Acne
Posted by dkwinter

Source: http://siouxlookoutareadocs.libsyn.com/acne

 

Remember to seek a secondary cause:

  • PCOS (esp if irregular periods)
  • High-androgen OCP (consider switching)
  • Pregnancy
  • Anabolic steroid use
  • Primary hormonal acne, which may respond to low-dose oral aldactone

 

  May become pregnant Pregnancy prevented

Mild

  • Comedomes
  • Azelaic acid cream (20%) QD-BID
  • BP (5%) QD-TID
  • Topical Isotretinoin gel (0.025%) QD-BID
  • BP (5%) QD-TID

Moderate

  • Inflammation
  • Pustules
  • Azelaic acid cream (20%) QD-BID
  • BP (5%) QD-TID
  • Topical antibiotic
  • Topical Isotretinoin gel (0.025%) QD-BID
  • BP
  • Topical antibiotic

Moderate-Severe

  • More inflammation
  • More pustules
  • Azelaic acid
  • BP
  • Systemic antibiotic
  • Topical Isotretinoin gel (0.025%) QD-BID
  • BP
  • Systemic antibiotic

Severe

  • Nodules
  • Cysts

 
  • Isotretinoin (accutane)

 

Topical antibiotics:

  • Clindamycin 1.2% gel QD-BID
    • e.g. "Dalacin T lotion"
  • Dapsone gel 5% BID

 

Systemic antibiotics:

  • Concurrent use of BP with antibiotics can help prevent antibiotic resistance
  • Avoid systemic antibiotics for greater than 3-6 months at a time due to increasing likelihood of developing antibiotic resistance
  • First line
    • Tetracycline 500 mg BID initially then 250-500 mg daily maintenance (cheaper)
      • Beware of phototoxicity
      • Allow 8-12 weeks for response then step-down to topical antibiotic (pulse treatment)​
    • Doxycycline 100 mg capsule daily (less AE)
  • Second line
    • Erythromycin 500 mg BID initially then 250-500mg daily maintenance
  • Third line
    • Trimethoprim 200-300 mg BID (quite expensive)

 

Isotretinoin:

  • Must be male or use two reliable forms of contraception
  • Dosing: 0.5 mg/kg/d for 4 weeks then 1 mg/kg/d for 3-7 months
  • Acne may flare up during first 1-2 months
  • Monitor CBC, LFTs, lipids
  • Severe inflammatory and scaring acne usually requires treatment for 10-12 months

 

Often effective regimen:

  • minocin 100mg bid for four months
  • tactuo gel twice daily for a year

 

Combination products:

  • Clindoxyl (benzoyl peroxide 5% and clindamycin 1% gel) qhs-BID
  • Bianca (clindamycin 1.2% and tretinoin 0.025%)
  • TactuPump (adapalene 0.1%/benzoyl peroxide 2.5%)

 

Notes:

  • Salicyclic acid generally not as effective as equal strength benzoyl peroxide
  • Spironolactone may be used in select cases
  • Steroids may be used for short-term benefit in acute cases of cosmetic concern

 

 

 

Source: Dr. Mike Evans