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A 16-year-old boy (Figure 96-1) with severe nodulocystic acne and scarring presents for treatment. After trying oral antibiotics, topical retinoids, and topical benzyl peroxide with no significant benefit, the patient and his mother request isotretinoin (Accutane). After 4 months of isotretinoin, the nodules and cysts cleared, and there remained only a few papules (Figure 96-2). He is much happier and more confident about his appearance. The skin fully cleared after the last month of isotretinoin.
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Acne is an obstructive and inflammatory disease of the pilosebaceous unit predominantly found on the face of adolescents. However, it can occur at any age and often involves the trunk in addition to the face.
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Acne vulgaris affects more than 80 percent of teenagers, and persists beyond the age of 25 years in 3 percent of men and 12 percent of women.1
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Etiology and Pathophysiology
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The four most important steps in acne pathogenesis:
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Sebum overproduction related to androgenic hormones and genetics.
Abnormal desquamation of the follicular epithelium (keratin plugging).
Propionibacterium acnes proliferation.
Follicular obstruction, which can lead to inflammation and follicular disruption.
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Neonatal acne is thought to be related to maternal hormones and is temporary (Figure 96-3).
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Acne can be precipitated by mechanical pressure as with a helmet strap (Figure 96-4) and medications such as phenytoin and lithium (Figure 96-5).
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There are some studies that suggest that consumption of large quantities of milk (especially skim milk) increase the risk for acne in teenagers.2
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Morphology of acne includes comedones, papules, pustules, nodules, and cysts.
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Obstructive acne = comedonal acne = noninflammatory acne and consists of only comedones (Figure 96-6).
Open comedones are blackheads (Figure 96-7) and closed comedones are called whiteheads and look like small papules.
Inflammatory acne has papules, pustules, nodules, and cysts in addition to comedones (Figure 96-5).
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Face, back, chest, and neck.
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None unless you suspect androgen excess and/or polycystic ovarian syndrome (PCOS).3 SOR A Obtain testosterone and DHEA-S levels if you suspect androgen excess and/or PCOS.
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Consider follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels if you suspect PCOS.
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Differential Diagnosis (Including Special Types of Acne)
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Acne conglobata is an uncommon and unusually severe form of acne characterized by multiple comedones, cysts, sinus tracks, and abscesses. The inflammatory lesions and scars can lead to significant disfigurement.4 Sinus tracks can form with multiple openings that drain foul-smelling purulent material (Figures 96-8 and 96-9). The comedones and nodules are usually found on the chest, shoulders, back, buttocks, and face. In some cases, acne conglobata is part of a follicular occlusion triad including hidradenitis and dissecting cellulitis of the scalp.
Acne fulminans is characterized by sudden onset ulcerative crusting cystic acne, mostly on the chest and back (Figures 96-10 and 96-11).5 Fever, malaise, nausea, arthralgia, myalgia, and weight loss are common. Leukocytosis and elevated erythrocyte sedimentation rate are usually found. There may also be focal osteolytic lesions. The term acne fulminans may also be used in cases of severe aggravation of acne without systemic features.5
Pomade acne is described as acne that is caused or exacerbate by greasy hair products that get on the skin of the forehead. It is more commonly seen in African Americans (Figure 96-12).
Rosacea can resemble acne by having papules and pustules on the face. It is usually seen in older adults with prominent erythema and telangiectasias. Rosacea does not include comedones and may have ocular or nasal manifestations (Chapter 97, Rosacea).
Folliculitis on the back may be confused with acne. Look for hairs centrally located in the inflammatory papules of folliculitis to help distinguish it from acne. Acne on the back usually accompanies acne on the face as well (Chapter 100, Folliculitis).
Acne keloidalis nuchae consists of papules, pustules, nodules, and keloidal tissue found at the posterior hairline. It is most often seen in persons of color after shaving the hair at the nape of the neck (Figure 96-13).
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Treatment is based on type of acne and severity. Categories to choose from are topical retinoids, topical antimicrobials, systemic antimicrobials, hormonal therapy, oral isotretinoin, and injection therapy.
