What are the Treatment Recommendations for Acne?

Patient Presentation
A 19-year-old female comes to clinic for her health maintenance examination. She has had mild acne in the past, mainly comedones and some papules, that has responded to oral antibiotics and benzoyl peroxide/clindamycin. Over the past 2 months her acne has gotten worse on these medications with more pustules and some nodules.
She is concerned about her appearance. She denies new soaps, lotions, haircare products or cosmetics. She wears a sunscreen recommended by her mother’s dermatologist.
The family history reveals ‘bad’ acne in her mother who continues to have occasionally acne problems that are related to her menstrual cycle.
The pertinent physical exam shows a healthy adolescent with normal growth parameters. She has about 75 total lesions mainly around her forehead, cheeks and around the nose. Most are comedomal, but there are ~10 lesions that are pustular and ~5 that are nodular.
She also has ~10 lesions on her upper back/neck area that are pustular.
The diagnosis of moderate acne was made that is failing past treatment. The patient, mother and physician agreed that a consultation with a dermatologist may be helpful considering the progression of symptoms, moderate psychological stress to the patient and the mother’s history. The patient was prescribed Retin-A® to use in the evening along with the benzoyl peroxide/clindamycin in the morning in the meantime.
The patient’s clinical course showed some improvement with the Retin A® and benzoyl peroxide treatment by the time of her dermatology appointment. The dermatologist also suggested possible oral contraceptive treatment now and possible Accutane® treatment if there was failure. The patient decided to try the oral contraceptives which also markedly improved her acne.

Discussion
Acne vulgaris is the most common skin disease with about 17 million people in the US affected. It commonly occurs in adolescents and young adults. The exact mechanism is unknown but combinations of bacteria (Propionibacterium acnes, an anaerobic bacterium), increased sebum production caused by increased androgens, and increased keratinocytes all appear to be partially responsible.
Acne affects the areas of the face, the upper part of the chest, and the back which have the densest population of sebaceous follicles.

Some external factors may cause acne to become worse and these include:

  • Some cosmetic agents and hair care products

  • Medications – i.e. steroids, lithium, some antiepileptics, and iodides.
  • Endocrine disorders with increased androgen production – i.e. congenital adrenal hyperplasia, polycystic ovary syndrome

Descriptive definitions of acne lesions include:

  • Closed comedone (whitehead): non-inflamed (non-red) follicular opening containing a keratotic plug with a thin overlying epidermal membrane
  • Open comedone (blackhead): non-inflamed (non-red) follicular opening containing a keratotic plug that appears black
  • Papule: small round to oval red elevation of the skin (1-4 mm)
  • Pustule: resembles a papule with a central pocket of pus
  • Nodule/Cyst: poorly marginated, red, tender, sometimes draining 0.2- to 3.0-cm indurated mass in the skin

Figure 27 – Cross section of normal skin

Figure 28 – Cross section of closed comedone

Figure 29 – Cross section of open comedone

Acne has different severity grades depending on the reference. A recent guideline uses a practical 3-step grading scale:

  • Mild – predominance of comedones (fewer than 20), or fewer than 15 inflammatory papules, or a comedone/papule count of fewer than 30 on the face.
  • Moderate – predominance of papules and pustules (about 15-50 lesions) with comedones and rare cysts. Total lesion (comedone, papule, pustule) count may range from 30 to 125 on the face.
  • Severe – primarily has inflammatory nodules and cysts. Also present are comedones, papules, and pustules or total lesion count of greater than 125 on the face.

It is important to assess the psychological impairment acne causes for the patient. Often the psychological stress necessitates more aggressive treatment than the objective grading of the acne. It is important to educate the patient and family about the treatment options, the proper way to use the medications prescribed, and especially the natural history.
Often acne becomes initially worse with the treatment before improvement is seen. Also, use of the medication often requires 8-12 weeks of treatment before improvement is actually seen. If patient’s do not understand this time course, they may discontinue treatment as they feel it is ineffective.

Learning Point
An algorithm for the evaluation and treatment of acne is available from the Institute for Clinical Systems Improvement.

Mild acne is often initially treated with benzoyl peroxide or benzoyl peroxide/topical antibiotic (combination product) once or twice a day. This can also be used with or without a topical retinoid.
If using a topical retinoid it used, use it in the evening and use the benzoyl peroxide product in the morning.

Topical Medications

  • Over the counter medications
    • Benzoyl peroxide – ex. Clearasil®, Desquam®, works by decreasing lipid formation and free fatty acids and causing mild desquamation, may be a single product or in combination with antibiotics (ex. Benzaclin®, Benzamycin®), products have concentrations up to 10%
    • Salicylic acid – works by keratolysis, products have concentrations of 0.5-2%
    • Other products – ex. glycolic acid, sulfur, resorcinol
  • Prescription medications
    • Topical retinoids – ex. Diffren® and Retin A®, works by increasing the turnover of follicular epithelial cells, promoting drainage of comedones, and inhibiting new comedone formation, generally used in the evening.
    • Azelaic Acid – antibacterial and comedomal medication
    • Topical Antibiotics- ex. clindamycin, erythromycin, sulfacetamide, works by decreasing Propionibacterium acnes within follicles and also may also possess direct anti-inflammatory effects
  • Systemic medications
    • Oral antibiotics – ex. erythromycin, doxycycline, minocycline, tetracycline are generally the first line antibiotics; clindamycin and Bactrim® are second line.
    • Oral retinoids – Accutane® – works by reducing sebum secretion, can cause severe birth defects and therefore its use is restricted to certified dermatologists
    • Oral contraceptives – ex. Ortho Tri-Cyclen® and Estrostep® have FDA approval for acne treatment, works by modulating androgen
    • Spironolactone – works by anti-testosterone effect
  • Other treatments
    • Intralesional corticosteroid injections
    • Blue light – ex. ClearLightTM approved by FDA for moderate acne

Questions for Further Discussion
1. What are the indications for referral to a dermatologist?
2. What steps and certification are required to prescribe Accutane?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Acne.

To view current news articles on this topic check Google News.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions and Answers About Acne. Available from the Internet at http://www.niams.nih.gov/hi/topics/acne/acne.htm (rev.10/2001 cited 8/25/05).

Institute for Clinical Systems Improvement (ICSI). Acne management. Bloomington (MN): 2003 Sep. 32 p. Available from the Internet at http://www.guideline.gov/summary/summary.aspx?doc_id=4164&nbr=3189&string=acne (rev.9/2003 cited 8/25/05).

Harper JC, Fulton J Jr. Acne Vulgaris. eMedicine.
Available from the Internet at http://www.emedicine.com/derm/topic2.htm (rev. 7/29/04, cited 8/25/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 17, 2005