Acne Vulgaris,acne diagnosis,acne tratment,acne device,acne scrub

Pharmacy Clinic

Acne Vulgaris

Therapy of Acne

To promote better compliance and outcomes, therapy should be individualized, with the goals of relieving discomfort,
preventing pitting or scarring and limiting psychosocial distress.

Non-drug therapy of acne

•        Good skin hygiene is a basic tenet in acne prevention
•        Twice-daily cleansing with warm water and a mild soap can effectively remove excess sebum and improve skin
appearance.
•        Aggressive skin washings will not alter the course of acne and may actually aggravate acne by promoting the
development of inflammatory lesions.
•        Abrasive or antibacterial cleansers are not recommended, and squeezing or picking of acne lesions should be
discouraged.
•        Drugs, cosmetics or other known precipitants also should be avoided.

Drug therapy

•        Retinoids work to normalize follicular keratinization;
•        isotretinoin and hormone manipulations decrease sebum production;
•        Antibiotics and benzoyl peroxide target P. acnes.
•        Antibiotics and retinoids also are used to prevent inflammation associated with bacterial colonization,
•        Topical therapy generally is preferred over systemic agents for mild to moderate acne.

Comedonal acne

Comedonal acne is the earliest clinical expression of acne, is usually non inflammatory
Typically affects the central forehead, chin, nose and paranasal areas.
This form of acne develops in the preteenage or early teenage years as a result of increased sebum production and
abnormal desquamation of epithelial cells.
Colonization by P. acnes has not yet occurred, so there usually are no inflammatory lesions. At this stage, therapy
should be focused on prevention, minimizing formation of new comedones and the proliferation of P. acnes.
Topical antibacterial agents, such as benzoyl peroxide,
comedolytic agents, such as salicylic acid and tretinoin (Retin-A), that unplug follicles with their exfoliative effects.

Benzoyl peroxide

Salicylic acid

Vitamin A analogues

Papular acne

•        Most patients with acne present with comedones and papules on the face and trunk.
•        Their formation begins with noninflammatory comedonal acne progressing to a small number of inflammatory
lesions on the face, which then evolve into a more generalized eruption first on the face and then trunk.
•        The goal of therapy for papular acne is to neutralize the pathophysiologic events.
•        Topical antibiotics are effective in treating mild to moderate inflammatory acne, and they offer the advantage of
direct topical application and less systemic absorption.
•        The side effects are minimal, the most common being mild burning or irritation.
•        They also can be used as an adjunct therapy in nodulocystic acne.
•        P. acnes usually is found in low numbers in normal skin, but the combination of abnormally desquamated cells and
excessive levels of sebum in the microcomedones of papular acne produce an environment that promotes the growth of
P. acnes.
•        Many antibiotics are effective against P. acnes in vitro, but not many can gain access to the lipid-rich environment
of the sebaceous follicles.
•        After colonization, P. acnes helps transform comedones to inflammatory pustules or papules by producing FFAs
•        Antibiotics are ineffective in existing lesions, they can prevent future lesions by decreasing sebaceous fatty acid
metabolic byproducts (a known inflammatory stimulus) by decreasing P. acnes colonization.
•        Tetracycline has been the most extensively studied and is relatively inexpensive.

Tetracycline
•        Available as a 2.2% solution (Topicycline).
•        A study of 85 patients found the use of tetracycline solution for 16 weeks with an 8-week course of oral
tetracycline effectively reduced the severity of acne in 94 percent of patients.
•        In comparison, only 57 percent of those patients treated with oral tetracycline and a liquid placebo solution
showed similar improvements.
•        Additionally, patients reported that topical tetracycline was cosmetically acceptable and well tolerated despite skin
irritation. Clindamycin
•        Available in a 1% solution, lotion or gel (Cleocin-T);
•        Various studies show it to be as effective as topical erythromycin or oral tetracycline.
•        A 12-week course of 1% clindamycin solution twice daily showed significant reduction in the number of
inflammatory and noninflammatory acne lesions.
•        Rare cases of pseudomembranous colitis have been reported with topical use of clindamycin.

Topical erythromycin
•        Considered to be the safest acne agent to use during pregnancy.
•        It is available in a 2% solution (Eryderm),
•        Erythromycin also is available in a 3% gel formulation combined with 5% benzoyl peroxide (Benzamycin).
•        For short-term use, the combination product is more effective in acne treatment than either agent used alone;
•        Its relative efficacy to the two individual agents used together is not known.
Vehicle consideration is important in topical formulations.
o        Gels usually have a high alcohol content that allows for better absorption, but they also can be more drying.
Therefore, a cream or ointment may be better tolerated in patients with sensitive skin.
o        Gels are useful for patients with oily skin.
o        For optimal results, the entire susceptible area, not just the lesions, should be treated.
o        Therapeutic effects from topical antibiotics can be seen earlier than with other topical therapies, with improvement
seen as early as two weeks after starting therapy and maximal efficacy after 12 weeks.
o        Topical antibiotics only inhibit the metabolism of P. acnes, acting to decrease lipase activity, FFAs and chemotactic
factors without killing the bacteria;
o        Chronic therapy may be necessary.
o        Choice of agents should be based on cost, adverse effects, pregnancy status and age.
o        All topical antibiotics should be applied twice daily.

