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Dermatology Forum 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 27/04/2012 11:02:10 Forum 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 44 FORUM May 2012 Dermatology Buckley-NH 2 27/04/2012 11:02:15