Acne management pdf

Selecting appropriate treatment in pregnant women can be challenging because many acne therapies are teratogenic; all topical and especially oral retinoids should be avoided.

Topical and oral treatment with erythromycin may be considered. Trials are being conducted with currently available therapies, in different strengths and combinations. Combining an allylamine antifungal agent with benzoyl peroxide may prove to enhance the effectiveness of benzoyl peroxide in treating acne while preventing antibiotic resistance. More studies are needed to resolve the long-standing controversy about the role of diet and acne.

As well, further direct treatment comparison and long-term trials are needed to determine the optimal sequence of treatment selection as well as to establish the effects on quality of life and long-term efficacy. Effective therapies for acne target one or more pathways in the pathogenesis of acne, and combination therapy gives better results than monotherapy. Topical therapies are the standard of care for mild to moderate acne. Systemic therapies are usually reserved for moderate or severe acne, with a response to oral antibiotics taking up to six weeks.

Hormonal therapies provide effective second-line treatment in women with acne, regardless of the presence or absence of androgen excess. Competing interests: None declared. This review was solicited and has been peer reviewed. National Center for Biotechnology Information , U. Author information Copyright and License information Disclaimer. Correspondence to: Dr. This article has been cited by other articles in PMC.

Open in a separate window. Figure Grade I mild acne showing comedones with few inflammatory papules and pustules. Table 1: Grading severity of acne 2 , 3. Grade Severity Clinical findings I Mild Open and closed comedones with few inflammatory papules and pustules II Moderate Papules and pustules, mainly on face III Moderately severe Numerous papules and pustules, and occasional inflamed nodules, also on chest and back IV Severe Many large, painful nodules and pustules. Is there an underlying cause?

Table 2: Approach to therapy for acne vulgaris 3 , 6. How well do topical treatments work? Antimicrobials Topical antimicrobials, including benzoyl peroxide and antibiotics, are effective in treating inflammatory disease.

Combination therapy Combination therapy, for example with retinoids and antibiotics, is more effective than either agent used alone.

Over-the-counter therapy Before seeing a physician, patients frequently use over-the-counter therapies for their acne. When should systemic therapy be started? Antibiotics When topical agents are insufficient or not tolerated, or in cases of moderate to severe acne, especially when the chest, back and shoulders are involved, systemic antibiotics are often considered the next line of treatment Table 3.

Hormonal therapies Hormonal agents provide effective second-line treatment in women with acne regardless of underlying hormonal abnormalities. What about alternative therapies? What physical treatments are available? How should children and pregnant women be treated? Key points Effective therapies for acne target one or more pathways in the pathogenesis of acne, and combination therapy gives better results than monotherapy.

Footnotes Competing interests: None declared. Psychological sequelae of acne vulgaris: results of a qualitative study. Haider A, Shaw JC.

Treatment of acne vulgaris. Guidelines of care for acne vulgaris management. James WD. American Association of Clinical Endocrinologists Polycystic Ovary Syndrome Writing Committee American Association of Clinical Endocrinologists position statement on metabolic and cardiovascular consequences of polycystic ovary syndrome. Management of acne: a report from a global alliance to improve outcomes in acne. A multicenter, double-blind, randomized comparison study of the efficacy and tolerability of once daily tazarotene 0.

A comparison of the efficacy and tolerability of adapalene 0. A double-blind evaluation of topical isotretinoin 0. Comparing 2. The effect of antimicrobial agents on leukocyte chemotaxis. Handojo I. The combined use of topical benzoyl peroxide and tretinoin in the treatment of acne vulgaris.

Efficacy and tolerability of combined topical treatment of acne vulgaris with adapalene and clindamycin: a multicenter, randomized investigator blinded study. Effective over-the-counter acne treatments. Treatment of acne vulgaris without antibiotics: tertiary amine-benzoyl peroxide combination vs. Oprica C, Nord CE. European surveillance study on the antibiotic susceptibility of Propionibacterium acnes.

Trimethoprim—sulfamethoxazole revisited. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomized controlled trial.

Lancet ; —95 [ PubMed ] [ Google Scholar ]. Erythromycin resistant propionibacteria in antibiotic treated acne patients: association with treatment failure. Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts. Induction of proinflammatory cytokines by a soluble factor of propionibacterium acnes: implications for chronic inflammatory acne.

Tetracyclines inhibit connective tissue breakdown by multiple non-antimicrobial mechanisms. Antibiotic resistant acne: lessons from Europe. Is antibiotic resistance in cutaneous propionibacteria clinically relevant? Implications of resistance for acne patients and prescribers. Samuelson JS. An accurate photographic method for grading acne: initial use in a double-blind clinical comparison of minocycline and tetracycline.

The role of androgens in determining acne severity in adult women. Dermatology ; —44 [ PubMed ] [ Google Scholar ]. A randomized controlled trial of second-versus third-generation oral contraceptives in the treatment of acne vulgaris.

