Acne Vulgaris Treatment
Acne Vulgaris
Acne vulgaris is a chronic disorder of the pilosebaceous gland caused by abnormal desquamation of follicular epithelium leading to obstruction of the pilosebaceous canal, resulting in inflammation and subsequent formation of papules, pustules, nodules, comedones, and scarring.
The pathology of acne is considered important in planning the treatment. Overactivity of the sebaceous glands and blockage in the ducts. The obstruction leads to the formation of comedones, which can become inflamed because of overgrowth of
Propionibacterium acnes.
Acne may be exacerbated by environmental factors (hot, humid, tropical climate), medications (e.g., iodine in cough mixtures, hair greases) , industrial exposure to halogenated hydrocarbons
Acne can be classified by the type of lesion (comedonal, papulopustular, and nodulocystic).
Mild acne is characterized by the presence of comedones (noninflammatory lesions), few papules and pustules (generally ,10), but no nodules.
Moderate acne is characterized by presence of several to many papules and pustules along with comedones . The presence of 40 papules and pustules along with larger, deeper nodular inflamed lesions (up to five) denotes moderately severe acne.
Severe acne will exhibit the presence of numerous or extensive papules and pustules as well as many nodular lesions.
The differential diagnosis of acne may include staphylococcal pyoderma, acne rosacea drug eruption,sebaceous hyperplasia,angiofibromas, basal cell carcinomas, osteoma cutis,occupational exposures to oils or grease and steroid acne.
History and physical examination should inquire about previous treatment. Careful drug history should be taken. Family history, history of cyclic menstrual flares,history of use of cosmetics and cleansers and oral contraceptive use should be asked.
Acne can be treated in a number of ways. Blue light (ClearLight therapy system) can be used for treatment of moderate inflammatory acne vulgaris. Light in the violet/blue range can cause bacterial death by a photoreaction in which porphyrins react with oxygen to generate reactive oxygen species, which damage the cell membranes of P. acnes. Treatment usually consists of 15-min exposures twice weekly for 4 weeks.
Treatment generally varies with the type of lesions (comedones, papules, pustules, cystic lesions) and the severity of acne.
Comedones (noninflammatory acne) can be treated with retinoids or retinoid analogs. Topical retinoids are comedolytic and work by normalizing follicular keratinization. Commonly available agents are Adapalene (Differin, 0.1% gel or cream, applied once or twice daily), tazarotene (Tazorac 0.1% cream or gel applied daily), tretinoin (Retin-A 0.1% cream or 0.025 gel applied once daily), tretinoin microsphere (Retin-A Micro, 0.1% gel, applied at bedtime). Tretinoin is inactivated by ultraviolet light and oxidized by benzoyl peroxide; therefore it should only be applied at night and not used concomitantly with benzoyl peroxide.
Tretinoin is pregnancy category C and tazarotene is pregnancy category X. Salicylic acid preparations (e.g., Neutrogena 2% wash) have keratolytic and antiinflammatory properties and are also useful in the treatment of comedones. Large, open comedones should be expressed.
Patients should be reevaluated after 4 to 6 wk. Benzoyl peroxide gel (2.5% or 5%) may be added if the comedones become inflamed or form pustules. The most common adverse effects are dryness, erythema, and peeling. Topical antibiotics (erythromycin, clindamycin
lotions or pads) can also be used in patients with significant inflammation. They reduce P. acnes in the pilosebaceous follicle and have some antiinflammatory effects. The combination of 5% benzoyl peroxide and 3% erythromycin (Benzamycin) or 1% clindamycin with 5% benzoyl peroxide (BenzaClin) is highly effective in patients who have a mixture of comedonal and inflammatory acne lesions.
Pustular acne can be treated with tretinoin and benzoyl peroxide gel applied on alternate evenings; drying agents (sulfacetamide-sulfa lotions [Novacet, Sulfacet]) are also effective when used in combination with benzoyl peroxide; oral antibiotics (doxycycline 100 mg qd
or erythromycin 1 g qd given in 2 to 3 divided doses) are effective in patients with moderate to severe pustular acne. Patients not responding well to these antibiotics can be switched to minocycline 50 to 100 mg bid; however, this medication is more expensive.
