ncc pediatrics continuity clinic curriculum: adolescent ... iii-residents.pdf · speciﬁc...

NCC Pediatrics Continuity Clinic Curriculum: Adolescent III: Acne

Overall Goal: Identify key adolescent health issues and become comfortable interviewing an adolescent.

Overall Outline: Adolescent I: Contraception

Adolescent II: Menstrual Irregularities

Adolescent III: Acne

********************************************************** Pre-Meeting Preparation:

• Acne And Its Management (PIR, 2013)• What’s in that product? Select a common non-prescription acne product and determine

what its active component(s) are and what its mechanism of action should be (e.g.Proactiv, Stridex, Clearasil, Neutrogena skinID).

Conference Agenda: • Complete Adolescent III Quiz & Case Studies• What’s in that product? Share your findings with your continuity group.

Extra Credit: • American Acne & Rosacea Society-Pediatric Treatment Recs- QUICK visual reference!• Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne

(Pediatrics, 2013- Clinical Practice Guideline)• Complementary, Holistic, and Integrative Medicine: Acne (PIR, 2013)• iPLEDGE: restricted-distribution program for Accutane for severe, recalcitrant nodular acne.

If you think your patient is eligible, place consult to see Adolescent or Derm. If female, placeon OCPs, as iPLEDGE requires 30 day window of “effective contraception”.

© Developed 2012 by MAJ Jennifer Hepps, MAJ Patricia Kapunan, Dr. Harshita Saxena, and COL Jeff Hutchinson. Edited 2018 by CPT Christopher Stark. Update C. Carr, 2019.

http://www.nccpeds.com/ContinuityModules-Fall/Fall%20Continuity%20Source%20Materials/Acne-Treatment%20Recs-Combined.pdf�

http://www.nccpeds.com/ContinuityModules-Fall/Fall%20Continuity%20Source%20Materials/Acne-AAP-CPG-2013.pdf�

http://www.nccpeds.com/ContinuityModules-Fall/Fall%20Continuity%20Source%20Materials/Acne-AAP-CPG-2013.pdf�

http://www.nccpeds.com/ContinuityModules-Fall/Fall%20Continuity%20Source%20Materials/Acne-CAM%20Therapies.pdf�

https://www.ipledgeprogram.com/default.aspx�

Acne and Its ManagementS. Alison Basak, MD, MA,*

Andrea L. Zaenglein, MD*†

Author Disclosure

Dr Basak has disclosed

no financial

relationships relevant

to this article. Dr

Zaenglein has

disclosed that she has

received research

grants from Galderma

Laboratories, Johnson

and Johnson, Medicis

Pharmaceutical Corp.,

Stiefel Laboratories

Inc., and Photocure

Inc., that she has

acted as a consultant

for Galderma, Promius,

Medicis, and Valeant

Pharmaceuticals

International, and that

she has been a speaker

for Galderma. This

commentary does

contain discussion of

unapproved/

investigative use of

a commercial product/

device.

Practice Gap

Acne is the most common skin disorder in the United States, affecting approximately

85% of young people between 12 and 24 years of age. Critical components to diminish

physical and psychological concerns and lessen the potential for permanent sequelae in-

clude correct choice of therapy, and promotion of adherence to therapeutic regimens by

educating patients regarding expected adverse effects, realistic expectations for im-

provement and the importance of maintenance regimens.

Objectives After completing this article, readers should be able to:

1. Diagnose different types of acne lesions and assess severity.

2. Recognize and correct common misconceptions about acne held by patients and their

parents.

3. Prescribe appropriate therapy according to the patient’s clinical presentation.

4. Educate patients regarding the expected course and potential adverse effects of

therapies.

IntroductionAcne vulgaris (acne) is the most common skin disorder in the United States. (1)(2) Theseverity can vary from mild comedonal acne to fulminant systemic disease that affects mul-tiple organ systems. Acne often is a cause of permanent scarring, emotional distress, anddecreased self-esteem, which has led to the development of a multibillion dollar industryof medications, beauty products, and procedures that target individuals with acne. (3)Highly effective treatments are available, so familiarity with the diagnosis and managementof this condition is essential for virtually all health care professionals.

EpidemiologyAcne vulgaris affects 40 million to 50 million individuals each year in the United States.(1)(4) Although acne, or one of its variants, can occur in people of every age, adolescentsare the most commonly affected group. Approximately 85% of people between 12 and24 years of age will have acne. (5) Adolescent acne usually begins with the onset of pu-berty, occurring earlier in girls than boys. Early on, blackheads and whiteheads predom-inate, and the midface, known as the T zone, is involved typically. Later, inflammatorylesions become more prevalent, and the lateral aspects of the cheeks, jaw, back, and chestare affected. Unfortunately, contrary to previous dogma, not all patients outgrow the

condition; 12% of women and 3% of men continue to haveclinical acne until 44 years of age. (6)

PathogenesisAcne is a chronic inflammatory process of the pilosebaceousunit, which consists of a hair, its associated sebaceous gland,and the opening of the follicle to the skin surface known asthe follicular ostium (colloquially called a pore). These unitsare concentrated on the face, back, and chest, which explains

Abbreviations

DHEAS: dehydroepiandrosterone sulfateFDA: Food and Drug AdministrationFSH: follicle-stimulating hormoneLH: luteinizing hormoneOTC: over the counter

*Department of Dermatology, Penn State Hershey Medical Center, Hershey, PA.†Department of Pediatrics, Penn State Hershey Medical Center, Hershey, PA.

Article dermatology

Pediatrics in Review Vol.34 No.11 November 2013 479

at USUHS LRC on December 22, 2014http://pedsinreview.aappublications.org/Downloaded from

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why acne is most prominent in these areas. Four interre-lated processes are known to contribute to acne develop-ment: abnormal keratinization with obstruction of thefollicle, androgen stimulation with increased sebum pro-duction, secondary inflammation, and proliferation ofbacteria (Fig 1).

Abnormal KeratinizationIndividual acne lesions begin with obstruction of the pi-losebaceous unit in a process known as comedogenesis.Normally, skin cells lining the upper portion of the hairfollicle are shed into the follicular lumen and extrudedthrough the follicular opening. In acne lesions, overpro-duction and abnormal cohesiveness of these desqua-mated epithelial cells leads to their retention within thefollicle and subsequent obstruction of the ostium.Termed microcomedones, these plugs prevent drainageof sebum out of the follicle and lead to its accumulationunderneath the skin, eventually forming clinically appar-ent comedones. Also, proinflammatory mediators, suchas interleukin 1 and tumor necrosis factor a are producedby keratinocytes that become activated in response to thedisrupted epithelium caused by accumulating sebum. (7)

Comedones can be divided into open and closed sub-types (blackheads and whiteheads, respectively). Theopen comedone is an easily visible, small, dome-shapedpapule with a widely dilated, black-appearing orifice. Al-though the exact cause of the black color is unknown, it isthought to be secondary to melanin deposition, oxida-tion of the keratinous material and lipids at the opening,or interference with light transmission through com-pacted epithelial cells. The color is not due to dirt or poorhygiene. Closed comedones are small, white or flesh-colored papules with no surrounding erythema. Often

they are not immediately obvious to the naked eye butcan be appreciated better on palpation, stretching, or sidelighting of the skin. Closed comedones are obstructedfollicles in which the opening to the surface has remainedmicroscopic and keeps the contents from escaping.Closed comedones are the lesions that, when they rup-ture, lead to the pustules, nodules, cysts, and scars seenin inflammatory acne.

