Control rather than cure is the goal of acne therapy. As the patient improves, he can be moved down the treatment ladder to the step at which his acne can be adequately controlled.
Tailor your treatment plan to the type and gradation of your patient’s acne, with the emphasis on correcting the pathophysiologic mechanisms that encourage bacterial activity. Also allow for his or her ability to comply: A young or immature patient may have trouble with a complicated regimen.
The patient with a occasional pimple or blackhead can use nonprescription products to treat very mild acne. Salicylic acid, available in rub-on lotions, may help unplug open comedones. Benzoyl peroxide prevents plug formation by causing peeling within the follicle, it also releases oxygen into the follicle to oxidize proteins of Propionibacterium acnes. Over-the-counter benzoyl peroxide products are available in lotions, creams, sticks, and pads.
Patients with more pervasive and persistent mild acne need prescription-strength medications. Tretinoin (Retin-A) cream, gel, or liquid is highly effective for mild comedonal (grade 1) acne because it penetrates the sebaceous follicle and stimulates epidermal turnover; it helsp reverse the plugging and “unseats” comedones. Begin with a low-strength preparation (0.05% or 0.1% cream or 0.01% or 0.025% gel) to be applied sparingly on an alternate-night basis. This will minimize the initial irritation, drying, and erythema induced by the medication. It takes the skin 1-2 weeks to adapt to the drug; if it is well tolerated (skin is pink in the morning, not “sunburned”), you can increase the frequency of application to once every day or switch to a preparation that is one step stronger. Ask your patient to report reaction to the medication after a few days, and then after a few weeks.
Recommend that your patient wash his face with a mild soap–such as Dove, Aveeno Bar, or Neutrogena–no more than 2-3 times a day and wait at least 30 minutes after washing before applying tretinoin. He may even look worse shortly after starting the medication program, but reassure him that he should have substantial improvement within 2-3 months. Since tretinoin increases photosensitivity, tell him to limit exposure to the sun and use a non-comedogenic sunscreen such as For Faces Only (Coppertone Sun Care Product).
Benzoyl peroxide, the therapy of choice for papular acne (grade 2), whether mild or moderate, is also potentially drying and irritating; 1-2 percent of patients may even develop contact dermatitis. Start treatment gradually, having the patient use small amounts of lower-strength gels (5% or 10% gel–Benzagel, Desquam-X, Persa-Gel, etc.), preferably every other night. After 2-3 weeks, if the patient’s skin seems able to tolerate it, prescribe 10% gel or switch to nightly use of the gel. If the patient reports excessive irritation, discontinue the preparation and have him resume it cautiously after several days.
Whether the patient is using tretinoin or benzoyl peroxide, he should gently apply a thin film of the medication to the affected area–the affected area is that prone to plugging, not just the area with obvious lesions. The degree of redness in the morning is his gauge to determining the right amount of medication to use. If too much is used, his face (or back) appears red; if too little is used, there will be no change–and no improvement.
Also, remind him that both tretinoin and benzoyl peroxide are prophylactic medications that should be incorporated into his daily routine–not reserved for the time when a pimple or blackhead develops. With regular use, some improvement should be evident within a month. This topical therapy should be continued–with reduced-strength preparations–until he is beyond the acne-prone years of adolescence.
Patients with moderate acne–grades 2 and 3 acne consisting of comedones, papules, and, in grade 3, pustules–show marked benefit from using both tretinoin (Retin-A) (0.05% or 0.1% cream or 0.01% or 0.025% gel) and benzoyl peroxide gel (5% or 10% Benzagel, Desquam-X, Persa-Gel, etc.). Use lower-strength preparations on light-complexioned patients. One preparations should be used alone daily until the patient’s skin has adapted, which will take about 1-3 weeks. When prescribing both agents, tell your patient to apply one in the morning and the other in the evening.
Be sure your patient understands how to use these preparations and what side effects to watch for. For example, if his or her skin gets too red and irritated, tel him to cut back to every-other-day use or to discontinue use for several days. Oil-free moisturizers–such as Shepard’s Cream or Lotion, Neutrogena Norwegian Formula Hand Cream, and Purpose Dry Skin Cream–may soothe weather or medication-related irritation.
