Elsevier

Clinics in Dermatology

Volume 22, Issue 5, September–October 2004, Pages 439-444
Clinics in Dermatology

Guidelines for treating acne

https://doi.org/10.1016/j.clindermatol.2004.03.002Get rights and content

Abstract

Acne, a chronic inflammatory disease of the pilosebaceous units of the face, neck, chest, and back, is the most common skin disorder occurring universally, with an estimated prevalence of 70–87%.1 It is a pleomorphic disorder characterized by both inflammatory (papules, pustules, nodules) and noninflammatory (comedones, open and closed) lesions. Grading of acne is mandatory to determine the appropriate therapeutic strategy. Mild acne can be purely comedonal or mild papulopustular, with a few papulopustules present as well.2 Moderate acne is characterized by numerous comedones, few to many pustules, and few small nodules, with no residual scarring.2 In severe acne papulopustules are numerous, many nodules can be detected, inflammation is marked, and scarring is present.2 Very severe acne can be recognized by sinus tracts, grouped comedones, many deeply located nodules, and severe inflammation and scarring.2 Although acne does not affect health overall, its impact on emotional well-being and function can be critical and is often associated with depression, anxiety, and higher-than-average unemployment rates.3 Effective treatment can dramatically improve a person's quality of life.

Section snippets

Mild comedonal acne

Topical retinoid therapy is the treatment of choice for mild comedonal acne. Exerting their action through nuclear receptors, retinoids help eliminate mature comedones and inhibit the formation of new ones.6 They also have anti-inflammatory actions (particularly third-generation retinoids), making them suitable for inflammatory forms of acne as well.6 Currently used topical retinoids include tretninoin, isotretinoin, adapalene, tazarotene, retinaldehyde, and 6-retinoylglucoronide.

Tretinoin is

Moderate acne

Systemic drug therapy is an integral aspect of treatment for moderate acne. Systemic therapy should always be considered in disease with a tendency for physical or psychological scarring or postinflammatory hyperpigmentation; in widespread disease involving the shoulders, back, and chest; and in patients resistant to topical treatment. Options include oral antibiotics, hormonal therapy, and oral retinoids.

Oral antibiotics prescribed for acne include erythromycin, the tetracyclines

Severe acne

Isotretinoin is the treatment of choice in cases of severe or very severe nodular acne. Patients with severe psychological disturbance, excessive seborrhea, visible scarring, and gram-negative folliculitis are also good candidates.

Isotretinoin is the most effective anti-acne treatment to date that targets all pathogenetic mechanisms. The optimal dosage is .5–1 mg/kg/day until a total cumulative dose of 120–150 mg/kg is reached. This will usually take 4–6 months. Lower doses may be administered

Maintenance therapy

Maintenance therapy is mandatory after every successful acne treatment. Topical retinoids are generally recommended; benzoyl peroxide may be added in some cases.

Cosmetic use

Cosmetics play an important role in treating all forms of acne. They should be noncomedogenic and should improve the skin's appearance by minimizing erythema and providing adequate camouflage. In particular, patients receiving isotretinoin therapy need moisturizing agents for the skin and lips to overcome the drying effects of the drug.

Treatment during pregnancy

For pregnant patients, oral or topical erythromycin and benzoyl peroxide are the safest choices.3 Should severe inflammatory lesions occur, short courses of oral steroids may be instituted.3

Conclusion

With all of the available treatments for acne, we should no longer encounter patients who are severely scarred emotionally or physically. The dermatologist should remember that combination therapies work better and should not reserve drastic therapies only for patients with severe acne.

The roles of lasers and phototherapy or photodynamic therapy in treating acne need to be further elucidated before any recommendations can be made. In the future, treatment likely will include new agents such as

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