Acne

from ACP Medicine

Posted 09/09/2004

Mark Lebwohl, M.D.

Definition/Key Clinical Features

* Characteristic skin lesions

o Open and closed comedones
o Erythematous papules
o Pustules
o Nodules
o Cysts
o Scars
* Most commonly affects face but can involve back and chest
* Earlier onset and increased severity in males
* Premenstrual flares common in females

Major forms

Comedonal Acne

* Comedones
o Keratinized cells
o Sebum
* Predominance of open (blackheads) and closed (whiteheads) comedones

Inflammatory Acne

* Erythematous papules (3-10 mm)

o Develop into pustules or resolve into fading erythematous macule
o May cause postinflammatory hyperpigmentation
o Pustules
o Superficial, dry in a few days
* Nodules (>/= 1 cm)
o Firm, erythematous, tender nodules becoming fluctuant or forming cysts
o Fluctuant sinuses result in postinflammatory pigmentary changes and scarring

Clinical Variants

* Acne conglobata
o Severe form with confluent large cysts, abscesses, and draining sinus tracts
* Acne cosmetica
o Low-grade form resulting from use of greasy, occlusive cosmetics and lotions
* Acne excoriée
o Large ulcers and erosions caused by picking of minor lesions
* Acne mechanica
o From repeated trauma and rubbing (e.g., wearing sports helmets, shoulder pads, or bras)
* Pomade acne
o Caused by thick oils in hair
* Neonatal and infantile acne
o Erythematous papules and pustules lasting 2-6 mo after birth
o May signal severe acne later in life

Differential Diagnosis

* Folliculitis
* Milia
* Perioral dermatitis
* Chloracne
* Hidradenitis suppurativa
* Favre-Racouchot disease
• Rosacea
Best Tests

• Diagnose by clinical features

Best Therapy

* Depends on acne type and severity

Topical Therapies

Comedonal Acne

* Topical retinoids to unplug follicles and allow topical antibiotic and benzoyl peroxide penetration.

Inflammatory Acne

* Treatment alternatives (by effectiveness)

o Retinoids and benzoyl peroxide most effective
o Topical antibiotics less effective but better tolerated.
+ Can be used in combination with benzoyl peroxide (clindamycin 1% and benzoyl peroxide 5%).
+ Common regimen: antibiotic-benzoyl peroxide in morning and topical retinoid in evening.
o Azelaic acid
+ Can be used in combination with topical retinoids, benzoyl peroxide, or topical antibiotics.
o Sulfur-resorcinol lotion
o Effective drying and peeling agent for treating individual lesions.

Topical Drugs for Acne

Retinoids

* Most effective
* Adverse effects
o Dryness
o Irritation
o Photosensitivity
* Adapalene
o Dose: 0.1% gel q.d.
o Cost/Mo: 15 g/$37.99
* Tazarotene
o Dose: 0.05% or 0.1% gel q.d.
o Cost/mo: 30 g/$75.99
* Tretinoin
o Dose: 0.01%-0.05% preparations q.d.
o Cost/mo: 20 g/$23.99

Benzoyl Peroxide

* Most effective
* Adverse effects
o Dryness
o Irritation
* Dose: 2.5%-10% preparations b.i.d.
* Cost/mo: 45 g/$13.99

Antibiotics

* Clindamycin
o Adverse effects
+ Antibiotic resistance
o Dose: 1% preparation b.i.d.
o Cost/mo: 30 g/$18.99
* Erythromycin
o Adverse effects
 + Antibiotic resistance
o Dose: 2% preparation b.i.d.
o Cost/mo: 30 g/$18.30
* Erythromycin-benzoyl peroxide
o Adverse effects
+ Dryness
+ Irritation
+ Contact dermatitis
o Dose: 3% erythromycin, 5% benzoyl peroxide gel b.i.d.
o Cost/mo: 46.6 g/$102.99
* Sodium sulfacetamide-sulfur
o Adverse effects
+ Dryness
+ Irritation
+ Contact dermatitis
o Dose: 10% sodium sulfacetamide, 5% sulfur lotion b.i.d.
o Cost/mo: 30 g/$21.99

