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 Retinoids B.Benzoyl Peroxide C.Topical Antibacterials D.Sulfur, Sodium Sulfacetamide, Resorcin, and Salicylic Acid E.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 % and 0.05% in cream base - May take 8-12 weeks before improvement occurs Should be applied at nightC AdapaleneWell tolerated retinoid like compound either in the morning or evening C TazaroteneStrong in action, relatively irritating once at night or every other nightX

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 mg, 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

DosageSide effects Doxycycline mg od or bid Photosensitivity reactions MinocyclineMost effective oral antibiotic in treating acne vulgaris; absorption is less affected by food or milk 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: 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

Strategies to prevent antibiotic resistance Limiting duration of treatment Good compliance Restricting antibiotic use to inflammatory acne Retreatment with the same antibiotic unless it has lost its efficacy Avoiding use of dissimilar oral and topical antibiotics at the same time Use of isotretinoin if unable to maintain clearance without oral antibiotic treatment

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: mg/day –Usually prescribed in combination w/ OC –Side effects: breast tenderness, headache, dizziness, light headedness, irregular menses, diuresis

Dexamethasone –Doses of 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: 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 MildModerateSevere 1. Comedonal -Topical retinoid +/- physical extraction (first line) -Alternate retinoid, salicylic acid, azelaic acid (2 nd line) 2. Papular/pustular -Topical antimicrobial combination + topical retinoid, benzoyl peroxide wash if mild trunkal lesions (1 st line) -Alternate antimicrobials + alternate topical retinoids, azelaic acid, sodium sulfacetamide- sulfur, salacylic acid (2 nd line) Papular/Pustular -Oral antibiotic + topical retinoid + benzoyl peroxide (1 st line) - Alternate antibiotic, alternate topical retinoid, alternate benzoyl peroxide (2 nd 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 comedonesComedo extraction Electrocautery Chemical peels Treatment of inflammatory nodulesIntralesional corticosteroids Treatment of inflammatory lesionsPhotodynamic Blue light 1450-nm laser Treatment of scarringChemical peels Dermabrassion Excision Laser resurfacing Filler 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