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What are the Treatment Recommendations for Acne?
Patient Presentation
A 19-year-old female comes to clinic for her health maintenance examination. She has had mild
acne in the past, mainly comedones and some papules, that has responded to oral antibiotics and
benzoyl peroxide/clindamycin. Over the past 2 months her acne has gotten worse on these
medications with more pustules and some nodules.
She is concerned about her appearance. She denies new soaps, lotions, haircare products or
cosmetics. She wears a sunscreen recommended by her mother’s dermatologist.
The family history reveals ‘bad’ acne in her mother who continues to have occasionally acne
problems that are related to her menstrual cycle.
The pertinent physical exam shows a healthy adolescent with normal growth parameters. She
has about 75 total lesions mainly around her forehead, cheeks and around the nose. Most are
comedomal, but there are ~10 lesions that are pustular and ~5 that are nodular.
She also has ~10 lesions on her upper back/neck area that are pustular.
The diagnosis of moderate acne was made that is failing past treatment.
The patient was prescribed Retin-A® to use in the evening along with the benzoyl
peroxide/clindamycin in the morning and she had a follow-up appointment in 6 weeks. The
patient’s clinical course showed some improvement with the Retin A® and benzoyl peroxide
treatment. However, the patient wanted to hear about additional treatment options to continue to
improve her acne. Oral contraceptives and Accutane® were discussed with the patient and her
mother. The decision was made to begin an oral contraceptive and a referral was made to a
dermatologist to further discuss Accutane® treatment. In 8 weeks at the visit with the
dermatologist, her acne had markedly improved and she decided to remain on oral contraceptives
plus topical treatment.
Discussion
Acne vulgaris is the most common skin disease with about 17 million people in the US affected.
It commonly occurs in adolescents and young adults. The exact mechanism is unknown but
combinations of bacteria (Propionibacterium acnes, an anaerobic bacterium), increased sebum
production caused by increased androgens, and increased keratinocytes all appear to be partially
responsible.
Acne affects the areas of the face, the upper part of the chest, and the back which have the
densest population of sebaceous follicles.
Some external factors may cause acne to become worse and these include:
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Some cosmetic agents and hair care products
Medications - i.e. steroids, lithium, some antiepileptics, and iodides.
Endocrine disorders with increased androgen production - i.e. congenital adrenal
hyperplasia, polycystic ovary syndrome
Descriptive definitions of acne lesions include:
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Closed comedone (whitehead): non-inflamed (non-red) follicular opening containing a
keratotic plug with a thin overlying epidermal membrane
Open comedone (blackhead): non-inflamed (non-red) follicular opening containing a
keratotic plug that appears black
Papule: small round to oval red elevation of the skin (1-4 mm)
Pustule: resembles a papule with a central pocket of pus
Nodule/Cyst: poorly marginated, red, tender, sometimes draining 0.2- to 3.0-cm
indurated mass in the skin
Figure 27 - Cross section of normal skin
Figure 28 - Cross section of closed comedone
Figure 29 - Cross section of open comedone
Acne has different severity grades depending on the reference. A recent guideline uses a
practical 3-step grading scale:
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Mild - predominance of comedones (fewer than 20), or fewer than 15 inflammatory
papules, or a comedone/papule count of fewer than 30 on the face.
Moderate - predominance of papules and pustules (about 15-50 lesions) with comedones
and rare cysts. Total lesion (comedone, papule, pustule) count may range from 30 to 125
on the face.
Severe - primarily has inflammatory nodules and cysts. Also present are comedones,
papules, and pustules or total lesion count of greater than 125 on the face.
It is important to assess the psychological impairment acne causes for the patient. Often the
psychological stress necessitates more aggressive treatment than the objective grading of the
acne. It is important to educate the patient and family about the treatment options, the proper way
to use the medications prescribed, and especially the natural history.
Use of the medication often requires 8-12 weeks of treatment before improvement is actually
seen. If patient’s do not understand this time course, they may discontinue treatment as they feel
it is ineffective.
Learning Point
Mild acne is often initially treated with a topical retinoid and/or benzoyl peroxide or benzoyl
peroxide/topical antibiotic (combination product) once or twice a day.
If using a topical retinoid, use it in the evening and use the benzoyl peroxide product in the
morning.
Topical Medications
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Over the counter medications
Benzoyl peroxide - ex. Clearasil®, Desquam®, works by decreasing lipid
formation and free fatty acids and causing mild desquamation, may be a single
product or in combination with antibiotics (ex. Benzaclin®, Benzamycin®),
products have concentrations up to 10%
o Salicylic acid - works by keratolysis, products have concentrations of 0.5-2%
o Other products - ex. glycolic acid, sulfur, resorcinol
o
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Prescription medications
o Topical retinoids - ex. Diffren® and Retin A®, works by increasing the turnover
of follicular epithelial cells, promoting drainage of comedones, and inhibiting new
comedone formation, generally used in the evening.
o Azelaic Acid - antibacterial and comedomal medication
o Topical Antibiotics- ex. clindamycin, erythromycin, sulfacetamide, works by
decreasing Propionibacterium acnes within follicles and also may also possess
direct anti-inflammatory effects
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Systemic medications
o Oral antibiotics - ex. erythromycin, doxycycline, minocycline, tetracycline are
generally the first line antibiotics; clindamycin and Bactrim® are second line.
o Oral retinoids - Accutane® - works by reducing sebum secretion, can cause
severe birth defects and therefore its use is restricted to certified dermatologists
o Oral contraceptives - ex. Ortho Tri-Cyclen® and Estrostep® have FDA approval
for acne treatment, works by modulating androgen
o Spironolactone - works by anti-testosterone effect
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Other treatments
o Intralesional corticosteroid injections
TM
o Blue light - ex. ClearLight approved by FDA for moderate acne
Questions for Further Discussion
1. What are the indications for referral to a dermatologist?
2. What steps and certification are required to prescribe Accutane?
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa