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Dermatology
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A stepwise approach to
management of acne
Treatment of acne should be aimed at both settling the acute symptoms,
as well as preventing relapse, writes David Buckley
Acne should be considered a chronic disease. Like many
other chronic diseases, such as asthma or rheumatoid
arthritis, treatment should be aimed at both settling the
acute symptoms (papules, pustules, nodules, cysts, etc)
and preventing relapse. This step-up, step-down approach
will hopefully simplify the management of acne and the
success of treatment (see Table 1).
When treating acne, regardless of the severity, it is important to reassure the patient that you can clear their acne,
although results may take six to twelve weeks and sometimes up to six months in more difficult cases. It is also
important to explain that the treatments don’t cure acne
(except Roaccutane) and that they will need ongoing topical
treatment maintenance when their acne has been brought
under control so as to prevent relapse.
It is important to understand the mode of action of various acne therapies (see Table 2). Then you can choose the
most appropriate treatment for the particular type of acne
you are treating and you can select logical combinations.
When faced with a patient with acne, many GPs immediately prescribe an oral antibiotic medication such as
lymecycline or minocycline as it takes little or no time to
explain to the patient how to use these medications. While
oral antibiotics will reduce the inflammatory component
of acne (papules and pustules) they do nothing for the
basic underlying problem, which is too much oil in the skin
leading to blocked pores and comedones (blackheads and
whiteheads).
If the oiliness of the skin and the comedones are not
treated, then the patient will not respond adequately to
treatment and will relapse quickly once the oral antibiotics
are stopped. The only way to treat oily skin and comedones
is with topical treatments (with the exception of Roaccutane, which we will deal with in a future article). Topical
anti-comedonal treatments are tricky to use, as most cause
dryness and sometimes redness and soreness of the skin,
particularly if they are used incorrectly.
The first step in the ladder in managing all patients with
acne is to use a good anti-acne wash. While a bar of ordinary soap will definitely help, specific anti-acne washes
containing salicylic acid are more effective but also more
drying. Most patients with very oily skin will tolerate a wash
containing 2% salicylic acid (eg. Acnisal, Roc Purifac or
Clearasil Ultra Acne Clearing Gel Wash). Those with more
sensitive skin may only be able to tolerate a 0.5% salicylic
acid wash (Normaderm Deep Cleansing Gel or Clearasil
Clear Daily Face Wash for Sensitive Skin).
Figure 1 (above): Comedonal
acne
Figure 2 (right): Papular
pustular acne
Women should be
advised not to moisturise
the acne affected areas
and should only use oilfree (‘non-comedogenic’) make-ups. All patients should be
advised to never scratch, squeeze or pick their spots. They
should be advised to have a healthy balanced diet and take
plenty of fresh air and exercise.
For most patients with mild acne, good results can be
obtained by combining a salicylic acid wash with topical
benzoyl peroxide 5%. Benzoyl peroxide is predominantly an
antibacterial agent and is best used when there are mostly
papules and pustules with not so many comedones (see
Figure 1). Benzoyl peroxide 5% is quite drying and has to
be used sparingly, particularly at the start. New formulations such as Acnecide 5% are less irritating than the older
formulations such as Quinoderm or Panoxil. Benzoyl peroxide is an over the counter medication, which makes it
cheaper than many other topical acne preparations. It also
comes in large tubes (60g) so it can be used on the chest
and back, as well as on the face, if necessary.
When using it on the neck or trunk you should warn
patients that it can bleach coloured clothing, so advise them
to wear white shirts. Benzoyl peroxide is as effective as topical antibiotics without the problem of developing resistance,
so it can be used long-term both to clear up the existing acne
and to prevent acne relapsing once under control. It also
reduces the carriage of antibiotic-resistant micro-organisms
and should be used in combination with oral or topical antibiotic acne therapies to improve their long-term efficacy.
