Medication Summary
The goals of pharmacotherapy are to reduce inflammation and eliminate infection, if present.
Corticosteroids
Class Summary
These agents are used for their anti-inflammatory properties, but they must be used with caution because they have local and systemic adverse effects. Topical corticosteroids may be used alone or in combination retinoic acid.
Triamcinolone (Kenalog-10, Kenalog-40, Aristospan)
Triamcinolone can be used topically or injected intralesionally. It decreases inflammation by suppressing the migration of PMN leukocytes and reversing capillary permeability.
Prednisone
Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. It is used when the patient has an acute flare.
Clobetasol propionate (Temovate, Clobex, Cormax)
Clobetasol propionate is a class 1, superpotent steroid that can be applied to the skin twice daily for 2 weeks. It comes in various formulations as solutions, lotions, creams, ointments, gels, and foams. Clobetasol propionate causes vasoconstriction, inhibits mitotic activity, and stimulates the synthesis of enzymes responsible for decreasing inflammatory reactions.
Halobetasol (Ultravate)
Halobetasol inhibits the initial manifestation of the inflammatory process, as well as the subsequent sequelae, which may include angiogenesis and fibroblast proliferation.
Fluocinonide (Vanos)
Fluocinonide is a class 2, potent topical steroid. It is available in various formulations, including a solution, cream, and ointment.
Retinoid-like Agents
Class Summary
Although the exact mechanism of action for AKN is unknown, retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, modulate keratinocyte differentiation, and have anti-inflammatory properties.
Isotretinoin (Claravis, Amnesteem, Sotret)
Isotretinoin is an oral retinoid indicated for recalcitrant, nodulocystic acne. It addresses all four pathogenic factors involved the development of acne: follicular hyperkeratinization, inflammation, sebum production, and Cutibacterium acnes (formerly Propionibacterium acnes) growth. Treatment is weight-based, usually dosed initially 0.5 mg/kg and increased to 1 mg/kg. The total dosage ranges from 120-150 mg/kg and is achieved over 4-6 months. Patients must be registered into the government-regulated iPledge program in order to receive the medication.
Tretinoin topical (Retin-A, Avita, Refissa, Renova, Tretin X, Atralin)
Although the exact mechanism of action of tretinoin is unknown, retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, modulate keratinocyte differentiation, and have anti-inflammatory properties. Tretinoin topical is available as 0.025%, 0.05%, and 0.1% creams and 0.01% and 0.025% gels.
Adapalene (Differin)
Adapalene inhibits microcomedo formation. It normalizes keratinocyte differentiation in sebaceous follicles and it has anti-inflammatory properties. Adapalene is available as 0.1% gel, cream, and lotion and 0.3% gel..
Tazarotene (Tazorac)
Tazarotene inhibits microcomedo formation. It normalizes keratinocyte differentiation in sebaceous follicles and has anti-inflammatory properties. Tazarotene is available as 0.05% and 0.1 creams and gels.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Mupirocin (Bactroban, Centany)
Mupirocin is a topical antibiotic; it inhibits bacterial growth by inhibiting RNA and protein synthesis.
Doxycycline (Doryx, Adoxa, Monodox, Vibramycin)
Doxycycline is a broad-spectrum antibiotic with excellent gram positive coverage, including most resistant staph organisms. It inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Rifampin (Rifadin)
Rifampin inhibits RNA synthesis in bacteria by binding to the beta-subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.
Acne Agents, Topical
Class Summary
Acne products are used for the treatment of mild to moderate acne vulgaris. These agents may have antibacterial and comedolytic properties. In severe cases, the agents may be used as an adjunct in therapeutic regimens.
Benzoyl peroxide (BenzeFoam, PanOxyl, Triaz, Neutrogena On The Spot, Invisible Acne Treatment, Acne Clear Maximum Strength)
Benzoyl peroxide is an oxidizing agent that possesses antibacterial properties and is comedolytic. Benzoyl peroxide is oxidized into benzoic acid with contact to the skin. It is available over the counter and by prescription. It can be used as a topical leave-on or wash-off product.
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Numerous acne keloidalis papules and plaques in a white man with straight hair.
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A large acne keloidalis plaque in a bandlike distribution at the posterior occiput in an African American man.
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A large acne keloidalis plaque on the occipital region in an African American patient. This man also had perifolliculitis of the scalp and acne conglobata (the follicular occlusion triad).
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Numerous papules that have coalesced into a large plaque, within which are tufts of hairs with several hair shafts exiting the same follicular orifice.
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A dense plasma cell infiltrate surrounding a hair follicle.
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Naked hair shafts embedded within a fibrotic dermis.