ACOG practice bulletin no. The effect of 2 combined oral contraceptives containing either drospirenone or cyproterone acetate on acne and seborrhea. Cutis ; 69 suppl4 :2—15 [ PubMed ] [ Google Scholar ]. Oral spironolactone improves acne vulgaris and reduces sebum excretion. Anti-androgen treatment in women with acne: a controlled trial. Long-term safety of spironolactone in acne: results of an 8-year follow-up study. Wolverton SE. Comprehensive dermatologic drug therapy.

Isotretinoin use and subsequent depression and suicide. Product monograph. Accutane Roche. Isotretinoin for acne vulgaris — 10 years later: a safe and successful treatment. A comparative study of tea-tree oil versus benzoyl peroxide in the treatment of acne.

Laser resurfacing for facial acne scars. CD Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Intralesional corticosteroids in the treatment of nod-ulocystic acne. Cutis ; 81 —8 [ PubMed ] [ Google Scholar ]. Support Center Support Center. External link. Please review our privacy policy. Open and closed comedones with few inflammatory papules and pustules. Topical therapies can accomplish continued efficacy months after discontinuation of systemic antibiotics.

Systemic antibiotics are recommended for use in moderate to severe inflammatory acne that are resistant to topical therapies. They should be used in combination with a topical retinoid and benzoyl peroxide.

Limiting antibiotic use to minimize antibiotic resistance is suggested. Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients unable to tolerate tetracyclines or in treatment-resistant patients.

Limit antibiotic use to the shortest possible duration, typically three months, to minimize the development of bacterial resistance. Limiting systemic antibiotic use is urged due to reported associations of inflammatory bowel disease, pharyngitis, Clostridium difficile infection, and induction of Candida vulvovaginitis.

Oral contraceptives may improve acne for many women. They could be used alone or in combination with other acne treatments. Spironolactone can be useful in the treatment of acne in select females, though evidence of its efficacy is limited. Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment.

Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related side effects. Routine monitoring of liver function tests, serum cholesterol and triglycerides at baseline and again until response to treatment is established is recommended. Every woman of child-bearing potential taking isotretinoin should be carefully counseled regarding various contraceptive methods that are available and the specific requirements of the iPLEDGE system at each clinic visit.

Patient-independent forms of birth control, including long acting reversible contraceptives, should be considered whenever appropriate. Prescribing physicians also should monitor their patients for any indication of inflammatory bowel disease and depressive symptoms and educate their patients about the potential risks with isotretinoin. There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne including:.

Intralesional corticosteroid injections are effective in the treatment of larger individual acne nodules. Although most of these products appear to be well tolerated, very limited data exist regarding the safety and efficacy of these agents to recommend their use in acne. View the Academy guidelines disclaimer. Go to the guideline. Acne Resource Center for patients.

Grading and classification. To facilitate therapeutic decisions and assess treatment response, clinicians can use a consistent method of grading and classifying acne using the following characteristics: Number of acne lesions Type of acne lesions Disease severity Anatomical sites Scarring Quality of Life QOL.

Microbiologic and endocrinologic testing. Microbiologic testing Routine testing is NOT recommended, though patients exhibiting acne-like lesions suggestive of gram negative folliculitis may benefit from microbiologic testing. Endocrinologic testing Routine testing is NOT recommended, though laboratory evaluation of acne patients with additional signs of androgen excess is recommended. Topical therapies. Systemic antibiotics. Other points of note Tetracyclines tetracycline, doxycycline, minocycline are the preferred systemic antibiotics Oral erythromycin and azithromycin use should be limited to those who cannot use tetracyclines: Pregnant women Children under 8 years of age Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients unable to tolerate tetracyclines or in treatment-resistant patients Use of all other systemic antibiotics is discouraged Monotherapy with systemic antibiotics is NOT recommended When prescribing systemic antibiotics, the issue of bacterial resistance remains a major concern The Centers for Disease Control CDC has stressed antibiotic stewardship Limit antibiotic use to the shortest possible duration, typically three months, to minimize the development of bacterial resistance.

Hormonal agents. Recommendations Estrogen-containing combined oral contraceptives for inflammatory acne in females Currently four FDA-approved combined oral contraceptives for the treatment of acne Acne reduction with these agents can take time Other points of note Spironolactone can be useful in the treatment of acne in select females, though evidence of its efficacy is limited Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment Long-term adverse effects of corticosteroids prohibit use as a primary therapy for acne.

Recommendations Oral isotretinoin is recommended for the treatment of severe nodular acne. Physical modalities and miscellaneous therapies. There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne including: Comedo removal Pulsed dye laser Potassium titanyl phosphate KTP laser Fractionated and non-fractionated infrared lasers Fractionated CO2 laser Photodynamic therapy PDT Glycolic acid peels Salicylic acid peels Intralesional corticosteroid injections are effective in the treatment of larger individual acne nodules.

Herbal and alternative therapies have been reported to have value in treating acne: Tea tree oil Topical and oral ayurvedic compounds Oral barberry extract Gluconolactone solution Although most of these products appear to be well tolerated, very limited data exist regarding the safety and efficacy of these agents to recommend their use in acne. Role of diet in acne.