Acne Vulgaris: Treatment
Treatment of acne vulgaris is directed toward elimination of comedones by normalization of follicular keratinization, decreasing sebaceous gland activity, decreasing the population of P. acnes, and decreasing inflammation. Minimal to moderate, pauci-inflammatory disease may respond adequately to local therapy alone. Although areas affected with acne should be kept clean, overly vigorous scrubbing may aggravate acne due to mechanical rupture of comedones. Topical agents such as retinoic acid, benzoyl peroxide, or salicylic acid may alter the pattern of epidermal desquamation, preventing the formation of comedones and aiding in the resolution of preexisting cysts. Topical antibacterial agents such as azelaic acid, topical erythromycin (with or without zinc), or clindamycin are also useful adjuncts to therapy.
Patients with moderate to severe acne with a prominent inflammatory component will benefit from the addition of systemic therapy, such as tetracycline in doses of 250–500 mg bid, or doxycycline, 100 mg bid. Minocycline may also be useful. Such antibiotics appear to have an anti-inflammatory effect independent of their antibacterial effect. Female patients who do not respond to oral antibiotics may benefit from hormonal therapy. Women placed on oral contraceptives containing ethinyl estradiol and norgestimate have demonstrated improvement in their acne when compared to a placebo control.
Patients with severe nodulocystic acne unresponsive to the therapies discussed above may benefit from treatment with the synthetic retinoid, isotretinoin. Its dose is based on the patient’s weight, and it is given once daily for 5 months. Results are excellent in appropriately selected patients. Its use is highly regulated due to its potential for severe adverse events, primarily teratogenicity. Additionally, patients receiving this medication develop extremely dry skin, cheilitis, and must be followed for development of hypertriglyceridemia. Recently there have also been concerns that it is associated with severe depression in some patients. The latter has not been proved. At present, prescribers must enroll in a program designed to prevent pregnancy and adverse events while patients are taking isotretinoin. These measures are imposed to ensure that all prescribers are familiar with the risks of isotretinoin; that all female patients have two negative pregnancy tests prior to initiating therapy and a negative pregnancy test prior to each refill; and that all patients have been warned about the risks associated with isotretinoin.
Acne and Hirsuitism in Adolescents
Guidelines of care for acne vulgaris management
Acne vulgaris: overview
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Female Adult Acne
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