Hormonal Stimulation of Sebum ProductionProduction of sebum, the oily, lipid-rich substance madeby sebaceous glands, is controlled primarily by gonadaland adrenal androgen hormone stimulation. Levels of de-hydroepiandrosterone sulfate (DHEAS), testosterone,and dihydrotestosterone notably increase at adrenarche,resulting in bigger sebaceous glands that produce moresebum. As the sebum accumulates, microcomedones en-large into visible comedones. The pressure eventuallyruptures the follicle wall in the dermis, causing extrusionof the comedo contents into surrounding epithelium andinitiating an inflammatory response. Although hormonesplay a critical role in the pathogenesis of acne, most pa-tients with acne have normal circulating hormone levels.(8)(9)

InflammationInflammation leads to the characteristic papules and pus-tules of acne. The clinical appearance of the lesion de-pends not only on the size of the comedo that hasruptured but also on the extent of the inflammatory re-action in the dermis. Pustules greater than 5 mm in diam-eter are termed nodules and tend to be seated deeper inthe dermis. They may coalesce into sinus tracts. The de-gree of inflammation, determined somewhat by host-specific responses, is a key determinant of scar forma-tion. A person’s innate immunity plays a large role inacne, with factors such as b-defensins and cathelicidinsall contributing to resultant inflammation. (10)(11)(12)

BacteriaThe ordinarily harmless bacterium, Propionibacteriumacnes, contributes significantly to the production of acne.These commensal, gram-positive, nonmotile rods arefound deep within the sebaceous follicle. They producechemotactic factors, proinflammatory mediators, and li-polytic enzymes through the Toll-like receptor 2 pathwaythat break down sebum into immunogenic components.All of these agents serve to intensify inflammation at rup-tured comedones. (13)(14)(15) Hypersensitivity toP acnes also may play a part in the more severe formsof acne. (16) Acne vulgaris is not an infection but ratherFigure 1. Pathogenesis of acne.

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480 Pediatrics in Review Vol.34 No.11 November 2013



an inflammatory process in which bacteria may aggravatebut not precipitate the disorder.

GeneticsThe tendency to develop acne and the severity of acne areoften familial. The number, size, and activity of sebaceousglands are inherited, and concordance of acne severityamong identical twins is high. (17) However, given theextremely high prevalence of acne and the influence ofenvironmental factors, it is not possible to attribute thepresence of acne solely to genetic factors. (18)

Environmental and Exacerbating FactorsIn addition to the pathogenic factors mentioned above,there may be other triggers or exacerbating conditions.Stress appears to be a common trigger for acne, possiblyvia activation of the hypothalamic-pituitary-adrenal axisand subsequent increase in androgen production. Me-chanical factors, such as skin occlusion from sports gear(such as helmets, chin straps, and shoulder pads) mayworsen acne. Premenstrual flares are common. Topicallyapplied occlusive preparations, such as pomades and co-coa butter, can contribute to physical blockage of pilose-baceous units. Oils or greases in the work environmentalso can cause obstructive lesions, affecting people suchas mechanics or fast-food workers. Several medicationsworsen acne, including anabolic steroids, progestins, lith-ium, isoniazid, hydantoin, and gold. (19)

Patients frequently are concerned about the effect oftheir diet on their acne. Diet’s role in acne currently isa hotly debated topic among acne researchers. Althoughsubstantiated dietary culprits may emerge in the future,several controlled studies to date have refuted the value

of dietary restrictions in limiting acne eruptions. (20)(21)(22) For many years, the elimination of foods suchas chocolate, soft drinks, milk, fatty foods, ice cream,and iodides was recommended; however, the literaturecurrently does not support these restrictions. (23) Al-though there may be many good reasons to limit intakeof these foods, prevention of acne is not one of them. Apatient occasionally will insist on an apparent relationshipbetween a particular food and acne flare-ups, in which caselimiting intake of that particular food is common sense.

Another common misperception is that frequent facewashing will improve acne. Dirt does not cause acne. Infact, frequent washing and the use of harsh products canirritate the skin, worsen acne, and impair a patient’s tol-erance for topical medications that truly have the capacityto improve their acne. Commonly held misconceptionsare reviewed in Table 1.

Clinical PresentationAcne can occur at any age, and presentations can varywidely. Acne’s protean clinical manifestations in-clude comedones, pustules, papules, nodules, scars,and dyspigmentation. Guidelines for the treatmentof childhood acne were recently published and en-dorsed by the American Acne and Rosacea Societyand the American Academy of Pediatrics to establishtreatment standards for children with acne. (24)

Neonatal AcneNeonatal acne is a common disorder, affecting up to 20%of healthy neonates. Involvement usually is limited to theface and most often presents within the first 30 days of life(Fig 2). This acneiform eruption is thought to be related

Table 1. Acne Misconceptions Corrected

Myth Reality

Acne is due to poor diet Overall, current evidence does not support this. Studies that suggest otherwise need tobe replicated before dietary restriction can be justified.

Bad hygiene causes acne Frequent washing has no improving effect on acne and can actually worsen it. It canalso decrease tolerance of acne medications that might otherwise be very effective.

Acne is infectious Acne is not contagious. Bacteria can worsen but do not cause acne.Make-up makes acne worse Greasy cosmetics should be avoided. Noncomedogenic products are fine.Squeezing pimples makesthem go away faster

Squeezing comedones and pustules increases the risk of scarring and can prolong theirpresence by inciting inflammation, especially if the lesions rupture into the skinrather than to the surface.

Acne only affects teenagers People of all ages can be affected by acne, and it may persist well beyond the teen years.Acne is cosmetic Clinicians often underestimate the psychological effect of acne. For many patients with

acne, it is devastating. Rare subtypes of acne can be associated with systemic illness.Moisturizer makes acne worse Noncomedogenic moisturizers are an important adjunct to topical retinoids and will not

undo the beneficial effects of the medication. Most modern over-the-counter lotionsare noncomedogenic.

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to stimulation of sebaceous glands by maternal androgensand colonization with yeast species. Malassezia furfurand Malassezia sympodialis often are visible on pustulesmears. Whether what most pediatricians know as neona-tal acne is true acne is controversial. Many pediatric der-matologists prefer the term neonatal cephalic pustulosis todescribe this common neonatal process. Most cases re-solve spontaneously in several weeks and do not requiretreatment. In pronounced cases, ketoconazole cream, 2%or hydrocortisone cream, 1%, can be used. If true come-dones or nodular lesions are noted, the child should betreated for infantile acne.

