Acne

Acne is a difficult disease to treat. The only predictably effective medication is isotretinoin (Accutane). This medication however is reserved for the severe forms of pustular and cystic acne. The disease in many cases responds slowly over a period of weeks and months to topical medications, oral antibiotics and other oral medications. Young people expect medications to work quickly and become discouraged when the response is slow. The slow response interferes with compliance and patients may use medications less frequently than prescribed.

Therapeutic agents include retinoids, topical and oral antibiotics, hormonal medicines such as oral contraceptives and testosterone blocking agents such as Aldactone. Most therapeutic programs involve the use of a combination of these agents.

Retinoids

Medications with retinoid properties include tretinoin, adapalene and tazarotene. These agents are applied topically and are fundamental to most treatment programs for acne. They disrupt the cells that bind together in the hair follicle structure that cause plugs. Some retinoids such as adapalene also have anti-inflammatory properties. They are usually applied at bedtime. They are less irritating if applied more than one half hour after face washing. Retinoids are both therapeutic and preventative.

 Tretinoin

Retin-A

Retin-A

Tretinoin (Retin-A) was the first retinoid developed. Gel preparations are used for patients with oily skin. Cream based preparations are used for patients with dry sensitive skin. Retin-A Micro is a micro-dispersed formulation, which may be less irritating. Tretinoin is applied to the entire skins surface of involved areas, not just to individual lesions. There may be some irritation initially but most patients adapt and will continue using the medication. Emollients may be used during this period of adaptation.

Adapalene

Differin

Differin (Adapalene)

Adapalene is applied at bedtime. This medication is less irritating than tretinoin. It is available as a gel, cream and lotion. Epiduo is a combination of adapalene and benzoyl peroxide. Adapalene (Differin) is available in a gel base in a concentration of 0.1 and 0.3.

Tazarotene

Tazorac

Tazorac gel (Tazarotene)

Tazarotene {Tazorac) is the most potent topical retinoid. It is possibly more effective than tretinoin and adapalene. Medication is available as a gel or cream. Most acne patients are treated with the gel preparation. There may be some initial irritation. Patient may use the medication less frequently or in combination with emollients during the adaptation period. It is important that retinoids be applied to the entire surface of affected areas and not just the individual lesions.

 

 

Topical antibiotics

Duac

Duac

Topical antibiotics in combination with retinoids are the Foundation of most treatment programs for acne. Benzoyl peroxide is available in several forms (gels, washes) and has broad-spectrum antibiotic properties.  It is available over-the-counter and by prescription. Topical clindamycin is available in several forms. Clindamycin is available in combination products mixed with benzoyl peroxide. Duac and BenzaClin are a combination of Bentyl peroxide and clindamycin. Clindamycin is also available combined with tretinoin (Veltin).

 

 

Oral antibiotics

Oral antibiotics have been used for over 40 years to treat acne. They are not predictably effective. Tetracycline and erythromycin were used years ago. Today doxycycline and minocycline are most often prescribed. Several other antibiotics such as ampicillin, amoxicillin, cephalosporins and trimethoprim/sulfamethoxazole have been used as second line drugs. Oral antibiotics are typically prescribed for 2 or 3 months and then tapered after a successful therapeutic outcome. Patient’s who have not responded after 2 months should discontinue the medication and possibly try another. Oral antibiotics are usually used in combination with topical retinoids.

Doxycycline

Doxycycline

Doxycycline

Tetracycline is still prescribed today but doxycycline is a first-line drug that is usually better tolerated. Doxycycline may be taken once or twice a day and is more effective when taken on an empty stomach. Many patients develop abdominal discomfort and find that taking medication with food is necessary. The medication may be only 10% less effective when taken with food. Bedtime dosing should be avoided to prevent abdominal discomfort. Taking doxycycline without water can result in severe esophageal irritation and erosions. Doxycycline can cause sun sensitivity in certain individuals. This is dose dependent. Many physicians will not prescribe doxycycline during the summer months. The dosage is 50, 75, or 100 mg once or twice a day.

Minocycline

Minocycline

Minocycline is possibly the most effective oral antibiotic for acne. Some patients experience vertigo and must stop the medication. The medication does not cause abdominal discomfort or sun sensitivity. The dosages are 50, 75 or 100 mg twice a day. A new time-release low-dose form of minocycline is now available (Sololdyn). There are many dosage forms for people of varying weight. Minocycline should not be taken for many months or years. Some patients develop blue pigmentation of the skin and nails after taking minocycline for more than a year.

