TREATMENT

1. TREATMENT

2. 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

3. 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

4. Topical Treatment • Preventive • Long term usage is the rule • Topical Retinoids • Benzoyl Peroxide • Topical Antibacterials • Sulfur, Sodium Sulfacetamide, Resorcin, and Salicylic Acid • Azeleic Acid

5. 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

7. 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

8. 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

9. 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

10. 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

11. Oral Antibiotics • 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

12. Tetracycline • Safest and cheapest • Given usually at an initial dose of 250-500mg, 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

14. Erythromycin • For those who cannot take tetracycline • Low efficacy • Side effects: gastrointestinal upset; vaginal itching (rare) • Initial dosage: 250-500 mg bid or qid, reduced gradually after control is achieved

15. 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

16. Other Antibiotics • Sulfonamides • Trimethoprim-sulfamethoxazole • Trimethoprim • Dapsone

17. Hormonal Therapy • 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

18. 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: 25-200 mg/day • Usually prescribed in combination w/ OC • Side effects: breast tenderness, headache, dizziness, light headedness, irregular menses, diuresis

19. Dexamethasone • Doses of 0.125-0.5 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

20. Oral Retinoid Therapy (Isotretinoin) • 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, pyodermafaciale, acne fulminans, hidradenitissuppurativa

21. Dose: 0.5-1 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

22. Summary of Acne Treatment

23. Surgical and Physical Agents

24. Complications • 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 • Pyogenicgranuloma 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