Infantile AcneInfantile acne usually has an age of onset between 3 and 6months of life. Typically, an admixture of comedones,papules, and pustules is observed on the face (Fig 3). In-fantile acne results from physiologic increased productionof adrenal and gonadal androgens. Most infants have nohyperandrogenism. However, a complete hormonal eval-uation is indicated in any infant with unusually severe orpersistent acne or other signs of hyperandrogenism. Mostcases resolve by 2 to 3 years of age, with some lasting upto age 5 years. (25)(26)

It is important to treat even mild cases of infantileacne because scarring is significantly more common inthis age group. Up to 50% of these infants can developpitted scars on their cheeks as a consequence of acne.(27) Treatment with a mild retinoid, such as adapalenegel, 0.1%, or tretinoin cream, 0.025%, may be used dailywith benzoyl peroxide cream, 2.5%. Certain formula-tions, such as washes and alcohol-based gels, should beavoided in infants because of the risk of irritation of skinand eyes. For treatment of more severe inflammatory

lesions, oral erythromycin, azithromycin, or trimethoprim-sulfamethoxazole can be used. For the rare cases of nodu-locystic acne, referral to a dermatologist for oral isotretinoinis appropriate.

Mid-Childhood AcneIn children between 1 and 7 years of age, new-onset acneis unusual, and hyperandrogenism should be ruled outwith a thorough history, physical examination, and labo-ratory evaluation. (28) During these years, androgen pro-duction should be minimal until approximately 7 years ofage, when adrenarche occurs with a resurgence of adrenalandrogen production. When acne occurs before the nor-mal timing of adrenarche, the child requires an evaluationfor causes of hyperandrogenism, such as congenital adre-nal hyperplasia, gonadal or adrenal tumors, Cushing syn-drome, and precocious puberty. Treatment is similar tothat for adolescent acne (with the exception of using tet-racyclines due to the risk of teeth staining) and includesregulation of any identified cause of hyperandrogenism.

Preadolescent AcneIn children 7 years and older, acne often is the first sign ofimpending puberty, especially in girls. Acne can precedepubic hair development, areolar budding in girls, and tes-ticular enlargement in boys. (28) Most affected childrenhave comedonal lesions that involve the T-zone of thechin, nose, and forehead (Fig 4). Therapy of acne in thisage group follows the same algorithm as adolescent acne.

Adolescent AcneAcne in adolescence can present in a variety of ways.Comedonal acne, as the name suggests, consists primarilyof noninflammatory blackheads and whiteheads on the

Figure 2. Neonatal acne. Figure 3. Infantile acne.

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face and, occasionally, the back and chest. Papulopustularacne is characterized by erythematous papules and pus-tules 1 to 5 mm in diameter. As the severity progresses,nodules form and become inflamed, indurated, and

tender. Acne cysts that contain pus and serosanguinousfluid develop deeper within the skin, resulting in the nod-ulocystic acne subtype. In the most severely afflicted pa-tients, these lesions coalesce into complex cystic plaques,abscesses, and sinus tracts. This severe degree of acne with-out systemic manifestations is termed acne conglobata.

Acne fulminans is a rare and severe variant, occurringalmost exclusively in boys between 13 and 16 years ofage. Acne fulminans is characterized by the abrupt onsetof nodular and suppurative acne in association with sys-temic manifestations, including fever, arthralgias, osteo-lytic bone lesions, myalgias, hepatosplenomegaly, andsevere fatigue. Laboratory abnormalities include leukocy-tosis and an increased erythrocyte sedimentation rate.Acne fulminans requires emergent evaluation by a derma-tologist for initiation of therapy with systemic corticoste-roids and isotretinoin. (29) In rare refractory cases,systemic treatment with dapsone, infliximab, cyclospor-ine, and azathioprine has been used as alternate or ad-junctive therapy. (30)(31)(32)(33)

In any patient with an inflammatory type of acne,postinflammatory hyperpigmentation and persistent mac-ular erythema often complicate the treatment of lesionsand tend to persist for many months, even when the acneis controlled. Patients can be reassured, however, thatthese changes will eventually resolve once the conditionis controlled. Continued use of topical retinoids canspeed resolution of postinflammatory hyperpigmenta-tion. (34) Unfortunately, scarring is permanent becauseit results from fibrous contraction after resolution of in-flammation. The type and extent of scarring depend on

Figure 4. Preadolescent acne.

Figure 5. Treatment algorithm for adolescent acne. Triple therapy is benzoyl peroxide (BP), topical retinoid, and oral antibiotic.Abx[topical antibiotic (such as topical clindamycin or erythromycin); COC[combined oral contraceptive.

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the acne severity and the patient’s individual susceptibilityto cicatrization. Scars on the face appear most commonlyas sharply punched-out deep or shallow pits. On thetrunk, the residual lesions typically are small hypopig-mented macules. Hypertrophic and keloidal scars can oc-cur in susceptible patients.

EvaluationThe most important part of an acne evaluation is the his-tory. A list of useful questions and their rationale is pre-sented in Table 2. Physical examination should includethe back, chest, and facial skin. Additional examinationshould be guided by the history. The general severityof acne can be categorized as mild (Fig 6), moderate(Fig 7), or severe (Fig 8), per the guidelines describedin Table 3. Most patients with acne do not have endo-crinologic abnormalities; therefore, laboratory evalua-tion should be reserved for those patients whose acne

is associated with additional evidence of androgen ex-cess. (35) Such evidence varies with the patient’s ageand sex but can include hirsutism, irregular menses,androgenetic alopecia, deepened voice, female clitorome-galy, male virilization, abrupt acne onset, or treatment-resistant acne.

Potential causes of androgen excess include polycysticovary syndrome, congenital adrenal hyperplasia, gonadalor adrenal tumors, Cushing syndrome, and precociouspuberty. Initial evaluation should include bone age deter-mination and measurement of prolactin, free and totaltestosterone, DHEAS, and 17-hydroxyprogesterone, aswell as the ratio of luteinizing hormone (LH) to follicle-stimulating hormone in females. Abnormalities warrantreferral to a pediatric endocrinologist. In menstruatingfemales, LH and FSH studies should be performed eitherjust before or during a menstrual period, and patientsshould not be taking hormonal contraceptives.

Table 2. Key Elements of the Acne History

Question Rationale

For All PatientsHow long has patient had acne? When did it begin? Early- or late-onset acne may indicate androgen excess. Abrupt

onset and treatment resistance may also be signs of androgenexcess.

What over-the-counter and prescription medicationshave been tried? How were they applied and forhow long? If applicable, why was use of medicationdiscontinued?

Is the patient treatment naive? If resistant, could impropertechnique or an insufficient therapeutic trial be the reasonfor failure? Would a different strength, combination product,or vehicle help tolerability?

What kinds of cosmetics and/or hair products doesthe patient use? Is the patient involved in anyoccupational or recreational activities that canworsen acne?

Can exacerbating factors be minimized? Occlusion from beautyproducts and/or pressure applied from sporting gear, tightclothes, or greases may worsen acne. Noncomedogenicproducts should be used.

Is there a history of other medical problems? Certain medical conditions are associated with recalcitrantacne. Adolescents with sensitive skin or a history of eczemamay have less tolerance for drying or irritating topical acnemedications.

Does the patient pick at their acne? Picking at lesions worsens inflammation and is more likely tolead to scarring. Behavior modification can make a hugedifference.

How much does the acne bother the patient? Severity of acne is highly subjective. The patient’s desire fortherapy and motivation for improvement should beconsidered to select the most appropriate treatment.

For Female PatientsIs the patient menstruating? If so, are mensesregular?

Could androgen excess, such as polycystic ovary syndrome, becontributing to patient’s acne?

