TOC
| Derm
Drugs
Acne
Mark Lebwohl, M.D.
Mt. Sinai School of Medicine
Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References
Definition/Key Clinical Features
-
Characteristic skin lesions
-
Open and closed comedones
-
Erythematous papules
-
Pustules
-
Nodules
-
Cysts
-
Scars
-
Most commonly affects face but can
involve back and chest
-
Earlier onset and increased severity
in males
-
Premenstrual flares common in
females
Major forms
Comedonal Acne
-
Comedones
-
Predominance of open (blackheads) and closed (whiteheads)
comedones
Inflammatory Acne
-
Erythematous papules (310 mm)
-
Develop into pustules or resolve into fading erythematous
macule
-
May cause postinflammatory hyperpigmentation
-
Pustules
-
Superficial, dry in a few days
-
Nodules (e 1 cm)
-
Firm, erythematous, tender nodules becoming fluctuant
or forming cysts
-
Fluctuant sinuses result in postinflammatory pigmentary
changes and scarring
Clinical Variants
-
Acne conglobata
-
Severe form with confluent large cysts, abscesses, and
draining sinus tracts
-
Acne cosmetica
-
Low-grade form resulting from use of greasy, occlusive
cosmetics and lotions
-
Acne excoriée
-
Large ulcers and erosions caused by picking of minor
lesions
-
Acne mechanica
-
From repeated trauma and rubbing (e.g., wearing sports
helmets, shoulder pads, or bras)
-
Pomade acne
-
Caused by thick oils in hair
-
Neonatal and infantile acne
-
Erythematous papules and pustules lasting 2-6 mo after
birth
-
May signal severe acne later in life
Differential
Diagnosis
-
Folliculitis
-
Milia
-
Perioral dermatitis
-
Chloracne
-
Hidradenitis suppurativa
-
Favre-Racouchot disease
-
Rosacea
Best
Tests
-
Diagnose by clinical features
Best
Therapy
-
Depends on acne type and severity
Topical Therapies
Comedonal Acne
-
Topical retinoids to unplug follicles and allow topical
antibiotic and benzoyl peroxide penetration.
Inflammatory Acne
-
Treatment alternatives (by effectiveness)
-
Retinoids and benzoyl peroxide most effective
-
Topical antibiotics less effective but better
tolerated.
-
Can be used in combination with benzoyl peroxide
(clindamycin 1% and benzoyl peroxide 5%).
-
Common regimen: antibioticbenzoyl peroxide in
morning and topical retinoid in evening.
-
Azelaic acid
-
Can be used in combination with topical retinoids, benzoyl
peroxide, or topical antibiotics.
-
Sulfur-resorcinol lotion
-
Effective drying and peeling agent for treating individual
lesions.
Back to top |
Home Page
Topical Drugs for
Acne
Retinoids
-
Most effective
-
Adverse effects
-
Dryness
-
Irritation
-
Photosensitivity
-
Adapalene
-
Dose: 0.1% gel q.d.
-
Cost/Mo: 15 g/$37.99
-
Tazarotene
-
Dose: 0.05% or 0.1% gel q.d.
-
Cost/mo: 30 g/$75.99
-
Tretinoin
-
Dose: 0.01%0.05% preparations q.d.
-
Cost/mo: 20 g/$23.99
Benzoyl Peroxide
-
Most effective
-
Adverse effects
-
Dose: 2.5%10% preparations b.i.d.
-
Cost/mo: 45 g/$13.99
Antibiotics
-
Clindamycin
-
Adverse effects
-
Dose: 1% preparation b.i.d.
-
Cost/mo: 30 g/$18.99
-
Erythromycin
-
Adverse effects
-
Dose: 2% preparation b.i.d.
-
Cost/mo: 30 g/$18.30
-
Erythromycinbenzoyl peroxide
-
Adverse effects
-
Dryness
-
Irritation
-
Contact dermatitis
-
Dose: 3% erythromycin, 5% benzoyl peroxide gel
b.i.d.
-
Cost/mo: 46.6 g/$102.99
-
Sodium sulfacetamide-sulfur
-
Adverse effects
-
Dryness
-
Irritation
-
Contact dermatitis
-
Dose: 10% sodium sulfacetamide, 5% sulfur lotion b.i.d.
-
Cost/mo: 30 g/$21.99
Azelaic Acid
-
Adverse effects
-
Dose: 20% cream b.i.d.
-
Cost/mo: 30 g /$45.99
Sulfur and Resorcinol
-
Adverse effects
-
Dryness
-
Peeling
-
Contact dermatitis
-
Dose: 2% resorcinol, 8% sulfur preparation q.d. or b.i.d.
-
Cost/mo: 18 g/$4.49
Salicylic Acid
-
Adverse effects
-
Dose: 0.5%2% preparations q.d. or b.i.d.
-
Cost/mo: 21 g/$7.99
Back to top |
Home Page
Systemic Therapies for
Nodulocystic Acne or Inflammatory Acne Unresponsive to Topical
Therapy
Antibiotics: First-line Therapy
-
Doxycycline
-
Adverse effects
-
Photosensitivity
-
GI symptoms
-
Candidiasis
-
Dose: 50100 mg p.o., b.i.d.
-
Cost/mo: $28.99
-
Erythromycin
-
Adverse effects
-
Dose: 250-500 mg p.o., b.i.d.
-
Cost/mo: $17.98
-
Minocycline
-
Adverse effects
-
GI symptoms
-
Candidiasis
-
Vertigo
-
Lupuslike syndrome (rare)
-
Hepatitis (rare)
-
Dose: 50 mg p.o., q.d. to 100 mg p.o., q.i.d.
-
Cost/mo: $13.99
-
Isotretinoin
-
Most effective agent; long-lasting remissions or cures;
not used as first-line therapy because of serious potential adverse effects
(teratogenicity, hyperlipidemia, cheilitis, alopecia, pyogenic granulomas,
dry eyes, epistaxis, pseudotumor cerebri [rare]); limit treatment to 4-6
months or refer.
-
Dose: 0.52 mg/kg/day in 2 divided doses
-
Cost/mo: $60
-
Tetracycline
-
Adverse effects
-
Photosensitivity
-
GI symptoms
-
candidiasis
-
Dose: 250 mg p.o., q.d. to 500 mg p.o., q.i.d.; b.i.d.
preferred
-
Cost/mo: $7.99
-
Trimethoprim-sulfamethoxazole
-
Adverse effects
-
Bone marrow suppression
-
Drug eruption
-
Dose: 160 mg trimethoprim, 800 mg sulfamethoxazole b.i.d.
-
Cost/mo: $28.98
-
Norgestimate-ethinyl estradiol
-
For women only; alternative to antibiotics and
isotretinoin.
-
Adverse effects
-
Thromboembolic disorders
-
Fluid retention
-
Hypertension
-
Breakthrough bleeding
-
Breast swelling and tenderness
-
Dose: 0.18 mg norgestimate, 0.035 mg ethinyl estradiol
p.o., q.d. for 21 days; repeat q. 4 wk
-
Cost/mo: $32.99
Other
Therapies
-
Consider referral for the following:
-
Specialized abrasion therapy
-
Injections
-
Surgery
Back to top |
Home Page
Best References
Bershad, et al: Arch Dermatol 138:481, 2002
Hirsch, et al: Semin Cutan Med Surg 20:190, 2001
Leyden, et al: Cutis 67(6 suppl):17, 2001
Strauss, et al: J Am Acad Dermatol 45:187, 2001
July 2004
Back to top |
Home Page