Medication Summary
Begin treatment with oral prednisone 1 mg/kg/day and taper over 6 weeks. By the fourth week, initiate isotretinoin at 0.25 mg/kg/day. If isotretinoin cannot be used, dapsone may be substituted for the retinoid, beginning at 50 mg/day and increasing to 100-150 mg/day.
Corticosteroids
Class Summary
These agents have profound and varied metabolic effects. They possess anti-inflammatory and immunosuppressive properties.
Prednisone
Prednisone is a synthetic adrenocortical steroid with predominantly glucocorticoid properties. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reducing capillary permeability. It stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
Prednisolone (Orapred, Pediapred, Millipred)
Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body.
Retinoid-like Agents
Class Summary
Vitamin A derivatives have many roles. They encourage cellular differentiation, are antiproliferative, and serve as immunomodulators.
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.
Suicidal ideation, a concern in seemingly healthy adolescents, should be anticipated in those with cosmetically disturbing skin disorders, such as acne fulminans. Some believe that isotretinoin may exacerbate this tendency.
Isotretinoin (Claravis, Amnesteem, Sotret)
Isotretinoin is an aral 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. It decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization.
Tretinoin topical (Avita, Retin-A, Retin-A Micro, Tretin-X)
Tretinoin topical is structurally related to vitamin A. It may be helpful for recalcitrant disease, but recurrence is common. Long-term, low-dose therapy may be suitable for selected patients. It may cause skin irritation in some patients. Also, it has been linked to the promotion of angiogenesis; however, it has not demonstrated increased telangiectasias. Tretinoin topical also inhibits microcomedo formation and eliminates lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. It is available as creams and gels.
Antibiotics, Other
Class Summary
These agents may inhibit bacterial growth by preventing the formation of folic acid.
Dapsone
Dapsone is bactericidal and bacteriostatic against Mycobacteria species; its mechanism of action is similar to that of sulfonamides, in which competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth. Its anti-inflammatory mechanism of action may involve suppression of neutrophil function by inhibition of the halide-myeloperoxidase system. Excretion is primarily in urine; its half-life is 28 hours.
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Granulomas and crusted acne lesions in acne fulminans. Courtesy of DermNet New Zealand (http://www.dermnetnz.org/assets/Uploads/doctors/follicular/images/fulmin2.jpg).