Does the patient have premenstrual flares? Premenstrual flares are common. Combined oral contraceptivesare often helpful in this situation.

Is there a history of hirsutism, oligomenorrhea,clitoromegaly, or androgenetic alopecia?

Are there signs of androgen excess that would indicate the needfor blood work and/or endocrine referral?

Does the patient use hormonal birth control? Progesterone-only hormonal contraceptives can worsen acne.Combination estrogen-progesterone products improve acne.

Adapted with permission from Krowchuk DP. Managing adolescent acne: a guide for pediatricians. Pediatr Rev. 2005;26(7):250–261.

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TherapyThere is no single most appropriate therapy for acne vul-garis. Rather, treatment must be individualized based onresponse to previously attempted therapies, degree of ac-tivity of the acne, patient distress, likelihood of patientcompliance, and severity of scarring. Patient educationis vital, regardless of the therapy chosen. The clinicianmust dispel acne myths, highlight the essential need forprolonged adherence to therapy, emphasize the delayedand gradual nature of improvement, and prepare the pa-tient for likely adverse effects and how to manage them.(36) When each of these components is not addressed,dissatisfaction with therapy is highly likely and patientsmay stop using a therapy that could have been safe andeffective if given a proper trial. Therapies control acnebut, with the possible exception of isotretinoin, do notcure it. A treatment algorithm is provided in Figure 5.

Topical TreatmentsTopical treatments often are the first line of therapy formild-to-moderate acne and also are useful as part of com-bination therapy for more severe acne. Commonly usedtopical medicines include antimicrobials, antibiotics, ret-inoids, and salicylic acid. Dosing, formulations, and

possible adverse effects for the most frequently prescribedtopical medications are summarized in Table 4. Topicalmedications are preventive and require 8 to 12 weeksof use to judge their efficacy. The entire area affectedby acne must be treated, not just current lesions, andlong-term therapy usually is required.

Several fixed-dose combination therapies are availableto treat acne (benzoyl peroxide– clindamycin, benzoylperoxide–erythromycin, adapalene benzoyl peroxide,and tretinoin-clindamycin). These products, althoughgenerally more costly, often have greater adherence be-cause of the once daily application. (37) Most manufac-turers offer coupon or rebate programs to patients toimprove affordability (see individual product websitesfor information).

BENZOYL PEROXIDE. Benzoyl peroxide is a commonactive ingredient in many over-the-counter (OTC) prod-ucts. Benzoyl peroxide is bactericidal for P acnes and alsohas comedolytic properties, possibly by decreasing forma-tion of free fatty acids, thereby enhancing follicular des-quamation and decreasing follicular plugging. Benzoylperoxide is an excellent medication for patients with mildcomedonal or inflammatory acne. Benzoyl peroxide alsoprevents the emergence of antibiotic-resistant P acnes,

Figure 6. Mild acne. Figure 7. Moderate acne.

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making it a useful adjunctive therapy in patients beingtreated with topical or oral antibiotics. (38)(39)(40)

Benzoyl peroxide is available both with and withouta prescription in concentrations ranging from 2.5% to10%. The prescription form generally involves a gel vehi-cle for enhanced efficacy or combines the benzoyl perox-ide with another topical agent, such as an antibiotic ora retinoid, for enhanced ease of use and improved patient

adherence. Products sold OTC include soaps, creams,washes, lotions, and gels. For most patients, a single dailyapplication of 5% is sufficient. Increasing to 10% occasionallyprovides greater efficacy but also increases adverse effects,which include dryness, irritation, and erythema. Benzoylperoxide creams are applied as a thin coat over all acne-proneareas. To apply the medication, a pea-sized amount may bedispensed on the finger and then dabbed on the forehead,cheeks, and chin. The cream is then spread over the entiresurface except for areas prone to irritation, such as the eyes,alar folds, and angles of the mouth. Larger areas, such as theback and chest, can be treated in the shower or bath witha benzoyl peroxide wash. Alternatively, for more efficacioustherapy, the gel or lotion formulation can be applied and al-lowed to remain in place for several hours (eg, overnight).

Adverse reactions include stinging after application, er-ythema, peeling skin, and dry skin. These reactions can becounteracted with the use of noncomedogenic emollients,decreased benzoyl peroxide strength, decreased frequencyof application, or use of a lotion-based rather than gel-based product. Contact dermatitis is an uncommon butpossible adverse effect and presents as erythema with smallpapules and vesicles that are pruritic. In such cases, themedication should be stopped immediately and alternatetherapeutic options tried. Patients should be warned thatbenzoyl peroxide will bleach clothing, towels, and bed-ding. The drug is rated pregnancy category C by theUS Food and Drug Administration (FDA), meaning thatpossible risk to the fetus cannot be excluded.

TOPICAL RETINOIDS. Topical retinoids are especially ef-fective in promoting normal desquamation and will ben-efit patients who have both comedones and inflammatorylesions. These agents reduce obstruction of the follicleand thereby decrease the risk for rupture and secondaryinflammation. (41)(42)(43) Retinoids also have a markedanti-inflammatory effect, inhibiting leukocyte activity andthe release of proinflammatory cytokines. They help inthe penetration of other active ingredients, such as

Table 3. Evaluation of Acne Severity

Grading Predominant Lesion Type Distribution Scarring Other Factors

Mild Few to several comedones, few scatteredpapules

<1/4th face, mostlyT zone

None None

Moderate Many papules and pustules, variablecomedones, 1-2 nodules

Roughly 1/2 face Few, shallow Involvement of thechest and back

Severe Numerous papules and pustules andnodules; variable comedones; sinustracts and/or cysts

Face, back, and/orchest

Moderate toextensive,hypertrophicand/or deep

Drainage, hemorrhage,pain

Figure 8. Severe acne.

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Table 4. Topical Prescription Acne Therapies

Type ofMedication Drug

Brand*: AvailableStrengths and Vehicles Directions

Potential Adverse Effectsand Comments

Antibiotics Clindamycin Cleocin T�: 1% solution,gel, pledgets, lotion

Clindagel� and Evoclin�:once daily

Usually well tolerated

Clindets�: 1% pledgets All others: twice daily Theoretical risk ofpseudomembranous colitis

Evoclin�: 1% foam Gel and pledgets are alcoholbased and may be irritating

Clindagel�: 1% gel Avoid in patients withclindamycin allergy

Clindamax�: 1% gel,lotion

Pledgets are single-use only;patients should use a freshpad for each medicationapplication

Clindamycin (generic):1% gel, solution,lotion, pledgets, foam

Clindamycinand benzoylperoxide

BenzaClin�: 1%/5% gel;1%/5% gel pump

BenzaClin� and generic:twice daily, unlesspart of combinationtherapy, then useonce daily

Contact dermatitis is rareand usually associated withitchy vesicles

Duac�: 1.2%/5% gel(kit with cleanser)

Duac� and Acanya�:once daily

Benzoyl peroxide bleachesfabric (eg, towels, shirts)

Acanya�: 1%/2.5% gelClindamycin and benzoylperoxide (generic):1%/5% gel

Erythromycin Akne-mycin�: 2%ointment

Twice daily Usually well tolerated

Ery�: 2% pledgets Gel and pledgets are alcoholbased and may be irritating

Erythromycin (generic):2% gel, solution,pledget

Avoid in patients witherythromycin or macrolideallergy

Pledgets are single-use only;patients should use a freshpad for each medicationapplication

