Acne Treatment

Treatment of Acne vulgaris

Systemic and topical retinoids, systemic and topical antimicrobials, and systemic hormonal therapies are the main classes of treatment
Multiple agents are often used with activity against different pathogenic causes (e.g. topical antibiotic plus retinoid)
Use topical antibiotics with benzoyl peroxide to prevent the development of antibiotic resistance
Acne scarring is difficult to treat, therefore aggressive prevention is important

Acne should be treated aggressively to avoid permanent scarring and cysts
Refer patients with difficult to control acne or the presence of scarring to dermatology

Mild comedonal: topical retinoid, +/- topical benzoyl peroxide
Mild papular/pustular: topical retinoid, topical antibiotics (clindamycin, erythromycin), topical benzoyl peroxide
Moderate papular/pustular: oral antibiotics with topical retinoid and benzoyl peroxide
Moderate nodular without scarring: oral antibiotic with topical retinoid and topical benzoyl peroxide
Severe nodular: refer to a dermatologist for oral isotretinoin
Scarring and keloids: refer to a dermatologist for oral isotretinoin

(tretinoin, all trans retinoic acid)

Topical retinoids are vitamin A derivatives
Used for acne vulgaris; photodamaged skin; fine wrinkles, hyperpigmentation
Patients should be warned of common adverse effects:
- Dryness, pruritus, erythema, scaling
- Photosensitivity
Available as a cream or gel
Do not apply at the same time as benzoyl peroxide because benzoyl peroxide oxidizes tretinoin

Benzoyl peroxide is a topical medication with both antibacterial and comedolytic properties
Available as a prescription and over-the-counter, as well as in combinations with topical antibiotics
Patients should be warned of common adverse effects:
- Bleaching of hair, colored fabric, or carpet
- May irritate skin; discontinue if severe
Available as a cream, lotion, gel, or wash

Used to reduce the number of P. acnes and reduce inflammation in inflammatory acne
Do not use as monotherapy (often used with benzoyl peroxide to prevent the development of antibiotic resistance in the treatment of mild-to-moderate acne and rosacea)
- Erythromycin 2% (solution, gel)
- Clindamycin 1% (lotion, solution, gel, foam)
Metronidazole 0.75%, 1% (cream, gel) is used in the treatment of rosacea

Topical acne treatments are often irritating and can cause dry skin
- When using retinoids or benzoyl peroxide, consider beginning on alternate days. Use a moisturizer to reduce their irritancy.
Topical agents take 2-3 months to see effect
Patients will often stop their topical treatment too early from “red, flakey” skin without improvement in their acne
Patient education is a crucial component to acne treatment

Tetracycline, doxycycline, minocycline
Use for moderate to severe inflammatory acne
Often combined with benzoyl peroxide to prevent antibiotic resistance
If the patient has not responded after 3 months of therapy with an oral antibiotic, consider:
- Increasing the dose,
- Changing the treatment, or
- Referring to a dermatologist

Oral isotretinoin, a retinoic acid derivative, is indicated in severe, nodulocystic acne failing other therapies
Should be prescribed by physicians with experience using this medication
Typically given in a single 5-6 month course
Isotretinoin is teratogenic and therefore absolutely contraindicated in pregnancy
- Female patients must be enrolled in a FDA-mandated prescribing program in order to use this medication
- Two forms of contraception must be used during isotretinoin therapy and for one month after treatment has ended

Isotretinoin: Side Effects

Common side effects of isotretinoin include:
- Xerosis (dry skin)
- Cheilitis (chapped lips)
- Elevated liver enzymes
- Hypertriglyceridemia
Individuals with severe acne may suffer mood changes and depression and should be monitored
Severe headache can be a manifestation of the uncommon side effect pseudotumor cerebri

Patient education and setting expectations are important components of effective acne treatment
- Lack of adherence is the most common cause of treatment failure
- With the patient, the physician should develop the therapeutic regimen with the highest likelihood of adherence
- Acne treatment is only treating new lesions, not the ones already there
Patients should use only the prescribed medications and avoid potentially drying over-the-counter products, such as astringent, harsh cleansers or antibacterial soaps
- Recommend daily moisturizer when patients are using solutions and gels because they have more drying effects than creams and ointments
Overaggressive washing and the use of particulate abrasive scrubs often exacerbates acne and should be avoided
Cosmetics are often labeled as “non-comedogenic” or “oil-free” if they do not cause or exacerbate acne