An important recent addition to the treatment of inflammatory acne is topical antibiotics that inhibit the growth of Propionibacterium acnes and decrease the number of inflammatory lesions. They seem to work most successfully in patients with superificial inflammatory lesions rather than with nodular or cystic lesions. Many authorities prefer the topical form to systemic antibiotics because side effects are less common. Clindamycin solution (Cleocin T), erythromycin solution (A/T/S, Eryderm, Staticin), and tetracycline HCl solution (Topicycline) are available in lotion form. The less irritating meclocycline sulfosalicylate (Meclan) comes as a cream. Add antibiotic lotion or cream applied twice daily for those with grade 3 acne who are not responding to the benzoyl peroxide-tretinoin combination.
Topical antibiotics can also be an alternative for the patient who is sensitive or allergic to benzoyl peroxide. They can be used with tretinoin if introduced after adaptation to tretinoin has taken place. A usually well-tolerated combinations consists of an application of a topical antibiotic in the morning and early evening and an application of tretinoin at bedtime.
Remind the patient that many of these antibiotic agents do sting on application.
Systemic antiobiotic therapy is effective for grades 3 and 4 inflammatory pustular or cystics acne and might also be appropriate for a patient with long-standing acne who is discouraged by previous treatment failures. Add this oral therapy to a topical regimen.
Tetracycline HCl is the preferred antibiotic, since it’s effective in low doses, relatively free of side effects, inexpensive, and can be used long term. For those with less severe cases, the usual starting dosage is 250 mg bid or qid. Use high dosages–1-2 gm bid or qid–to treat patients with severe cystic acne. Advise the patient to take the drug an hour before or two hours after a meal to ensure maximum absorption. As the ache improves after several weeks, gradually reduce the dosage to 250 mg daily or every other day. When clinical improvement allows, discontinue the antibiotic completely and continue to maintain the patient with topical medications.
Although tetracycline has a wide margin of safety, long-term therapy is accompanied by several potential side effects. Vargnal candidiasis is the most frequent complication. Other occasional complaints are symptoms of gastrointestinal irritation such as anorexia, nausea, vomiting, and diarrhea. Its use is precluded in children under age 12 and in pregnant women because of its tendency to stain developing teeth.
When side effects occurs or if tetracycline is not producing desired results, try using another antibiotic such as erythromycin, 250 mg qid, or minocycline HCl (Minocin), 50-100 mg bid.
If long-term use of a systemic antibioitic is indicated, get a baseline CBC and order specific blood tests to check hepatic and renal function. Reorder these tests on an annual basis.
An estimated 3 percent of patients are unresponsive despite intensive treatment efforts. These patients are usually males with disfiguring inflammatory nodules on the face, chest, and back. Recently, the Food and Drug Administration approved the use of a synthetic derivative of vitamin A, isotretinoin (Accutane), for use in severe nodulocystic acne that is unresponsive to other therapy. At maximum dosages of 1-2 mg/kg/day given in two divided doses, the drug clears cystic acne in four months. Remissions lasting for several years have been reported.
This powerful drug has significant dose-related adverse effects on the skin and mucous membranes. These include cheilitis, facial dermatitis, conjunctivitis, dry nasal mucosa, myalgia, headache, thinning of hair, and peeling of the skin from the palms and soles. These symptoms disappear when the drug is stopped. Isotretinoin should not be taken by those with elevated lipid levels or by pregnant women. Long-term consequences such as potential teratogenicity have not been adequately studied. Because of the potential for serious side effects and a lack of long-term follow-up data, authorities recommend that you consult with a dermatologist experienced in acne treatment before reaching a final decision on the use of the drug.
The time invested in educating the patient about acne can provide valuable rewards in cooperation and understanding. Your patient, particularly if he or she is a teenager, needs a great deal of support, reassurance, and honesty. Tell the patient that acne is a condition that may require many years of attentionf there are few overnight cures. In fact, sometimes the treatment may even make his face look worse temporarily. The good news in that medications are available that will control (if not cure) his acne.
OFfer a specific promise of improvement. “If you faithfully apply your medications as we teach you to, in one month you’re going to be 30 percent better, in two months you’re going to be 75 percent better, and in three months you’ll be 95 percent better.” The “if,” of course, is that medication must be applied routinely as directed. Tell him, “This is not your parents’ job; it’s yours. If your mother–or anyone else–has to remind you to put on your cream, we might as well quit right now. I can give you the medication, but you must make the effort.”