Erythromycinand benzoylperoxide

Benzamycin�: 3%/5%gel

Twice daily, unless partof combinationtherapy, thenuse once daily

Contact dermatitis is rare andusually associated with itchyvesicles

Erythromycin andbenzoyl peroxide(generic): 3%/5% gel


Azelaic acid Azelex�: 20% cream Once or twice daily Slight transient burning commonMay cause hypopigmentationin darker skin types

Dapsone Aczone�: 5% gel Twice daily Topical use safe in G6PDdeficient patients

Retinoids Adapalene Differin�: 0.1% cream,gel, lotion; 0.3% gel

Once daily at bedtime One of the less irritating topicalretinoids (less erythema, dryskin, peeling, burning)

Adapalene (generic):0.1% cream, gel

Good choice in patients withsensitive skin

Able to use with benzoyl peroxideMore light-stable compared withother topical retinoids

Continued

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benzoyl peroxide and antibiotics. Retinoids are the pre-ferred agents in maintenance therapy and should be usedin most patients with acne. In patients with purely com-edonal acne, they may be the only antiacne medicationrequired. For patients with mild inflammatory acne,

a combination of a retinoid and topical benzoyl peroxideor benzoyl peroxide–antibiotic combination is more effi-cacious. In severe inflammatory acne, systemic antibioticsmay be used in combination with benzoyl peroxide anda topical retinoid.

Table 4. (Continued)

Type ofMedication Drug

Brand*: AvailableStrengths and Vehicles Directions

Potential Adverse Effectsand Comments

Adapalene andbenzoylperoxide

Epiduo�: 0.1%/2.5%gel

Once daily at bedtime Convenient once daily fixedcombination therapy

Erythema, dry skin, peeling,stinging may occur


Each component can beprescribed individually ifcost for the combination isa concern

Tazarotene Tazorac�: 0.05% cream,gel; 0.1% cream, gel

Once daily at bedtime More commonly associated withskin irritation (erythema, dryskin, peeling, stinging)

Good choice for patients withoily skin

Mild photosensitivityPregnancy category X

Tretinoin Retin-A�: 0.025%,0.05%, 0.1% cream;0.01%, 0.025% gel

Once daily at bedtime Branded formulations able touse with benzoyl peroxide

Retin-A Micro�: 0.04%,0.1% gel

Skin irritation (erythema, dryskin, peeling, stinging) morecommon at higher strengths

Avita�: 0.025% cream,gel

Generic formulations not stablewith benzoyl peroxideor sunlight

Atralin�: 0.05% gel Generic tretinoin, Retin-A,Avita, and Tretin-X gels arealcohol based

Tretin-X�: 0.025%,0.05% cream kit withcleanser; 0.0375%cream; 0.1% gel kitwith cleanser; 0.01%,0.025% gel

Tretinoin (generic):0.025%, 0.05%,0.1% cream; 0.01%,0.025% gel

Tretinoin andclindamycin

Ziana�: 0.025%/1.2%gel

Once daily at bedtime Mild skin irritation (erythema,dry skin, peeling, stinging)

Veltin�: 0.025%/1.2%gel

Use with benzoyl peroxideto decrease bacterial resistance

Medications listed are examples; the list is not intended to be exhaustive. G6BP¼glucose-6-phosphate dehydrogenase.*Manufacturer and location of brand name medications: Acanya�, Akne-mycin�, Atralin�, BenzaClin�, Benzamycin�, Retin-A�, Retin-A Micro� (ValeantPharmaceuticals International, Bridgewater, NJ); Aczone�, Azelex�, Tazorac� (Allergan, Inc, Irvine, CA); Avita� (Mylan Pharmaceuticals, Morgantown,WV); Cleocin T� (Pfizer, Inc, New York, NY); Clindagel�, Differin�, Epiduo� (Galderma Laboratories, Inc, Fort Worth, TX); Clindamax� (PharmaDerm,Florham Park, NJ); Clindets�, Duac�, Evoclin�, Veltin� (GlaxoSmithKline, Philadelphia, PA); Ery� (Perrigo, Allegan, MI); Tretin-X� (OnsetDermatologics, Cumberland, RI); and Ziana� (Medicis Pharmaceuticals Corp, Scottsdale, AZ).

dermatology acne




Tretinoin, a vitamin A derivative, was the first retinoidavailable for acne and comes in cream and gel formu-lations. The vehicle affects efficacy, tolerability, andcompatibility. Newer formulations of tretinoin into mi-crospheres and a polyolprepolymer appear to be as effec-tive but less irritating than traditional formulations. Thesepreparations also make the active ingredient more stablein the presence of light and benzoyl peroxide. (Generictretinoin is inactivated by light and benzoyl peroxide.)There have been no epidemiologic studies supportingconcerns about increased malformations occurring in in-fants born to women who used tretinoin during preg-nancy. However, because tretinoin’s chemical structureis nearly identical to that of isotretinoin, a known terato-gen, tretinoin is classified as pregnancy category C andgenerally is avoided during pregnancy.

Adapalene is another topical retinoid available for acnetreatment. This agent is a synthetic compound that binds toa specific retinoid receptor. (44) In a 0.1% gel formulation,it is as effective as tretinoin gel, 0.025%, but less irritating.(45)(46) Adapalene also is light-stable and less susceptibleto oxidation by benzoyl peroxide. The method of applica-tion and other principles of use are similar to those of tre-tinoin. Adapalene also is classified as pregnancy category C.

Tazarotene is another receptor-specific synthetic reti-noid that is formulated in 0.05% and 0.1% gels andcreams. This agent regulates follicular corneocyte cohe-sion and normalization of keratinization. Designated aspregnancy category X, tazarotene is contraindicated inpregnancy. Contraceptive counseling should be providedfor all women of childbearing potential who are pre-scribed this medication.

The most common adverse effects of all retinoids (tre-tinoin, adapalene, and tazarotene) are irritation, redness,and dryness, all peaking at approximately 2 weeks of use.In darker skin types, this inflammation can result in hy-perpigmentation that can persist for months. To limit ad-verse effects, most patients are prescribed a low-strengthpreparation and titrated up according to efficacy and tol-erability. As with benzoyl peroxide preparations, a pea-sized amount should be dispensed onto the finger,dabbed over the face, and spread in evenly. If drynessand irritation are severe, the medication can be appliedevery other night for several weeks until the skin adjusts.Application of a noncomedogenic moisturizer should beencouraged if tolerability is an issue. In addition, it is im-portant to counsel patients to use a gentle cleanser, avoidharsh scrubs or astringents, and be cautious with wax hairremoval or laser therapy on treated areas.

Patients must be warned that temporary worsening ofacne can occur within the first month of starting

treatment and does not indicate medication failure. Theyshould continue to treat through this phase, which willresolve spontaneously with continued medication use.They also may have increased sensitivity to sunlightand should be diligent about sun protection.

