eMedicine Specialties > Dermatology > Diseases of the Adnexa
Acne Conglobata: Treatment & Medication
Updated: Jun 4, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The therapy of choice for acne conglobata (AC) is isotretinoin 0.5-1 mg/kg for 4-6 months.
- Simultaneous use of systemic steroids, such as prednisone 1 mg/kg/d for 2-4 weeks, may also prove beneficial, particularly if systemic symptoms are evident.
- Alternatives include oral tetracycline 2 g/d or erythromycin 2 g/d, either alone or with isotretinoin or prednisone.
- For treatment-resistant cases, dapsone 50-150 mg/d is recommended; this treatment should be carefully monitored.18
- Along with vigorous medical therapy, emotional support is essential.
- Treatment of acne conglobata with infliximab has been tried19 ; the authors do not recommend this therapy.
- Successful treatment of perifolliculitis capitis abscedens et suffodiens, including acne conglobata, has been described with combined isotretinoin and dapsone.20
- Acne conglobata has been successfully treated by carbon dioxide laser combined with topical tretinoin therapy.21
Surgical Care
- Large hemorrhagic nodules may be aspirated.
- Intralesional triamcinolone or cryotherapy may also be valuable.22
- Occasionally, surgical excision of interconnecting large nodules may be beneficial.23
Medication
The goals of pharmacotherapy and surgical approaches are to reduce morbidity and to prevent complications. They may be combined.24 For example, acne conglobata can be treated by fractional laser after carbon dioxide laser abrasion of cysts combined with topical tretinoin therapy.25
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisolone (Delta-Cortef, Econopred, Articulose-50)
Synthetic adrenocortical steroid with predominantly glucocorticoid properties. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Stabilizes lysosomal membranes and also suppresses lymphocyte and antibody production.
Adult
0.5-1 mg/kg/d PO for 6 wk; taper as condition improves
Single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect
Pediatric
Initial: 0.14-2 mg/kg/d PO divided tid/qid (4-60 mg/m2/d)
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, connective tissue, or tubercular infection; peptic ulcer disease; hepatic dysfunction; GI tract disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
Retinoids
Vitamin A derivatives have many roles. They encourage cellular differentiation, they are antiproliferative, and they serve as immunomodulators.
Isotretinoin (Accutane)
Oral agent that treats serious dermatologic conditions. Isotretinoin is the synthetic 13-cis isomer of the naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to beta-carotene. Decreases sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
Effective March 1, 2006, FDA requires that prescribers of isotretinoin, patients who take isotretinoin, and pharmacists who dispense isotretinoin all must register with the iPLEDGE system.
Adult
Initial: 0.5 mg/kg/d PO, increase gradually (usually 1 mg/kg/d) for 20 wk
Pediatric
Administer as in adults
Toxicity may occur with beta carotene coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; exaggerated healing response of acne lesions (ie, excessive granulation with crusting) may occur; patients with diabetes may experience problems in controlling blood glucose levels while on isotretinoin; avoid exposure to UV light or sunlight until tolerance is achieved; discontinue if rectal bleeding, abdominal pain, or severe diarrhea occurs; mood swings or depression may occur; caution in history of depression
Tretinoin (Avita, Retin-A, Retin-A Micro)
Structurally related to vitamin A. May be helpful for recalcitrant disease, but recurrence is common. Long-term, low-dose therapy may be suitable for selected patients.
May cause skin irritation in some patients. Also, has been linked to promotion of angiogenesis; however, has not demonstrated increased telangiectasias.
Also inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
Adult
Begin with lowest concentration of tretinoin formulation and increase as tolerated; apply hs or qod; lower frequency of application if irritation develops
Pediatric
Not established
Toxicity may occur with vitamin A coadministration; toxicity increased when coadministered with sulfur, benzoyl peroxide, resorcinol, or any product with strong drying effects; phototoxicity increased when coadministered with tetracyclines, fluoroquinolones, or thiazides
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with excessive sunlight exposure; burning, stinging, peeling, pruritus, or erythema has been reported at site of application; caution with eczema (may cause severe irritation); avoid contact with mucous membranes, mouth, and angles of nose
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.
Roxithromycin (Rulid, Oxoid)
Not available in the United States. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, thereby arresting RNA-dependent protein synthesis.
Adult
150-300 mg PO bid for 4-6 wk, continue if response is favorable
Pediatric
Not established
Toxicity increases with coadministration of fluconazole and pimozide; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease; GI tract adverse effects are common (administer doses pc); discontinue if nausea, vomiting, malaise, abdominal colic, or fever occur
Clarithromycin (Biaxin)
6-methoxy erythromycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, thereby arresting RNA-dependent protein synthesis.
Adult
250-500 mg PO bid for 4-6 wk, continue if response is favorable
Pediatric
Not established
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and GI tract adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl is <30 mL/min; diarrhea may indicate pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; fewer GI tract adverse effects occur than with erythromycin; more expensive
More on Acne Conglobata |
| Overview: Acne Conglobata |
| Differential Diagnoses & Workup: Acne Conglobata |
 Treatment & Medication: Acne Conglobata |
| Follow-up: Acne Conglobata |
| Multimedia: Acne Conglobata |
| References |
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References
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Further Reading
Keywords
acne conglobata, AC, pyoderma gangrenosum, aseptic arthritis, PAPA syndrome, acne fulminans, AF
