1. Oral antibiotics such as tetracycline (25–50
mg/kg/d divided bid not to exceed 3 g/d),
erythromycin (30–50 mg/kg/d divided bid,
not to exceed 2 g/d), doxycycline (5 mg/ kg/d
divided qid–bid, not to exceed 200 mg/d), or minocycline
(2 mg/kg/d, not to exceed 200 mg/d) are
probably the most effective and can be tapered to lower doses once
the acne is under good control. Minocycline, tetracycline, and doxycycline
should only be used in children older than 8 years because of potential
permanent staining of growing teeth. Erythromycin should not be
taken with astemizole, terfenadine, or cisapride, and can also increase
theophylline levels. All oral antibiotics also theoretically interfere
with the efficacy of oral contraceptives (OCP) and backup contraceptive
methods should be used.
2. In females, acne can be controlled with oral contraceptives.
Three OCPs are currently FDA-approved for the treatment of acne:
- (1) A triphasic OCP with norgestimate (preogestin)-ethinyl estradiol
35 μg (Estrostep).
- (2) Graduated ethinyl estradiol (20–35 μg) with norethindrone
- (3) 20 mg of ethinyl estradiol with 3 μg drospirenone (Yaz or
In Europe and Canada, 2 mg cyproterone (a progestational antiandrogen)
with ethinyl estradiol (35 or 50 μg) is available (Diane-35) and
3. Oral spironolactone blocks androgen receptors and 5α-reductase.
Doses or 50 to 100 mg daily can reduce sebum production and improve
acne. Patients taking spironolactone should be cautioned regarding
hyperkalemia and hypotension side effects.
4. Oral 13-cis-retinoic acid (isotretinoin) is highly effective
for cystic acne. As retinoids are teratogenic, it is necessary that
female patients have a pretreatment pregnancy test and they must
be on two forms of birth control at least 1 month prior to beginning
treatment, throughout treatment, and for 1 month after treatment
is discontinued. Furthermore, a patient must have a negative serum
pregnancy test within the 2 weeks prior to beginning treatment.
Dosage: 0.5 to 2 mg/kg/d with meals for a 15-
to 20-week course, which is usually adequate. Approximately 30% of patients
require a second course. Careful monitoring of the blood is necessary
during therapy, especially in patients with elevated blood triglycerides
before therapy is begun. Currently, isotretinoin use is regulated
by the iPLEDGE program which requires prescriber, patient, and pharmacist
to sign off electronically on a monthly basis during treatment.
Common side effects of isotretinoin include xerosis, dry oral
and nasal mucosa, xerophthalmia, myalgias, and skeletal hyperostoses.
Serious side effects include idiopathic intracranial hypertension
(pseudotumor cerebri), depression, suicidal ideation, and teratogenicity.
5. Incising and expressing comedones can improve cosmetic appearance
6. Intralesional steroids for deep and inflamed lesions can quickly
help them resolve.
7. Acne scarring can be treated with dermabrasion, laser resurfacing,
chemical peels, filler substances, or punch grafting.