TOPICAL ANTIBIOTICS. Topical antibiotics reduce con-centrations of P acnes and inflammatory mediators,making them useful in treating mild to moderate inflam-matory acne. In the United States, clindamycin anderythromycin are available in a number of topical formu-lations and have comparable efficacy. Sodium sulfaceta-mide is available also and is especially useful in patientswhose acne has a rosacea component. (47) Dapsonegel, 5%, is a newer topical agent that has demonstratedefficacy against comedonal and inflammatory lesions.(48)(49) Patients do not need glucose-6-phosphate de-hydrogenase testing before using it, although clinicallyinsignificant hemolysis may occur in glucose-6-phosphatedehydrogenase–deficient patients. (50) Temporary or-ange or yellow discoloration of skin may occur if appliedconcomitantly with benzoyl peroxide and usually can beavoided by applying the medications at different timesduring the day. (51)

Antibiotics are well tolerated but should not be used asmonotherapy because of increasing antibiotic resistance.Concurrent therapy with benzoyl peroxide reduces thisproblem, and several commercial combinations of ben-zoyl peroxide, 2.5% to 5%, with clindamycin or erythro-mycin are marketed. These conditions demonstrate greaterefficacy than either drug alone. (38)(39)(52)(53)(54) Ifcost is an issue, OTC benzoyl peroxide and topical eryth-romycin or clindamycin can be used simultaneously in themorning. (55) Use in conjunction with a nightly retinoidalso will speed the response by allowing greater penetrationof the medication. In patients with mixed comedonal andinflammatory acne, the topical antibiotic should be used incombination with a topical retinoid and benzoyl peroxide.

SALICYLIC ACID. Salicylic acid is another common ac-tive ingredient in many different OTC formulations:washes, gels, creams, and pads. Salicylic acid is primarilya gentle comedolytic that can be useful in mild comedo-nal acne. It is less effective than topical retinoids but alsobetter tolerated.

AZELAIC ACID. Azelaic acid is a dicarboxylic acid man-ufactured as a 20% topical cream that can be of benefit inmild inflammatory and comedonal acne. Azelaic acid re-verses abnormal keratinization and inhibits the growth ofP acnes. (56) It also lightens postinflammatory hyperpig-mentation. Azelaic acid is remarkably well tolerated.

dermatology acne




When adverse effects occur, they usually are mild and in-clude pruritus, tingling, burning, or erythema. With long-term use, azelaic acid can cause hypopigmentation, whichmay be problematic for darker-skinned patients. Azelaicacid is a good choice for patients who do not tolerate ret-inoids or as an adjunctive treatment in patients with prom-inent postinflammatory hyperpigmentation. (57)

Oral TherapiesSYSTEMIC ANTIBIOTICS. Oral antibiotics are the most

common type of systemic acne therapy. They are effectivefor treating moderate or severe inflammatory acne. Anti-biotics act via several mechanisms: decreasing P acnes,inhibiting bacterial lipases, suppressing neutrophil che-motaxis (and therefore follicular inflammation), and re-ducing free fatty acid concentrations in sebum. (58)(59)(60)(61)(62) Tetracycline-class antibiotics are pre-scribed most commonly because they have documentedefficacy and a long history of use in acne. (63)(64)(65)Other antibiotics, including erythromycin, clindamycin,trimethoprim-sulfamethoxazole, azithromycin, and cepha-lexin, should be reserved for select patients. Dosing, for-mulations, and possible adverse effects for the mostcommonly used oral antibiotics are described in Table 5.

General guidelines for oral antibiotic use in patientswith acne include avoiding the oral agent if a topicalagent will suffice and avoiding concomitant oral and top-ical treatment with dissimilar antibiotics to avoid emer-gence of cross-resistant P acnes. (66) As with topicaltherapies, oral antibiotics require 8 to 12 weeks to achievetheir maximum effect. Once disease activity has dimin-ished and an effective topical combination routine is es-tablished, use of the antibiotic can be discontinued.

In patients who do not respond to oral antibiotics, thepossibility of resistant P acnes should be considered. Toavoid development of resistant strains, patients shouldconcomitantly use a benzoyl peroxide product while tak-ing oral antibiotics. A multipronged approach to acne us-ing benzoyl peroxide, a topical retinoid, and an oralantibiotic often is referred to as triple therapy. Patientswho are also using hormonal birth control can be reas-sured that the antibiotics used to treat acne will not de-crease birth control efficacy. (67) Overall, the commonlyused antibiotics for acne are well tolerated, adverse effectsare uncommon and typically reversible, and laboratorymonitoring is not necessary.

Tetracycline-class antibiotics are the criterion standardof oral antibiotic therapy for acne. In the past, tetracyclineitself was used traditionally because of its efficacy, safety,and affordability. Themost commonly experienced adverseeffect with tetracycline is gastrointestinal upset because the

medication cannot be taken with milk or food for adequateamounts to be absorbed into the body (ie, take at least 30minutes before a meal or 2 hours after a meal). There isa risk of phototoxicity, and vaginitis or perianal itching sec-ondary to Candida albicans occurs in roughly 5% of pa-tients. To reduce the incidence of esophagitis, all of thetetracycline-class antibiotics should be taken with a fullglass of water well before bedtime or lying down. Pseudo-tumor cerebri can complicate tetracycline-class therapyrarely. None of the tetracycline-class antibiotics are ap-proved for use in children younger than 9 years or pregnantwomen because these drugs can cause tooth discolorationand bony abnormalities.

Recently, tetracycline shortages due to manufacturerdelays have led to increased use of doxycycline andminocycline in treating acne. Doxycycline, like tetracy-cline, is also highly efficacious and inexpensive. (68) Pho-tosensitivity reactions are more common than with othertetracyclines, and patients must be cautioned to use me-ticulous sun protection. One advantage of doxycycline isthat it can be taken with food, which greatly decreasesthe incidence of gastrointestinal disturbances. This pointshould be emphasized with patients because many phar-macies place a “take on an empty stomach” label on alltetracycline-class antibiotics regardless of the specific drugprescribed. Taking doxycycline with food significantly in-creases its tolerability and hence patient adherence.

Minocycline is also used commonly in the treatmentof acne. Minocycline generally is more expensive thanthe other tetracyclines. As a lipophilic derivative of tetra-cycline, its efficacy may be due to deeper penetration ofthe sebaceous follicle. (69) Minocycline also can be takenwith food, and photosensitivity is rare. However, vertigo,dizziness, and headaches may occur. Rarely, a bluish dys-pigmentation of oral tissues, nails, scars, teeth, and scleracan occur. Additional potentially serious but typically re-versible adverse effects include a lupuslike syndrome,drug hypersensitivity reactions, autoimmune hepatitis,and serum sickness–like reactions. Although rare, theseadverse effects should be discussed with patients and theirfamilies when minocycline is being considered.

