Acne Vulgaris Treatment & Management

Treatment should be directed toward the known pathogenic factors involved in acne. These include follicular hyperproliferation, excess sebum, P acnes, and inflammation. The grade and severity of the acne help in determining which of the following treatments, alone or in combination, is most appropriate. When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance.

Topical treatments

Topical retinoids are comedolytic and anti-inflammatory. They normalize follicular hyperproliferation and hyperkeratinization. Topical retinoids reduce the numbers of microcomedones, comedones, and inflammatory lesions. They may be used alone or in combination with other acne medications. The most commonly prescribed topical retinoids for acne vulgaris include adapalene, tazarotene, and tretinoin. These retinoids should be applied once daily to clean, dry skin, but they may need to be applied less frequently if irritation occurs. Skin irritation with peeling and redness may be associated with the early use of topical retinoids. The use of mild, nondrying cleansers and noncomedogenic moisturizers may help reduce this irritation. Alternate-day dosing may be used if irritation persists. Topical retinoids thin the stratum corneum, and they have been associated with sun sensitivity. Instruct patients about sun protection. Also see Sunscreens and Photoprotection.

Topical antibiotics are mainly used for their role against Propionibacterium acnes. They may also have anti-inflammatory properties. Topical antibiotics are not comedolytic, and bacterial resistance may develop to any of these agents. The development of resistance is lessened if topical antibiotics are used in combination with benzoyl peroxide.^[18] Commonly prescribed topical antibiotics for acne vulgaris include erythromycin and clindamycin alone or in combination with benzoyl peroxide. Clindamycin and erythromycin are available in a variety of topical agents. They may be applied once or twice a day. Gels and solutions may be more irritating than creams or lotions. Clindamycin has maintained better efficacy than erythromycin.

Benzoyl peroxide products are also effective against P acnes, and bacterial resistance to benzoyl peroxide has not been reported.^[19] Benzoyl peroxide products are available over the counter and by prescription in a variety of topical forms, including soaps, washes, lotions, creams, and gels. Benzoyl peroxide products may be used once or twice a day. These agents may occasionally cause a true allergic contact dermatitis. More often, an irritant contact dermatitis develops, especially if used with tretinoin or when accompanied by aggressive washing methods. If intensive erythema and pruritus develop, a patch test with benzoyl peroxide is indicated to rule out allergic contact dermatitis.

Systemic treatments

Systemic antibiotics are a mainstay in the treatment of acne vulgaris. These agents have anti-inflammatory properties, and they are effective against P acnes. The tetracycline group of antibiotics is commonly prescribed for acne. The more lipophilic antibiotics, such as doxycycline and minocycline, are generally more effective than tetracycline. Greater efficacy may also be due to less P acnes resistance to minocycline. However, P acnes resistance is becoming more common with all classes of antibiotics currently used to treat acne vulgaris.^[20]P acnes resistance to erythromycin has greatly reduced its usefulness in the treatment of acne. Subantimicrobial therapy or concurrent treatment with topical benzoyl peroxide may reduce the emergence of resistant strains.

Although continued use of systemic tetracycline group antibiotics was believed to result in colonization with tetracycline-resistant Staphylococcus aureus, this does not appear to be true. A study by Fanelli et al found that S aureus remained sensitive to tetracycline even after prolonged use of that antibiotic for acne. This has significant ramifications when considering efforts to control the spread of methicillin-resistant S aureus (MRSA) because tetracycline group antibiotics are currently one of the primary options for outpatient treatment of MRSA.^[21]

Other antibiotics, including trimethoprim alone or in combination with sulfamethoxazole, and azithromycin, reportedly are helpful.^{[22, 23]}

Some hormonal therapies may be effective in the treatment of acne vulgaris. Oral contraceptives increase sex hormone–binding globulin, resulting in an overall decrease in circulating free testosterone. Combination birth control pills have shown efficacy in the treatment of acne vulgaris.^{[24, 25, 26, 27]}

Spironolactone may also be used in the treatment of acne vulgaris.^[28] Spironolactone binds the androgen receptor and reduces androgen production. Adverse effects include dizziness, breast tenderness, and dysmenorrhea. Dysmenorrhea may be lessened by coadministration with an oral contraceptive. Periodic evaluation of blood pressure and potassium levels is appropriate. Pregnancy must be avoided while taking spironolactone because of the risk of feminization of the male fetus.

Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne vulgaris. Isotretinoin causes normalization of epidermal differentiation, depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of P acnes. Isotretinoin therapy should be initiated at a dose of 0.5 mg/kg/d for 4 weeks and increased as tolerated until a cumulative dose of 120-150 mg/kg is achieved. Coadministration with steroids at the onset of therapy may be useful in severe cases to prevent initial worsening. Some patients may respond to doses lower than the standard recommendation dosages. A lower dose (0.25-0.4 mg/kg/d) may be as effective as the higher dose given for the same time period and with greater patient satisfaction. Lower intermittant dosing schedules (1 week out of each month) are not as effective.^[29]

Isotretinoin is a teratogen, and pregnancy must be avoided. Contraception counseling is mandatory, and 2 negative pregnancy test results are required prior to the initiation of therapy in women of childbearing potential. The baseline laboratory examination should also include cholesterol and triglyceride assessment, hepatic transaminase levels, and a CBC count. Pregnancy tests and laboratory examinations should be repeated monthly during treatment.

Acne can be a very depressing situation. It freezes personality development in the adolescent stage and may create hostility, anger, and antisocial behavior. Associated mood changes and depression have also been reported during treatment. Isotretinoin may heighten feelings of depression and suicidal thoughts.^[30] Do not administer isotretinoin to a depressed or suicidal teenager. Although a cause-and-effect relationship has not been established, patients should be informed of this potential effect and must sign a consent form acknowledging they are aware of this potential risk.^{[31, 32]}

A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.

While using isotretinoin, the patient is considered at high risk for abnormal healing and the development of excessive granulation tissue following procedures. Many dermatologists delay elective procedures, such as dermabrasion or laser resurfacing (eg, with carbon dioxide laser or erbium:YAG laser), for up to 1 year after completion of therapy. Other procedures to be avoided during therapy include tattoos, piercings, leg waxing, and other epilation procedures. Note the images below.

A summary of the American Academy of Dermatology treatment guidelines, Guidelines of care for acne vulgaris management, may be of interest.^[33] Also see the Medscape Acne Resource Center.

Procedural treatments include manual extraction of comedones and intralesional steroid injections. Additionally, some patients may benefit from superficial peels that use glycolic or salicylic acid. Phototherapy using red light or blue light and photodynamic therapy are being assessed as potential treatments for acne.^{[34, 35]} The usefulness of some fractional laser treatments in the management of acne is also being evaluated.

If the patient is feeling depressed while taking isotretinoin, refer him or her to a specialist for help.

Diet therapy has been suggested. Drs Kligman, Fulton, and Plewig performed a study on chocolate, having teenage patients with acne consume 1 bar of chocolate each day. Some of the patients improved and some worsened, but the vast majority were unchanged. This study helped decrease the emphasis on diet as a causal factor in acne vulgaris. However, investigators always returned to the diet question. Data suggest that the westernization of certain Native American populations and the consumption of unhealthy "junk" foods (eg, potato chips, soft drinks) has had a negative impact on general and skin health, resulting acne flares.

Investigators have also focused on a low-glycemic diet to avoid stress from high-carbohydrate diets and to reduce insulin levels. Studies have been encouraging,^[36] so the author recommends the "South Beach Diet"^[37] and provides patients with the glycemic index of foods. The author recommends that acne patients eat nothing higher than 70 on the glycemic index.