Although you’ve stressed that it’s the youngster’s responsibility to care for his acne, you may wish to invite the parents into your office after you’ve interviewed and examined the patient alone. Sharing with them your findings and recommendations provides the parents with the same informations as the youngsters regarding the etiology and treatment of acne. You can also use this time as an opportunity to clear up the parents’ misconceptions along with the adolescent’s. Giving everyone the same information reduces the chance of future conflict over what you did or didn’t say.
Begin the acne treatment program by discussing the pathogenesis of acne (see “How acne develops,” page 134). Using diagrams or sketches, tailor your explanation to the patient’s age and maturity (see the patient education aid “Answers to your questions about acne,” page 160).
Explain how the medications you’re recommending will control the acne. Outline the expected sequence of events–initial irritation, adaptation, and gradual improvement. Also, tell the patient whether the agents you’re prescribing are likely to cause any problems such as photosensitivity, irritation, and excessive dryness.
Your interest and a willingness to spend extra time with your patients are usually the only requisites for successful treatment of acne. Consider arranging consultation with a dermatologist, however, for the small number (perhaps 10 percent) whose acne is unresponsive or who need specialized treatment techniques.
Several adjunctive treatments have fallen into disfavor. X-ray treatments are no longer recommended because of potential carcinogenic effects. The use of ultraviolet light is also controversial, with adverse effects seeming to outweigh the benefits. In general, these treatments are no longer recommended due to risks of overexposure and accelerated aging of skin.
Of the ancillary measures that remain widely accepted, acne surgery, intralesional steroid therapy, cryotherapy, and therapy for acne scarring are helpful in selected patients.
*Comedo extraction. This technique does not affect the usual course of acne, but does allow the patient to look better immediately. The process is painstaking and time-consuming since inaccurate placement of excessive pressure can rupture comedonal walls, causing inflammation.
* Intralesional steroid therapy. The injection of steroids into larger nodules or cysts iduces involution of these lesions within a few hours. Lesions are healed in several days instead of several weeks. When properly performed, this procedure helps reduce the likelihood of scarring.
* Cryotherapy. The application of liquid nitrogen and solid carbon dioxide to cystic inflammatory lesions accelerates their resolution by inducing peeling. This technique also speeds the involution of small pustular lesions, particularly on the back. Rapid clearing of cystic lesions sometimes offers a psychological boost to a patient beginning treatment.
* Scar removal. Although many acne scars improve significantly on their own, several methods are available for patients with residual scarring. Topical chemotherapy with trichloroacetic acid appears to smooth pitted scars. In selected patients, dermabrasion may achieve excellent results. The possible complications of this procedure are hypo- or hyperpigmentation, infection, or further scarring. Punch grafts and collagen injections have proven helpful in reconstruction of atrophic acne scars. These techniques are used selectively by dermatologists and plastic surgeons with special expertise in scar removal.
As a general rule, plan to see your patient who’s receiving topical therapy within a month after the first visit. The purpose of the second visit is to gauge the effect of therapy and to check–by the degree of redness–whether the medication is being applied correctly. This appointment willalso allow you to clarify you instructions further and to make any necessary modifications in the treatment. Encourage the patient to bring a list of questions to this appointment.
While you will probably want to check the patient monthly the first few months, once the response to therapy is obvious, you can lengthen the intervals to eight weeks. When your patient’s acne is controlled–and if he or she is not taking any systemic medication–you may not need to see him other than for a periodic checkup.
While almost all patients with acne need ongoing support and reassurance, a few will require a referral for counseling and psychotherapy. Occasionally, a young patient may have more serious problems in addition to his acne. Since his acne is the most visible problem, it is likely to be the one that brings him to your office. If this is the case, you’ll probably want to guide him to someone who can help him handle his underlying problems. Tell him, “I think your acne is aggravating your problems, and your problems are aggravating your acne. I’m glad to talk with you anytime, but I think you need some extra help. I’d like you to see someone who might be able to help you work out some of these problems.”
Often the patient who has had severe acne that is finally under control becomes upset at relatively minor flares. He may fear that this represents the beginning of a need continual reassurance that current therapies will keep acne under control.