For those patients who cannot take tetracyclines be-cause of drug allergy, young age, or pregnancy, erythro-mycin can be considered. Gastrointestinal discomfort iscommon, but otherwise there are few adverse effects.Phototoxicity is not a concern. Efficacy is low comparedwith tetracycline-class antibiotics, and bacterial resistancelimits the usefulness of erythromycin. (70)

ORAL CONTRACEPTIVE PILLS. Combined oral contra-ceptive pills that contain estrogen and progesterone are

dermatology acne




Table 5. Oral Antibiotics Commonly Used to Treat Acne

Oral Antibiotics

Class ofAntibiotic Drug

Brand*: AvailableStrengths andFormulations Directions

Potential AdverseEffects and Comments

Tetracyclines Tetracycline Tetracycline hydrochloride(generic): 250-mg,500-mg capsule

250-500 mg daily totwice daily

Dental staining <8 years oldDecreased absorption withdairy products or food

Gastrointestinal upsetPhotosensitivityVulvovaginal candidiasisPseudotumor cerebri (rare)Recent unavailability

Minocycline Minocin�: 50-mg, 75-mg,100-mg capsule

50-100 mg daily totwice daily

Dental staining <8 years old

Dynacin�: 50-mg, 75-mg,100-mg tablet

Extended-release dosing Gastrointestinal upset (lessdiscomfort but stillefficacious if take withfood)

Solodyn�: 45-mg, 65-mg,90-mg, 115-mg, 135-mgextended-release tablet

45-54 kg: 45 mg oncedaily

Photosensitivity less commonthan with othertetracyclines

Minocycline hydrochloride(generic): 50-mg, 75-mg,100-mg tablet; 45-mg,90-mg, 135-mgextended-release tablet


Blue-gray skin pigmentation


Vulvovaginal candidiasis

103-125 kg: 115 mgonce daily

Lupuslike reaction (rare)

126-136 kg: 135 mgonce daily

Pseudotumor cerebri (rare)

Doxycycline Doxycycline hyclate 100 mg daily to twicedaily

Dental staining <8 years old

Vibramycin�: 50-mg/5-mLsyrup, 100-mg capsule

Delayed release:150 mg daily

Gastrointestinal upset (lessdiscomfort but stillefficacious if take withfood)

Doryx�: 150-mgdelayed-release tablet

Esophagitis: take pills withfull glass of liquid

Doxycycline hyclate (generic):50-mg, 100-mg capsule;150-mg delayed releasetablet

Photosensitivity

Doxycycline monohydrate Photo-onycholysisAdoxa�: 150-mg capsule Vulvovaginal candidiasisMonodox�: 50-mg, 75-mg,

100-mg capsulePseudotumor cerebri (rare)

Doxycycline monohydrate(generic): 50-mg, 75-mg,100-mg, 150-mg tabletor capsule

Macrolides Erythromycin Erythromycin base Child Gastrointestinal upsetcommon

Ery-Tab�: 250-mg, 333-mg,500-mg delayed-releasetablet

30-50 mg/kg/d dividedevery 6-8 hours; donot exceed 2 g/d(as base or stearate)

Used in younger childrenand tetracycline-allergicpatients

Continued

dermatology acne




another treatment option for female patients with acne,regardless of whether serum androgen levels are abnor-mal. The primary goal of these therapies is to opposethe effects of androgens on the sebaceous glands. Cur-rently, ethinyl estradiol–norgestimate, ethinyl estradiol–norethindrone, and ethinyl estradiol–drospirenone areapproved by the FDA for use in the treatment of acne vul-garis, although many other oral contraceptives that con-tain estrogen and progesterone are efficacious as well.Results often take at least 3 months to become apparentand usually are maximal by 6 months. Acne may be ex-acerbated by endocrine disorders, such as polycysticovarian syndrome or metabolic syndrome, and com-bined oral contraceptive pills may be particularly usefulin these settings. Use of long-acting progestin implantsor depot medroxyprogesterone acetate may actuallyworsen acne.

ISOTRETINOIN. Isotretinoin is an orally administeredvitamin A derivative that is highly effective in treating re-calcitrant nodulocystic acne and is the only acne therapythat has curative potential. The exact mechanism of

action is unknown, but isotretinoin markedly inhibits se-bum synthesis, decreases P acnes concentration, inhibitsneutrophil chemotaxis, and has comedolytic effects.(71)(72)(73) Because it is a potent teratogen, the FDAmandates that only authorized physicians can prescribeisotretinoin and that all patients taking isotretinoin mustenroll in a monitoring program with monthly clinic visitsthat, for female patients, include pregnancy tests.

Isotretinoin is the most effective drug for treatmentof severe acne unresponsive to conventional therapyand can clear even severe acne in a 5- to 6-month treat-ment course. (74)(75) Many patients will remain clear af-ter finishing therapy. For those whose acne recurs, thecondition often can be managed with the conventionaltherapies that had failed previously.

Nearly all patients will experience generalized skindryness while using isotretinoin, and cholesterol and liverenzyme abnormalities are common. A number of moreserious adverse events, such as suicidal ideation, major de-pressive disorder, and inflammatory bowel disease, havebeen attributed to isotretinoin, although data implyingcausation are lacking. (76)(77)(78) Pediatricians should

Table 5. (Continued)

Oral Antibiotics

Class ofAntibiotic Drug

Brand*: AvailableStrengths andFormulations Directions

Potential AdverseEffects and Comments

or 3.2 g/d (asethylsuccinate)

PCE�: 333-mg, 500-mgtablet

Adolescent/adult Vulvovaginal candidiasis

Erythromycin base (generic):250-mg, 500-mg tablet;250-mg delayed-releasecapsule

Base or stearate:250-500 mgevery 6-12 hours

Erythromycin ethylsuccinate Base, delayed release:333 mg every 8 hours

E.E.S.�: 200-mg/5-mLsuspension, 400-mg tablet

Ethylsuccinate:400-800 mgevery 6-12 hoursEryPed�: 200-mg/5-mL,

400-mg/5-mL suspensionErythromycin ethylsuccinate(generic): 400-mg tablet

Erythromycin stearateErythrocin�: 250-mg,500-mg tablet

Medications listed are examples; the list is not intended to be exhaustive.*Manufacturer and location of brand name medications: Adoxa� (PharmaDerm, Florham Park, NJ); Doryx� (Warner Chilcott Laboratories, Dublin,Ireland); Dynacin�, Solodyn� (Medicis Pharmaceuticals Corp, Scottsdale, AZ); Ery-tab�, Erythrocin�, PCE�, E.E.S.�, EryPed� (Arbor Pharmaceuticals,Atlanta, GA); Minocin� (Onset Dermatologics, Cumberland, RI); Monodox� (Aqua Pharmaceuticals, West Chester, PA); and Vibramycin� (Pfizer, Inc,New York, NY).

dermatology acne




be aware of these associations and the other adverse ef-fects of isotretinoin.

Scar TreatmentsAlthough an in-depth discussion of scar therapy is beyondthe scope of this article, many patients are concernedabout scarring, and clinicians must be aware that thera-peutic options exist. Often, patients mistake postinflam-matory hyperpigmentation and the macular erythema ofresolving lesions for scarring. In these instances, the pa-tient can be reassured that these color changes will fadeover time but may require up to a year to diminish. Actualscars will continue to remodel for several years, graduallybecoming subtler and less noticeable, although they willnot disappear fully.

For deeper scars, options include chemical peels, micro-dermabrasion, injections, punch excision, or laser resurfac-ing. (79)(80)(81)(82)(83) Acne should be well controlledbefore scar-reducing procedures are pursued. Historically,patients treated with isotretinoin were counseled to avoiddermabrasion and other resurfacing techniques until 6 to12 months after completion of therapy because of the per-ceived risk of developing excessive wound healing or keloi-dal scarring. (84)(85) Several recent studies, however,contradict these data and support the safety and efficacyof earlier intervention. (86)(87) Needless to say, patientsinterested in acne scar treatment should consult a specialistwho has expertise using these therapies, such as a plasticsurgeon or cosmetic dermatologist.

