Acne vulgaris

• It is important that patients apply the medicine to the whole treatment area (e.g., the entire face), not to specific acne lesions.

• Topical retinoids include tretinoin,[C Evidence] adapalene, [36] [B Evidence] and tazarotene.

• Most topical retinoids produce some degree of fine peeling and erythema, especially early in treatment. Patients are started with lower potency, increased to higher potency if skin irritation is minimal.

• Salicylic acid is keratolytic, but is considered a less effective comedolytic agent compared to topical retinoids.

Primary Options

Secondary Options

• Combination therapy is the mainstay of inflammatory acne treatment. [34] These products may be used individually in combination, or together as a combination product (erythromycin/benzoyl peroxide, clindamycin/benzoyl peroxide). [35]

• Topical retinoids include tretinoin,[C Evidence] adapalene, [36] [B Evidence] and tazarotene.

• Topical retinoids should be considered in combination with topical antibacterial regimens. Patients are started with lower potency, increased to higher potency if skin irritation is minimal. Benzoyl peroxide[C Evidence] products should be applied at a different time to topical retinoids to avoid inactivation of either or both drugs. [32] Topical adapalene is less likely to cause irritation than tretinoin. [45]

• Adapalene-benzoyl peroxide is a novel combination treatment combining 2 known effective drugs for treatment of comedonal and noncomedonal acne. [38] [39] [40]

• Topical antibiotics, which include clindamycin,[C Evidence] erythromycin,[C Evidence]and dapsone, [37] are not recommended as monotherapy because of potential for bacterial resistance. [32] Topical antibiotics may be combined with benzoyl peroxide, thus potentially increasing patient compliance and decreasing the risk of antibiotic resistance development.

• Topical antibiotics may be discontinued once improvement is noted; if no improvement is noted within 6 to 8 weeks, they are discontinued and alternate therapy considered. [32]

Primary Options

• Azelaic acid is an antimicrobial with mild comedolytic and anti-inflammatory properties. [41] It can be helpful in reducing post-inflammatory hyperpigmentation.

Primary Options

• For patients with primarily comedonal acne, topical retinoids may be used. These include tretinoin,[C Evidence] adapalene, [36] [B Evidence] and tazarotene.

• It is important that patients apply the medicine to the whole treatment area (e.g., the entire face), not to specific acne lesions.

• Most topical retinoids produce some degree of fine peeling and erythema, especially early in treatment. Start with lower potency and increase to higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin. [45]

Primary Options

• For best results, the combination of oral antibiotics and topical retinoids should be considered. Topical retinoids include tretinoin,[C Evidence] adapalene, [36] [B Evidence] and tazarotene. Patients are started with lower potency of a topical retinoid, increased to higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin. [45]

• If oral antibiotics need to be used for >2 months, the addition of topical benzoyl peroxide[C Evidence] should be considered. [32]

• Oral antibiotics are typically administered for at least 6 to 8 weeks and for up to several months, although some patients require indefinite antibiotic therapy.[C Evidence] If re-treatment is necessary, an antibiotic that was effective in the past should be considered again; otherwise an alternative antibiotic can be prescribed. Doxycycline, minocycline, and tetracycline have been associated with photosensitivity. [32] [46] [47]

• Trimethoprim/sulfamethoxazole is used for acne resistant to tetracyclines and macrolides.

Primary Options

Secondary Options

Tertiary Options

• Topical benzyl peroxide may be added to the treatment regimen if oral antibiotics need to be used for >2 months. [32] [C Evidence] Benzoyl peroxide products should be applied separately from topical retinoids to avoid inactivation of either or both drugs. [32]

Primary Options

• Azelaic acid is an antimicrobial with mild comedolytic and anti-inflammatory properties. [41] It can be helpful in reducing post-inflammatory hyperpigmentation.

Primary Options

• Before treatment with oral isotretinoin, patients require counselling about the potential adverse effects. Severe headaches, decreased night vision, or signs of adverse psychiatric events are signs for prompt discontinuation.

• There are conflicting studies on whether or not isotretinoin increases the incidence of depression and/or suicide attempts, but signs and symptoms of depression should be monitored during and after the completion of treatment. [48] [49] There may also be a slightly increased risk of developing ulcerative colitis in patients who take isotretinoin, [50] but this has been disputed in other studies. [51]

• FBC, lipid panel, and LFTs are monitored regularly.

• Isotretinoin is teratogenic; therefore, women undergo pregnancy tests before starting isotretinoin, and monthly while taking the drug.

• In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme (PPP), while in the US, it can only be prescribed through the iPledge system. [iPledge system (for isotretinoin prescribing)] These programmes are aimed at decreasing the number of birth defects associated with this medicine.

Primary Options

• For best results, the combination of oral antibiotics and topical retinoids should be considered. Topical retinoids include tretinoin,[C Evidence] adapalene, [36] [B Evidence] and tazarotene. Patients are started with lower potency of a topical retinoid, increased to higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin. [45]

• If oral antibiotics need to be used for >2 months, the addition of topical benzoyl peroxide[C Evidence] should be considered. [32]

• Oral antibiotics are typically administered for at least 6 to 8 weeks and for up to several months, although some patients require indefinite antibiotic therapy.[C Evidence] If re-treatment is necessary, an antibiotic that was effective in the past should be considered again; otherwise an alternative antibiotic can be prescribed. Doxycycline, minocycline, and tetracycline have been associated with photosensitivity. [32] [46] [47] Trimethoprim/sulfamethoxazole is used for acne resistant to tetracyclines and macrolides.

Primary Options

Secondary Options

Tertiary Options

• Azelaic acid is an antimicrobial with mild comedolytic and anti-inflammatory properties. [41] It can be helpful in reducing post-inflammatory hyperpigmentation.

Primary Options