions can be treated with subcision or injection of collagen or another filler. Fillers, including collagen, hyaluronic acid, and polymethylmethacrylate, are temporary and must be repeated periodically. 1.Dall'Oglio F, Nasca M, Fiorentini F, Micali G: Diet and acne: Review of the evidence from 2009 to 2020.Int J Dermatol60(6):672–685, 2021. doi: 10.1111/ijd.15390. 2.Bienenfeld A, Nagler AR, Orlow SJ: Oral antibacterial therapy for acne vulgaris: An evidence-based review.Am J Clin Dermatol18(4):469–490, 2017. doi: 10.1007/s40257-017-0267-z 3.Hebert A, Thiboutot D, Stein Gold L, et al: Efficacy and safety of topicalclascoteronecream, 1%, for treatment in patients with facial acne: Two phase 3 randomized clinical trials.JAMA Dermatol156(6):621–630, 2020. doi:10.1001/jamadermatol.2020.0465 4.Blasiak RC, Stamey CR, Burkhart CN, et al: High-doseisotretinointreatment and the rate of retrial, relapse, and adverse effects in patients with acne vulgaris.JAMA Dermatol149(12):1392–1398, 2013. doi: 10.1001/jamadermatol.2013.6746 5.Lee SY, Jamal MM, Nguyen ET, et al: Does exposure toisotretinoinincrease the risk for the development of inflammatory bowel disease? A meta-analysis.Eur J Gastroenterol Hepatol28(2):210–216, 2016. doi: 10.1097/MEG.0000000000000496 