Follow-up and MaintenanceMost patients with acne should be seen 3 to 4 monthsafter initiating a therapeutic regimen, although patientsshould be encouraged to contact the office sooner ifquestions or concerns arise regarding the appropriateuse of their medications or adverse effects. This intervalgives the medications ample time to achieve their maxi-mum benefit and allows the clinician to judge their effi-cacy at follow-up, as long as the patient has been diligentabout their use. If there is minimal or no response, inquir-ing into when and how the patient is using the medicinescan help distinguish medication failure from nonadher-ence. If they are not using a medication, find out why.Often, a lower-strength or different vehicle can makea huge difference. For recalcitrant acne, consider referralto a dermatologist.

Once an effective therapeutic regimen has been estab-lished, maintenance of improvement becomes the focus.Topical acne medications are safe to use indefinitely andare the preferred long-term maintenance medications.(66)(88) Oral antibiotics generally should be used for

up to 6 to 12 weeks to get an adequate response butshould be tapered thereafter as quickly as can be toleratedby the patient. (89)

Emotional ConsiderationsAcne is never inconsequential or trivial to those it affectsand should not be dismissed as such. The psychologicaleffect of this disease often is far greater than the blemisheson the skin would suggest, and what may seem minimalto a clinician can be devastating to the patient. Currenttreatment regimens focus on combination therapies toensure the quickest and most effective results. Therefore,it is important that primary care physicians be current onacne standards of care to ensure the best outcomes fortheir patients.

References1. Fleischer AB Jr, Feldman SR, Rapp SR. Introduction: themagnitude of skin disease in the United States. Dermatol Clin.2000;18(2):xv–xxi

Summary

• Acne is a common and distressing disorder that canaffect patients of all ages and may persist beyondadolescence.

• Acne is a multifactorial disease in which follicularobstruction, androgens, inflammation, genetics, andbacteria all play a role.

• Current evidence does not definitively support the roleof diet in acne. At this time, the consensus of pediatricdermatologists is not to restrict the diet based on thepresence of acne. This practice may change as moreclinical trials directly evaluating the role of diet inacne are conducted.

• Studies show that most patients with acne havenormal hormone levels. Red flags that obligate anendocrine evaluation include treatment-resistantacne, acute acne onset or worsening, additionalclinical indicators of androgen excess, and acne inpatients 2 to 7 years old.

• There are no universally accepted published guidelinesfor determination of the severity of acne. Clinicaljudgment, number of papulopustules, body areasaffected, the presence or absence of scarring and cysts,and patient distress all contribute to categorizationand subsequent management strategies.

• Triple therapy, which consists of benzoyl peroxide,a topical retinoid, and an oral antibiotic, often ishighly effective in treating moderate to severe acne.

• Topical retinoids are central to acne management andare the preferred maintenance medication for allpatients with acne.

dermatology acne




Adolescent III Quiz:

1a. Complete the following diagram, using the 4 pathogenic processes discussed in the article. 1b. Indicate, in the table below, which medications address each component of the pathogenesis.

1c. Circle the medications that comprise triple therapy 1d. Underline which of these medications prevents antibiotic resistance 1e. Box which of these medications improves penetration of other topical therapies 1f. Cross-out which of these medications should not be used as monotherapy

2. Acne is most common in adolescents, with _____ of teens/young adults affected. That said,please complete this chart comparing the other ages & stages of acne. In which of these stages isnew-onset acne unusual? ___________________________________________________________

Neonatal Infantile Mid-Childhood Pre-Adolescent Age Range

Appearance

Cause

Treatment

Adolescent III Mega-Case:

15 year-old twins Jack and Jill present for routine sports physicals. Mom reports a concern about their acne “not going away” despite expensive OTC treatments. When you ask the twins about it, Jack just shrugs and Jill rolls her eyes and says “Mom, you are so embarrassing”. What do you want to know about their acne?

You interview Jack and Jill separately—and with their mother out of the room— so that you can also complete a HEADSS exam as part of your history. You find out the following:

Jack • Has had acne since age 12• Has tried Clearasil face wash, “sometimes”• Denies other meds or drugs, including steroids• h/o atopic dermatitis, for which he uses “some lotion”• Competitive wrestler (wears headgear daily and can't remember the last time it was washed)

• Today is an “average skin day . . . it’s not really a big deal”

Jill• Has had acne since age 11• Has tried tea-tree oil, Neutrogena, Clean & Clear, and Proactiv. Intermittently compliant.• Denies other meds or drugs, including steroids• Uses MAC cosmetics (“I never go out without cover up and foundation”). Competitive dancer (“AndI have to wear stage make-up for competitions”)• Menses at age 13. “Irregular” (2-6 mo between periods, last 2-10 days, light to moderate flow).“Hooks up” (she defines as “everything but” intercourse). Not on OCPs.• Today is a “bad skin day . . . a horrible, horrible day”.

What should you include on your physical exam?

You complete a physical exam on both twins, focusing on the skin. You observe the following:

Jack: ½ of the face involved. Many papules and pustules. No nodules. Multiple small pits and scars. Lesions on chest and back.

Jill: ¼ of the face is involved (T-zone). Mostly blackheads and whiteheads. 1-2 papules. No lesions on chest and back.

What are the different types of presentations of adolescent acne?

How would you characterize the twins’ acne?

Do you want to pursue any further evaluation? If so, what are your next steps?

What is your initial treatment for each?

How will you counsel Jack & Jill to use the topical products? Any side-effects?

If you decide to recommend a PO product, how will you counsel them to use it?

What are the benefits to the newer (and more expensive) combination products?

When should the twins see an effect? When do you want to follow up?

Jack and Jill pledge to follow your instructions and be patient with the results. 6 weeks later, you find them both on your schedule. Jill tells you, “Things are not getting any better, and we couldn’t wait any longer!” Jack reports that his acne worsened 3 weeks after your visit, and it has gotten only slightly better from baseline since then. Jill admits that she has more “good skin days” now, but she is distressed by her persistent break-outs. Now what?

Jack shows some interest in Accutane. How will you counsel him?

Adolescent III Board Review:

1. A 14-year-old boy requests treatment for his acne. He is using no medications and has no known drugallergies. Physical examination of the face reveals a few small inflammatory papules and numerousblackheads and whiteheads; there is no scarring. No acne lesions are present on the chest and back.

Of the following, the MOST appropriate treatment is A. benzoyl peroxide topicallyB. benzoyl peroxide topically and tetracycline orallyC. benzoyl peroxide topically and tretinoin topicallyD. clindamycin topicallyE. tretinoin topically

2. A 16-year-old girl requests treatment for acne. She has used a nonprescription medication containingbenzoyl peroxide without significant benefit. Physical examination reveals inflammatory lesions andopen and closed comedones on the face and inflammatory lesions on the chest and back; there is noscarring. She has no known allergies to medications.

Of the following, the MOST appropriate treatment is A. benzoyl peroxide topically and tretinoin topicallyB. clindamycin topicallyC. doxycycline orally and tretinoin topicallyD. isotretinoin orallyE. tretinoin topically

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