Fixed-dose combinations of clindamycin phosphate 1.2% and tretinoin 0.025% are available (Veltin gel, Ziana) and are more effective than either product used alone; however, they are much more expensive than the individual generic components.
Patients with nodular cystic acne can be treated with systemic agents: antibiotics (erythromycin, tetracycline, doxycycline, minocycline), isotretinoin (available on restricted basis), or oral contraceptives. Periodic intralesional triamcinolone (Kenalog) injections by
a dermatologist are also effective. The possibility of endocrinopathy should be considered in patients responding poorly to therapy.
Oral contraceptives reduce androgen levels and therefore sebum production. They represent a useful adjunctive therapy for all types of acne in women and adolescent girls. Commonly used agents are norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) and drosperinone/ ethinyl estradiol (Yasmin).
Isotretinoin is indicated for acne resistant to antibiotic therapy and severe acne. It is available only on a restricted basis. Dosage is 0.5 to 1 mg/kg/day in 2 divided doses (maximum of 2 mg/kg/day); duration of therapy is generally 20 wk for a cumulative dose 120 mg/kg for severe cystic acne. Before using this medication patients should undergo
baseline laboratory evaluation. This drug is absolutelycontraindicated during pregnancy because ofits teratogenicity. It should be used with caution in patients with history of depression.
Azelaic acid is a bacteriostatic dicarboxylic acid used to normalize keratinization and reduce inflammation.
Precaution should be considered with acne medication. Patients who are candidates for therapy with isotretinoin should have baseline liver enzymes, cholesterol, and triglycerides checked because this medication may result in elevation of lipids and liver enzymes.
If hyperandrogenism is suspected in female patients, levels of dehydroepiandrosterone sulfate, testosterone (total and free), and androstenedione should be measured. For women with regular menstrual cycles, serum androgen measurements generally are not
necessary.
A negative serum pregnancy test or two negative urine pregnancy tests should also be obtained in females 1 wk before initiation of isotretinoin; it is also imperative to maintain effective contraception during and 1 moth after therapy with isotretinoin ends because of its teratogenic effects. Pregnancy status should also be rechecked at monthly visits.
Acne vulgaris is a chronic disorder of the pilosebaceous gland caused by abnormal desquamation of follicular epithelium leading to obstruction of the pilosebaceous canal, resulting in inflammation and subsequent formation of papules, pustules, nodules, comedones, and scarring.
The pathology of acne is considered important in planning the treatment. Overactivity of the sebaceous glands and blockage in the ducts. The obstruction leads to the formation of comedones, which can become inflamed because of overgrowth of
Propionibacterium acnes.
Acne may be exacerbated by environmental factors (hot, humid, tropical climate), medications (e.g., iodine in cough mixtures, hair greases) , industrial exposure to halogenated hydrocarbons
Acne can be classified by the type of lesion (comedonal, papulopustular, and nodulocystic).
Mild acne is characterized by the presence of comedones (noninflammatory lesions), few papules and pustules (generally ,10), but no nodules.
Moderate acne is characterized by presence of several to many papules and pustules along with comedones . The presence of 40 papules and pustules along with larger, deeper nodular inflamed lesions (up to five) denotes moderately severe acne.
Severe acne will exhibit the presence of numerous or extensive papules and pustules as well as many nodular lesions.
The differential diagnosis of acne may include staphylococcal pyoderma, acne rosacea drug eruption,sebaceous hyperplasia,angiofibromas, basal cell carcinomas, osteoma cutis,occupational exposures to oils or grease and steroid acne.
History and physical examination should inquire about previous treatment. Careful drug history should be taken. Family history, history of cyclic menstrual flares,history of use of cosmetics and cleansers and oral contraceptive use should be asked.
Acne can be treated in a number of ways. Blue light (ClearLight therapy system) can be used for treatment of moderate inflammatory acne vulgaris. Light in the violet/blue range can cause bacterial death by a photoreaction in which porphyrins react with oxygen to generate reactive oxygen species, which damage the cell membranes of P. acnes. Treatment usually consists of 15-min exposures twice weekly for 4 weeks.
Treatment generally varies with the type of lesions (comedones, papules, pustules, cystic lesions) and the severity of acne.
