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Introduction: Acne Diagnosis and Treatment

Heidi James, MD and Rob Orman, MD

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There is no ‘one ring to rule them all’ when it comes to treating acne.

  • The cause of acne is not completely understood.  The pathogenesis is believed to have four main mechanisms:

    • follicular hyperkeratinization,

    • androgen driven increase in sebum production,

    • colonization and proliferation of Propionibacterium acnes, and

    • inflammation.

  • There are two types of acne.

    • Noninflammatory acne is comedonal and presents with blackheads and whiteheads.  It tends to be the first kind of acne that people get in adolescence.

    • Inflammatory acne is sometimes referred to as cystic acne.  People with this form have papules, pustules, nodules, or cysts.  In advanced cases, sinus tracts may form between lesions.

  • When evaluating a patient with acne, especially if the pattern is atypical, what other diagnoses should be considered?  Rosacea, perioral dermatitis, sebaceous hyperplasia, and folliculitis are in the differential diagnosis.  If there are signs of hyperandrogenism or virilization, consider polycystic ovarian syndrome, congenital adrenal hyperplasia, and adrenal or ovarian tumors.

  • Acne comes in varying degrees of severity, from mild to severe.  What are the different treatment options?

    • Mild acne (comedonal)

      • Discontinue use of comedogenic make-up and facial scrubs.

      • Daily use of a gentle cleanser, such as Cetaphil.

      • If possible, stop medications that may trigger acne.

      • Avoid picking at the lesions.

      • Stop any dietary triggers and manage stress.

      • Topical retinoid therapy can prevent the hyperproliferation of keratinocytes and reduce the release of proinflammatory cytokines.  The three most commonly used retinoids are tretinoins, tazarotene, and adapalene.  Adapalene is the most effective and best tolerated; it is available in different concentrations and in different vehicles, such as gels, lotions, and creams.  This treatment can cause a primary irritant dermatitis, manifested as erythema and dryness.  Start with the lowest concentration possible.  

      • Azelaic acid can be used for comedonal acne and also for some cases of mild pustular acne.  Trade names are Finacea and Azelex.  

    • Moderate acne (papular-pustular)

      • Benzoyl peroxide can be used alone or as an add-on treatment to retinoids.  It is available in a combination form with adapalene.  Propionibacterium acne does not develop resistance to it.

      • If acne persists after 6-8 weeks of benzoyl peroxide and retinoids, consider starting a topical antibiotic.  Topical antibiotics are more effective when used in conjunction with benzoyl peroxide and retinoids than when used as monotherapy.  Clindamycin is the most commonly used topical agent.

      • Oral antibiotics, in particular minocycline or doxycycline, can be used if topical antibiotics do not suffice.  Results require 12-16 weeks of use, and some recommend a longer course at a lower dose for suppressive therapy.   Trimethoprim-sulfamethoxazole is an alternative for patients with an allergy to tetracyclines.  

      • Oral contraceptive pills are officially listed as a second-line treatment for acne.  They are especially helpful for women with polycystic ovarian syndrome.  The three agents with FDA indications for the treatment of acne are:  Estrostep, Ortho Tri-cyclen and Yaz.

    • Severe acne

      • Isotretinoin (Accutane) can change the course of severe acne that is recalcitrant to other treatments.  

        • It is highly teratogenic, and, therefore, patients should be encouraged to use two forms of highly effective birth control while taking it.  Pregnancy tests should be performed before starting treatment, during treatment, and one month after cessation of therapy.  

        • Accutane can cause an elevation of transaminases and triglycerides, so these should be checked initially and monitored  until the triglycerides peak.  James checks them after one and two months of therapy, while the drug monograph suggests checking them weekly or bi-weekly until the peak is reached.

        • Side effects include dry mucous membranes, dry skin, decreased night vision, myalgias, and pseudotumor cerebri.  Despite lay concern, there is no clear link between Accutane and suicide.

        • Dosing may seem complicated.  The goal is a total dose of 120-150 mg/kg spread out over a treatment period of 4-6 months.  Most recommend starting at 0.5 mg/kg daily for the first month, then increasing to 1 mg/kg daily.  James starts at only 10 mg daily for the first month, then slowly increasing to 1 mg/kg daily.  She finds that this helps to minimize the acne flare that is commonly seen with Accutane initiation.

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