Isotretinoin

Accutane

Accutane

Isotretinoin (Accutane) is in oral retinoid with a profound and predictable therapeutic effect. It is indicated for severe nodular cystic acne or other forms of acne that have the potential to scar and are not responding to conventional topical and oral treatment programs. It is important to treat acne aggressively to prevent scarring. Unfortunately many patients do not seek the advice of a physician until after scarring has occurred. Isotretinoin is usually taken at a dose of 1 mg per kilogram per day for about 20 weeks. Most patients will be clear at the end of this treatment program. Some patients will flare months later and require a second or even third course of treatment. The drug causes severe birth defects. All patients must be registered in a program called ipledge that was developed to prevent pregnancy in isotretinoin patients. Physicians must be registered in this program before there are allowed to prescribe isotretinoin.

Oral contraceptives

Ortho tri-cyclen

Ortho tri-cyclen

Ortho Tri-Cyclen, Estrostep, Yaz and Yasmin and many other oral contraceptives may be effective for treating acne in women. The problem with these medications is that they are not predictably effective and make some women worse. Some women respond and do not require any other therapeutic agents.

 

 

Spironolactone

Spironolactone

Spironolactone

This drug has anti-androgen properties. The dosage ranges from 25 mg per day to 200 mg per day. Most women take an average dose of 50 mg twice a day. Breast tenderness and breakthrough bleeding are uncommon. Hyperkalemia is also very uncommon in young healthy people. The drug is usually reserved for women over the age of 25 who fail conventional therapy. The drug may be taken for several months with very gratifying results. It is often prescribed in combination with oral contraceptives. Patients must not become pregnant while taking this drug. Many women find that they can discontinue topical treatment and remain well controlled with this drug alone.

 

Treatment programs

 

Diet

A low glycemic diet should be encouraged. There is some evidence that a rapid increase in insulin causes follicular occlusion. Instruct patient to avoid sugared drinks, milk and simple carbohydrates. These lower quality foods are everywhere and difficult to avoid. Minimize the consumption of processed food. There is some evidence that avoiding milk and milk products is beneficial. Information about a low glycemic diet is the South Beach Diet.

Comedone acne (noninflammatory)

Acne Closed Comedones (White heads)

Acne Closed Comedones (White heads)

Patients with open (black heads) or closed (white heads) comedones are treated with a topical retinoids. A typical treatment program would be to apply tretinoin gel 0.01 to the entire affected area one half hour after washing the face. A 5% benzoyl peroxide wash could be used in the morning. Patients who report little irritation with previously used over-the-counter benzoyl peroxide preparations could be started on Tazorac gel 0.1%. Differin gel 0.1 would be a good choice for patients with sensitive skin. Differin gel does not cause sun sensitivity. Epiduo is a combination of adapalene and benzoyl peroxide. These combination products are effective and enhance compliance. Patient’s who fail to respond after 2 months maybe advanced to higher concentrations of medication. Oral antibiotics are not indicated for this group of patients who have noninflammatory lesions.

 

Papular pustular acne

Papular pustular acne

Papular pustular acne

Start with the same topical program described above for comedone acne. Retinoids are applied in the evening and topical antibiotics such as benzoyl peroxide gels or clindamycin liquid or foam are applied in the morning. Combinations of benzoyl peroxide and clindamycin such as Duac or BenzaClin have an increased therapeutic effect over single agent topical antibiotics. They are not irritating and have a pleasant well-tolerated base. Patients with moderate-to-severe activity may be prescribed an oral antibiotic such as doxycycline or minocycline at the first visit. The antibiotic may be changed if there is no response in 2 months.

Aczone (5% dapsone) gel is a new agent with antibiotic and anti-inflammatory properties. It may be used alone as initial therapy or tried if the above program fails.

Patients who fail to respond or are beginning to scar should consider using isotretinoin.

Nodulocystic acne

Cystic acne

Cystic acne

Some patients will respond to topical retinoids such as Tazorac or Differin 0.3 used in combination with oral antibiotics. Intralesional corticosteroids such as Kenalog 10 mg per mL can be very effective. Injected cysts can improve markedly in 24-48 hours. Deep injections into a cyst may cause atrophy.  Cysts that are close to the surface may be drained after a puncture with an 11 surgical blade.

Isotretinoin is prescribed for patient’s who fail conventional therapy and are beginning to scar.

Consider using oral contraceptives at any time in these treatment programs.

Some patients with severe papular-pustular or nodular-cystic acne present with extensive, highly inflammatory disease. These patients may respond rapidly to a short course of prednisone. Prednisone, 20 mg twice a day, will usually rapidly reverse the disease. Slowly taper the prednisone to prevent flares. Isotretinoin may be started during this period of treatment with anti-inflammatory steroids.