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Medications For Acne Therapy
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In a review of 250 comparisons, the Agency for Health-care Research and Quality found 14 had evidence of level A.6 These comparisons demonstrated the efficacy over vehicle or placebo control of topical clindamycin, topical erythromycin, benzoyl peroxide, topical tretinoin, oral tetracycline, and norgestimate/ethinyl estradiol.4 Level A conclusions demonstrating equivalence include: Benzoyl peroxide at various strengths was equally efficacious in mild/moderate acne; adapalene and tretinoin were equally efficacious.6 SOR A
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Benzoyl peroxide—Antimicrobial effect (gel, cream, lotion) (2.5%, 5%, 10%) 10 percent causes more irritation and is not more effective.1 SOR A
Topical antibiotics—Clindamycin and erythromycin are the mainstays of treatment.
Erythromycin—Solution, gel.3 SOR A
Clindamycin—Solution, gel, lotion.3 SOR A
Benzamycin gel—Erythromycin 3 percent, benzoyl peroxide 5 percent.3 SOR A
BenzaClin gel—Clindamycin 1 percent, benzoyl peroxide 5 percent.3 SOR A
Dapsone 5 percent gel.7 SOR B
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Tretinoin (Retin-A) gel, cream, liquid, micronized.1 SOR A
Adapalene gel—Less irritating than tretinoin.1 SOR A
Tazarotene—Strongest topical retinoid with greatest risk of irritation.8 SOR A
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Topical retinoids will often result in skin irritation during the first 2 to 3 months of treatment, but new systematic reviews do not demonstrate that they worsen acne lesion counts during the initial period of use.2
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Oral antibiotics.
Doxycycline 40 to 100 mg qd to bid—Inexpensive, well tolerated, can take with food and increases sun sensitivity.3 SOR A
Minocycline 50 to 100 mg qd to bid—Expensive, not proven to be better than other systemic antibiotics including tetracycline.3,9 SOR A
Erythromycin 250 to 500 mg bid—Inexpensive, frequent gastrointestinal (GI) disturbance but can be used in pregnancy.3 SOR A
Trimethoprim/sulfamethoxazole DS bid—Effective but risk of Stevens-Johnson syndrome is real. Reserve for short courses in particularly severe and resistant cases.3 SOR A
Oral azithromycin has been prescribed in pulse dosing for acne in a number of small poorly done studies and has not been found to be better than oral doxycyline.10
Isotretinoin (Accutane) is the most powerful treatment for acne. It is especially useful for cystic and scarring acne that has not responded to other therapies.3 SOR A Dosed at approximately 1 mg/kg per day for 5 months. Any female of childbearing potential must be abstinent from sexual intercourse or use two forms of contraception. Other risks that are controversial but important to discuss with patients and their parents are depression, suicide, and inflammatory bowel disease.
The US Food and Drug Administration requires that prescribers of isotretinoin, patients who take isotretinoin, and pharmacists who dispense isotretinoin all must register with the iPLEDGE system (www.ipledgeprogram.com).
Hormonal treatments are for females only:
Oral contraceptives—Choose ones with low androgenic effect.3 SOR A FDA-approved oral contraceptives are Ortho Tri-Cyclen, Yaz, and Estrostep. Other oral contraceptives with similar formulations also help acne in women even though these have not received FDA approval for this indication. Note: Yaz and Yasmin have progestin drospirenone, which is derived from 17a-spirolactone. It shares an antiandrogenic effect with spironolactone.
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Complementary/Alternative Therapy
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Tea tree oil 5 percent gel.11 SOR B
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Steroid injections for acne are useful for painful nodules and cysts. SOR C Patients often report that the lesion flattens and becomes painless by the next day. Follow these directions to avoid producing skin atrophy.
Dilute 0.1 mL of 10 mg/mL triamcinolone acetonide (Kenalog) with 0.4 mL of sterile saline in a 0.1 mL syringe to make a 2 mg/mL suspension. Shake the suspension well before injecting.
Inject 0.1 mL of this suspension into each nodule or cyst using a 30-gauge needle (Figure 96-15).
Acne surgery is a fancy name for extracting the material from open comedones. It helps to nick the comedone with a needle or #11 blade before expressing the material with a comedone extractor (Figure 96-16). The patient in Figure 96-7 is a very good candidate for this procedure along with medical therapy.