Pustular acne

Patients with moderate to severe inflammatory acne may require oral antibiotics in addition to topical therapy
Systemic antibiotics can achieve a more rapid clinical improvement, usually two to six weeks, with maximal clinical
improvement in three to four months
The disadvantages of oral antibiotics, though, lie in their side effects: gastrointestinal distress and vaginal candidiasis.
In general, they should be reserved for patients with moderate to severe acne, patients intolerant or unresponsive to
topical agents or those with acne on the trunk, back or shoulders.
Twice-daily dosing of systemic antibiotics normally improves compliance, is usually as effective as more frequent dosing
and may be used for chronic therapy
Long-term use of antibiotics has been found to be safe and effective in treating acne

Tetracycline
•        Generally considered the first choice of oral agents in pustular acne due to its documented effectiveness and low
cost
•        With a usual starting dose of 250 mg four times daily or 500 mg twice daily, 250 mg twice daily for four months
also was found to be safe and effective in treating papulopustular acne, with 95 percent of patients showing clinical
improvement

Minocyline
•        The antibiotic of choice in acne if cost were not a consideration.
•        It is highly effective in acne treatment due to its lipid solubility and ability to penetrate the sebaceous follicle
•        Minocycline is used in patients with tetracycline-resistant acne and achieves good absorption even when
administered with food.
•        The usual starting dose is 50 mg twice daily or 100 mg once daily.
•        Side effects include diarrhea, nausea, dizziness and rare color changes in the acne scar
•        Minocycline was the most frequent antibiotic used for acne in the United Kingdom, but enthusiasm waned with
reports of systemic lupus erythematosus implicating minocycline.
•        Several cases of autoimmune hepatitis were also associated with minocycline and led to dramatic decreases in the
medication's use

Doxycycline Is less expensive than minocycline and its high lipid profile also makes it a good agent in acne treatment
The usual dose is 100 mg once daily, and side effects include photosensitivity and gastrointestinal distress
The usual dose of erythromycin is similar to that for tetracycline.
P. acnes resistance to erythromycin is more common than with tetracyclines according to various studies and
gastrointestinal side effects limit its use.
Erythromycin, though, has the advantages of not inducing photosensitivity and not interacting with antacids and dairy
products.

Trimethoprim-sulfamethoxazole is reserved for severe cases of acne refractory to other antibiotics
Therapy initiated at one double-strength tablet of trimethoprim - sulfamethoxazole daily
Potential side effects include rash, photosensitivity, dizziness and Steven-Johnson's syndrome “SJS, is an extreme
allergic reaction, usually to a drug, but also to certain bacterial and viral infections”, a severe eruption reaction.
This medication is well tolerated, except for patients allergic to the sulfa component, and is considered an excellent
therapeutic choice

Failure of antibiotic therapy
Despite the relative success of antibiotic therapy, many patients do not achieve full suppression of inflammatory lesions
with continued antibiotic usage, explanations for which include differences in dosage regimens, drug absorption and
patient compliance
Resistance to P. acnes should be considered in patients whose response decreases with therapy that previously was
successful

It did not become a problem until the mid 1970s, despite nearly two decades of antibiotic usage
British studies reveal that resistance to erythromycin is most prevalent, with the majority of the strains also being
resistant to clindamycin. Cross-resistance between tetracycline and doxycycline also has been reported.

The development of bacterial resistance may have greater consequences than simply failure of acne treatment
Resistance to antibiotics is encoded by specific genes on plasmids transmissible between different strains and species of
bacteria, and the skin appears to be an active site of resistance exchange

The spread of antibiotic resistance to Staphylococci has become a growing concern, because such an organism can have
deleterious consequences in immunocompromised patients or those with surgical prostheses. Such concerns have
encouraged the use of benzoyl peroxide, azelaic acid, combination therapy and, to a lesser degree, topical retinoids as
ways to minimize antibiotic resistance.

Nodulocystic acne

Patients with severe inflammatory acne unresponsive to conventional therapy should be referred to a dermatologist
Treatment options for these patients include isotretinoin, steroid injections and hormone therapy
Systemic antibiotics can also be used in treating cystic acne, but long-term use may be limited by resistance and adverse
effects, including photosensitivity, gastrointestinal disorders and vaginitis

Isotretinoin

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