Treatment (table of topical/oral tx at bottom)

• Topical keratolytics to relieve follicular obstruction; will control 80-85% of adolescent acne; recommended for primary therapy for comedonal and mild popular forms of acne. Continuous use for several months is often required.
  • Two classes, synergistic: retinoids (retinoic acid, adapalene) and agents with both antibacterial and keratolytic properties (benzoyl peroxide, azelaic acid)
  • May be used alone, once daily or in combination
    • If retinoic acid/adapalene is used, apply at night
    • An agent from another class should be applied in the morning
  • Retinoic acid, adapalene, and benzoyl peroxide are most effective in the gel forms; lotions and solutions, especially OTC preps have less efficacy
  • Azelaic acid is available only in cream form
  • Severe dryness may result from using an alcohol-acetone-containing gel; this can discourage use of the medication. May use gel qod, cream preps, or use a noncomedogenic moisturizer after application of the gel (Moisturel, Purpose lotion, Neutrogena moisture)
• For papular acne, benzoyl peroxide gel or azelaid acid should be used once or twice daily
• For comedonal acne, retinoic acid or adapalene should be used once daily as initial therapy; if no improvement occurs in 4-6 weeks, the other form of keratolytic can be added.
• For inflammatory acne: topical keratolytics plus oral antibiotics  are recommended as initial therapy. Topical keratolytics are not used when oral retinoids (i.e. isotretinoid) are required.

Antibiotics

·         Topical abx: most useful for maintenance therapy after improvement from the use of oral antibiotics is observed; oral abx can be dc’ed and improvement maintained with topical abx plus topical keratolytics

o        Most effective: Clindamycin phosphate 1% (diarrhea and colitis may occur rarely due to percutaneous absorption). Clinda/benzoyl, erythro/benzoyl (benzamycin) combo available.

o        Quite effective: topical erythromycin solution 1%, 1.5%, 2%, ointment 2%, gel 3%, meclocycline cream 1%

o        Minimally effective: topical tetracycline 1%, 2.2%

·         Oral abx that are concentrated in sebum are very effective in inflammatory acne (tetracycline, minocycline, doxycycline, erythromycin); continue 1-3 months until all acne lesions are suppressed; use in combination with topical keratolytics; routine lab monitoring is unnecessary

o        Erythromycin, Tetracycline (take on empty stomach): 500 to 1000 mg divided bid

o        Minocycline, doxycycline (most photosensitizing): 100-200 mg div bid

Oral retinoids

·         Isotretinoin: very effective in nodulocystic acne resistant to standard therapeutic regimens

o        Not recommended as 1^st line therapy

o        40 mg once or twice daily (0.5 to 1 mg/kg/day) for 4 mos (longer is not recommended); at least a 4 month rst is recommended before a 2^nd treatment course.

o        Not effective for comedonal or other mild forms of acne

o        Side effects: dryness, scaliness of skin, dry eyes and nose, 10% with mild hair loss (reversible); rarely, elevation of LFTs, blood lipids

o        Teratogenic – malformations of CNS in 25% of women who become pregnant. Usage in young women of childbearing age is not recommended. Do pregnancy test, and monthly contraceptive counseling and pregnancy tests.

 Other acne treatments

·         No convincing evidence that dietary management, mild drying agents, abrasive scrubs, oral vit A, UV light, cryotherapy or I&D have any beneficial effects

·         OCPs have been shown to be effective

also see Pityrosporum Folliculitis

 Factors that aggravate acne

• Avoid oil-based cosmetics, hair styling mousse, face creams and hair sprays

 Patient education

• Important to explain the mechanism of acne and the treatment plan
• Explain that not much improvement can be expected for 4 to 8 weeks
• Inquire what peers, relatives and others have advised
• Discourage fingernail removal of acne -> scarring

 Follow-up visits

• Initially every 4-6 weeks
• Criterion for ideal control: a few new lesions every 2 weeks
• Don’t expect to completely prevent any new acne lesions from appearing
• At a followup visit, stop oral abx when 90% improvement in red papules and pustules is observed; maintain results with topical abx bid
• Red-purple scars require 6-12 mos to fade and are not influenced by abx or keratolytics

Color Textbook of Pediatric Dermatology. 3^rd edition.