Azelaic Acid

* Adverse effects
o Stinging
o Irritation
* Dose: 20% cream b.i.d.
* Cost/mo: 30 g /$45.99

Sulfur and Resorcinol

* Adverse effects
o Dryness
o Peeling
o Contact dermatitis
* Dose: 2% resorcinol, 8% sulfur preparation q.d. or b.i.d.
* Cost/mo: 18 g/$4.49

Salicylic Acid

* Adverse effects
o Dryness
o Irritation
* Dose: 0.5%-2% preparations q.d. or b.i.d.
* Cost/mo: 21 g/$7.99

Systemic Therapies for Nodulocystic Acne or Inflammatory Acne Unresponsive to Topical Therapy

Antibiotics: First-line Therapy

* Doxycycline
o Adverse effects
+ Photosensitivity
+ GI symptoms
+ Candidiasis
o Dose: 50-100 mg p.o., b.i.d.
o Cost/mo: $28.99
* Erythromycin
o Adverse effects
+ GI symptoms
+ Candidiasis
o Dose: 250-500 mg p.o., b.i.d.
o Cost/mo: $17.98
* Minocycline
o Adverse effects
+ GI symptoms
+ Candidiasis
 + Vertigo
+ Lupuslike syndrome (rare)
+ Hepatitis (rare)
o Dose: 50 mg p.o., q.d. to 100 mg p.o., q.i.d.
o Cost/mo: $13.99
* Isotretinoin
o Most effective agent; long-lasting remissions or cures; not used as first-line therapy because of serious
potential adverse effects (teratogenicity, hyperlipidemia, cheilitis, alopecia, pyogenic granulomas, dry eyes, epistaxis,
pseudotumor cerebri [rare]); limit treatment to 4-6 months or refer.
o Dose: 0.5-2 mg/kg/day in 2 divided doses
o Cost/mo: $60
* Tetracycline
o Adverse effects
+ Photosensitivity
+ GI symptoms
+ candidiasis
o Dose: 250 mg p.o., q.d. to 500 mg p.o., q.i.d.; b.i.d. preferred
o Cost/mo: $7.99
* Trimethoprim-sulfamethoxazole
o Adverse effects
+ Bone marrow suppression
+ Drug eruption
o Dose: 160 mg trimethoprim, 800 mg sulfamethoxazole b.i.d.
o Cost/mo: $28.98
* Norgestimate-ethinyl estradiol
o For women only; alternative to antibiotics and isotretinoin.
o Adverse effects
+ Thromboembolic disorders
+ Fluid retention
+ Hypertension
+ Breakthrough bleeding
+ Breast swelling and tenderness
o Dose: 0.18 mg norgestimate, 0.035 mg ethinyl estradiol p.o., q.d. for 21 days; repeat q. 4 wk
o Cost/mo: $32.99

Other Therapies

* Consider referral for the following:

o Specialized abrasion therapy
o Injections
o Surgery

Best References

Bershad S, Kranjac Singer G, Parente JE, et al: Successful treatment of acne vulgaris using a new method: results of a
randomized vehicle-controlled trial of short-contact therapy with 0.1% tazarotene gel. Arch Dermatol 138:481, 2002

Hirsch RJ, Lewis AB: Treatment of acne scarring. Semin Cutan Med Surg 20:190, 2001 [PMID 11594674]

Leyden J, Grove GL: Randomized facial tolerability studies comparing gel formulations of retinoids used to treat acne
vulgaris. Cutis 67(6 suppl):17, 2001

Strauss JS, Leyden JJ, Lucky AW, et al: A randomized trial of the efficacy of a new micronized formulation versus a
standard formulation of isotretinoin in patients with severe recalcitrant nodular acne. J Am Acad Dermatol 45:187, 2001
[PMID 11464179]