Comedones (noninflammatory acne) can be treated with retinoids or retinoid analogs. Topical retinoids are comedolytic and work by normalizing follicular keratinization. Commonly available agents are Adapalene (Differin, 0.1% gel or cream, applied once or twice daily), tazarotene (Tazorac 0.1% cream or gel applied daily), tretinoin (Retin-A 0.1% cream or 0.025 gel applied once daily), tretinoin microsphere (Retin-A Micro, 0.1% gel, applied at bedtime). Tretinoin is inactivated by ultraviolet light and oxidized by benzoyl peroxide; therefore it should only be applied at night and not used concomitantly with benzoyl peroxide.
Tretinoin is pregnancy category C and tazarotene is pregnancy category X. Salicylic acid preparations (e.g., Neutrogena 2% wash) have keratolytic and antiinflammatory properties and are also useful in the treatment of comedones. Large, open comedones should be expressed.
Patients should be reevaluated after 4 to 6 wk. Benzoyl peroxide gel (2.5% or 5%) may be added if the comedones become inflamed or form pustules. The most common adverse effects are dryness, erythema, and peeling. Topical antibiotics (erythromycin, clindamycin
lotions or pads) can also be used in patients with significant inflammation. They reduce P. acnes in the pilosebaceous follicle and have some antiinflammatory effects. The combination of 5% benzoyl peroxide and 3% erythromycin (Benzamycin) or 1% clindamycin with 5% benzoyl peroxide (BenzaClin) is highly effective in patients who have a mixture of comedonal and inflammatory acne lesions.
Pustular acne can be treated with tretinoin and benzoyl peroxide gel applied on alternate evenings; drying agents (sulfacetamide-sulfa lotions [Novacet, Sulfacet]) are also effective when used in combination with benzoyl peroxide; oral antibiotics (doxycycline 100 mg qd
or erythromycin 1 g qd given in 2 to 3 divided doses) are effective in patients with moderate to severe pustular acne. Patients not responding well to these antibiotics can be switched to minocycline 50 to 100 mg bid; however, this medication is more expensive.
Fixed-dose combinations of clindamycin phosphate 1.2% and tretinoin 0.025% are available (Veltin gel, Ziana) and are more effective than either product used alone; however, they are much more expensive than the individual generic components.
Patients with nodular cystic acne can be treated with systemic agents: antibiotics (erythromycin, tetracycline, doxycycline, minocycline), isotretinoin (available on restricted basis), or oral contraceptives. Periodic intralesional triamcinolone (Kenalog) injections by
a dermatologist are also effective. The possibility of endocrinopathy should be considered in patients responding poorly to therapy.
Oral contraceptives reduce androgen levels and therefore sebum production. They represent a useful adjunctive therapy for all types of acne in women and adolescent girls. Commonly used agents are norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) and drosperinone/ ethinyl estradiol (Yasmin).
Isotretinoin is indicated for acne resistant to antibiotic therapy and severe acne. It is available only on a restricted basis. Dosage is 0.5 to 1 mg/kg/day in 2 divided doses (maximum of 2 mg/kg/day); duration of therapy is generally 20 wk for a cumulative dose 120 mg/kg for severe cystic acne. Before using this medication patients should undergo
baseline laboratory evaluation. This drug is absolutelycontraindicated during pregnancy because ofits teratogenicity. It should be used with caution in patients with history of depression.
Azelaic acid is a bacteriostatic dicarboxylic acid used to normalize keratinization and reduce inflammation.
Precaution should be considered with acne medication. Patients who are candidates for therapy with isotretinoin should have baseline liver enzymes, cholesterol, and triglycerides checked because this medication may result in elevation of lipids and liver enzymes.
If hyperandrogenism is suspected in female patients, levels of dehydroepiandrosterone sulfate, testosterone (total and free), and androstenedione should be measured. For women with regular menstrual cycles, serum androgen measurements generally are not
necessary.
A negative serum pregnancy test or two negative urine pregnancy tests should also be obtained in females 1 wk before initiation of isotretinoin; it is also imperative to maintain effective contraception during and 1 moth after therapy with isotretinoin ends because of its teratogenic effects. Pregnancy status should also be rechecked at monthly visits.