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Acne Therapy By Severity
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Comedonal acne (Figures 96-6, 96-7, 96-17)
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Topical retinoids or azelaic acid are the most beneficial agents.
No need for antibiotics—Do not need to kill P. acnes.
Benzoyl peroxide may be beneficial.
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Topical antibiotics and benzoyl peroxide.
Topical retinoid or azelaic acid.
May add oral antibiotics if topical agents are not working (Figure 96-18).
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Papulopustular or nodulocystic acne—moderate to severe—inflammatory
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Topical antibiotic, benzoyl peroxide, and oral antibiotic.
Oral antibiotics are often essential at this stage especially if the trunk is involved.
Topical retinoid or azelaic acid.
Steroid injection therapy—For painful nodules and cysts.
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Severe cystic or scarring acne
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Acne fulminans (Figures 96-10 and 96-11)
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Start with systemic steroids (prednisone 40 to 60 mg/day—Approximately 1 mg/kg per day).12 SOR C
Systemic steroid treatment rapidly controls the skin lesions and systemic symptoms. The duration of steroid treatment in one Finnish series was 2 to 4 months to avoid relapses.12 SOR C
Therapy with isotretinoin, antibiotics, or both was often combined with steroids, but the role of these agents is still uncertain.12 SOR C
One British series used oral prednisolone 0.5 to 1 mg/kg daily for 4 to 6 weeks (thereafter slowly reduced to zero).13 SOR C
Oral isotretinoin was added to the regimen at the fourth week, initially at 0.5 mg/kg daily and gradually increased to achieve complete clearance.13 SOR C
Consider introducing isotretinoin at approximately 4 weeks into the oral prednisone if there are no contraindications. SOR C
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Acne conglobata (Figures 96-8 and 96-9) may be treated like acne fulminans but the course of oral prednisone does not need to be as long. SOR C
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Combination Therapies
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Combination therapy with multiple topical agents can be more effective than single agents.3 SOR B
Topical retinoids and topical antibiotics are more effective when used in combination than when either are used alone.3 SOR B
Benzoyl peroxide and topical antibiotics used in combination are effective treatment for acne by helping to minimize antibiotic resistance.3 SOR B
The adjunctive use of clindamycin/benzoyl peroxide gel with tazarotene cream promotes greater efficacy and may also enhance tolerability.14
Combination therapy with topical retinoids and oral antibiotics can be helpful at the start of acne therapy. However, maintenance therapy with combination tazarotene and minocycline therapy showed a trend for greater efficacy but no statistical significance versus tazarotene alone.15
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The most affordable medications for acne include topical benzoyl peroxide, erythromycin, clindamycin, and oral tetracycline and doxycycline. The most expensive acne medications are the newest brand-name combination products of existing topical medication. These medications are convenient for those with insurance that covers them (Epiduo contains benzoyl peroxide and adapalene; Ziana contains clindamycin and tretinoin).
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Newer Expensive Modes of Therapy
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Intense pulsed light and photodynamic therapy (PDT) use lasers, special lights, and topical chemicals to treat acne.16–18 These therapies are very expensive and the data do not suggest that these should be first-line therapies at this time. Light and laser treatments have been shown to be of short-term benefit if patients can afford therapy and tolerate some discomfort. These therapies have not been shown to be better than simple topical treatments.2
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One comparative trial demonstrated that PDT was less effective than topical adapalene in the short-term reduction of inflammatory lesions.2
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Isotretinoin requires monthly follow-up visits but other therapies can be monitored every few months at first and then once to twice a year. Keep in mind that many treatments for acne take months to work, so quick follow-up visits may be disappointing.
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Adherence with medication regimens is crucial to the success of the therapy. Adequate face washing twice a day is sufficient. Do not scrub the face with abrasive physical or chemical agents. If benzoyl peroxide is not being used as a leave-on product, it can be purchased to use for face washing.
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Provider Resources
Usatine R, Pfenninger J, Stulberg D, Small R: Dermatologic and Cosmetic Procedures in Office Practice. Philadelphia: Elsevier; 2012—Covers how to do acne surgery, steroid injections for acne, chemical peels, PDT and laser treatment for acne. It is also available as an app: www.usatinemedia.com.
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