For patients with oily skin and many comedones, it is
worth considering using topical retinoids combined with
FORUM May 2012 43
Dermatology Buckley-NH 1
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Dermatology
Table 1
Stepwise approach to the management of acne
Severe
Moderate/severe
Oral antibiotics*** and anti-androgens +/- PD laser
Moderate
Roaccutane
Oral antibiotics or anti-androgens**** or PD laser*****
Mild/moderate
Topical retinoids**
Mild
BPO* +/- 2% salicylic acid wash
*BPO = benzoyl peroxide 5%
**Topical retinoid = adapalene (Differin gel) or topical isotretinoin (Isotrex) or azelaic acid (Skinoren) or nicotinamide 4% (Nicam)
*** Oral antibiotics = tetracyclines (eg. lymecycline) or trimethoprim (x 3-6/12) or erythromycin (if risk of pregnancy)
**** Anti-androgens = Dianette x 6-12/12 or high-dose oestrogen pill
*****PD laser = pulsed dye laser (eg. N-Lite)
Table 2
Mode of action of acne therapies
Mode of action
Salicylic
acid wash
Benzoyl
peroxide
Topical
retinoids
Azelaic acid
(Skinoren)
Topical
antibiotics
Oral
antibiotics
Pulsed
dye laser
Decrease sebum
production
Reduce follicular
plugging
Reduce propionibacterina acnes
+
+
+
+
+
Reduce
inflammation
2% salicylic acid (see Figure 2). Topical retinoids, such as
isotretinoin (Isotrex) or retinoid-like agents, such as adapalene (Diferin gel) are primarily anti-comedonal. Patients
should be instructed to put these agents on over the affected
areas of the face and neck and not just on the individual
spots. The patient needs to be instructed to apply them sparingly, especially at the start of treatment, until their skin gets
used to the preparations. It is important to tell the patient
that these products can take months rather than weeks to
clear comedones and to have a significant effect on acne.
For more mild to moderate acne, combining benzoyl peroxide with a topical retinoid-like agent can be very effective
for both treating acne and preventing relapse. However, the
combined effect of a salicylic acid wash, benzoyl peroxide
in the morning and a topical retinoid at night can be very
drying and irritating. They should be started individually
and sparingly and added in one week at a time.
While topical therapies will work very well for mild or mild
to moderate acne, for more troublesome acne, a systemic
treatment may have to be added to these topical agents
or introduced at the same time. Oral antibiotics, such as
lamicycline (Tetralycal) should be used for at least three
months and not more than six months. If the acne has not
cleared after six months of oral antibiotics combined with
good topical agents, then a different class of oral antibiotics could be tried, such as trimethoprim 200-300mg BD or
doxycycline 100mg daily for three to six months. Erythromycin 500mg BD for three to six months is useful if there is
a risk of pregnancy and in children less than 12 years old.
I rarely use topical antibiotics when treating acne and
if I do, I only use them for a maximum of three months,
as resistance is almost inevitable after this length of time.
Again, it is important to realise that topical antibiotics have
no effect on the oiliness of the skin or comedones. For this
+
High-dose oestrogens
and/or anti-androgens
Roaccutane
+
+
+
+
+
+
+
+
+
+
reason, it is probably better to combine topical antibiotics
with a topical retinoid such as Isotrexin or with a benzoyl
peroxide such as Duac for a maximum of three months.
Once stopped, a topical retinoid and/or benzoyl peroxide
should be continued on their own to prevent relapse.
Pulsed dye lasers have a similar anti-inflammatory effect
as oral antibiotics and have been shown to be as effective
as oral antibiotics when used with good topical agents without the inherent risks associated with oral antibiotics.
In younger non-smoking women, Dianette or any other
high-dose oestrogen contraceptive pill combined with benzoyl peroxide topically is an option, especially if she has other
indications for the oral contraceptive pill, such as for contraception, menstrual problems or polycystic ovarian syndrome.
They usually need to be continued for six to 12 months.
Sometimes Dianette can be combined with oral antibiotics
and good topical agents, although if the acne is bad enough
to warrant this combination then the doctor should be considering Roaccutane. Progesterone-only contraceptives such
as the mini-pill Implanon and the Mirena coil should be
avoided in acne sufferers as they may make acne worse.
Regardless of which systemic agent is used for acne, it is
important to remember to step down the treatment ladder
to a topical maintenance treatment once the acne is under
control to prevent relapse. Three monthly follow-up until
the acne is under control is important to monitor response,
check compliance and advise on maintenance treatment.
Roaccutane should be considered for patients with severe
nodular cystic acne, scarring acne or less severe acne not
responding or relapsing after at least six months of a combination of topical and systemic treatments. This treatment
option will be discussed in a future article.
David Buckley is in practice in Tralee, Co Kerry
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