706.1 – Other acne

Acne, or acne vulgaris (typical teenage acne), is an extremely common, usually self-limited chronic inflammatory condition of the pilosebaceous unit. The pathogenesis involves multiple factors, including (1) increased sebum production, (2) follicular hyperkeratinization, (3) proliferation of the bacterium Propionibacterium acnes, and (4) inflammation. It typically begins at puberty as a result of androgen stimulation of the pilosebaceous unit and changes in the keratinization at the follicular orifice.

There is a wide spectrum of clinical disease, ranging from a few comedones to many inflamed papules, pustules, and nodules. Acne vulgaris is most commonly found on areas of skin with the greatest density of sebaceous follicles, such as the face, back, and upper chest. Acne can last through the teenage years into adulthood. Women are more likely than men to have acne in adulthood. There is no racial predilection. While a benign condition, acne can lead to physical scarring and significant psychosocial distress; hence, initiation of treatment in the earliest stages is preferable.

Open comedones (blackheads) and closed comedones (whiteheads), and erythematous papules and pustules. Nodules and cysts can result in pitted or hypertrophic scars. In adult women, deeper-seated, tender, red papules are common along the jaw line. Acne most frequently targets the face, neck, upper trunk, and upper arms.

In adult women, touching, rubbing, and overcleansing the face may exacerbate acne. In men, acne tends to be more severe on the trunk. Consider external agents such as grease from working in fast-food restaurants, occlusion from sports equipment, and drugs (eg, progesterone-only birth control, steroids, some anticonvulsants, lithium, isoniazid).

Congenital adrenal hyperplasia, polycystic ovarian syndrome, and certain other endocrine disorders that cause hyperandrogenism may predispose to the development of acne.

In women, if there is a perioral predilection, this may represent perioral dermatitis, not acne.

In women, if there is a perioral predilection, this may represent perioral dermatitis, not acne.
Milia
Folliculitis
Pityrosporum folliculitis
Flat warts
Molluscum contagiosum
Rosacea
Acne conglobata
Sebaceous hyperplasia
Syringomas

This is usually a clinical diagnosis, although a skin biopsy will define the process if there is any doubt.

An assessment of acne severity is necessary for choosing the appropriate therapy.

If the clinical scenario warrants (poor response to therapy, hirsutism, irregular menses, etc), check sex hormone levels: testosterone, sex-hormone binding globulin, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and dehydroepiandrosterone (DHEA).

Late-onset congenital adrenal hyperplasia can be screened for using 9:00 AM levels of cortisol and 17-α-hydroxyprogesterone.

Consider obtaining skin and nasal swabs to exclude gram-negative folliculitis if acne is not responding to traditional therapy.

Several tests are indicated prior to initiating therapy with isotretinoin as well as monthly while on therapy: CBC, glucose, liver function tests, fasting lipids, and a pregnancy test in female patients.

Acne often resolves after the teenage years. Severe cases of nodulocystic acne will require more aggressive treatment. Acne needs consistent, regular care administered over months. Make sure the patient has the correct expectation and applies topical medication to the entire area of potential acne involvement, not just on individual lesions.

If there are cysts and scarring, consider timely referral to a dermatologist for isotretinoin therapy and to minimize permanent scarring. Referral to a dermatologist who regularly prescribes this medication is recommended, as a systematized method for monitoring patients for side effects and pregnancy-avoidance in women is essential. Isotretinoin is teratogenic, and every effort must be made to monitor and manage these patients appropriately.

Combination products with a topical antibiotic and benzoyl peroxide, if tolerated, are preferable to antibiotic preparations alone, as they may discourage the development of antibiotic resistance and enhance compliance.

For mild comedonal acne (whiteheads and blackheads predominate), use a topical retinoid:

• Tretinoin (Retin-A® 0.025%–0.1% nightly)
• Tazarotene (Tazorac® 0.05%–0.1% cream or gel applied once daily)
• Adapalene gel (Differin® gel 0.1%–0.3% nightly)
• Tretinoin combination (Ziana® gel: tretinoin 0.025% and clindamycin phosphate 1.2%)
• Adapalene combination (Epiduo® gel: adapalene 0.1% and benzoyl peroxide 2.5%)

For mild papular or pustular acne, use or add a topical antibiotic/benzoyl peroxide combination:

• Erythromycin / benzoyl peroxide (Benzamycin® gel)
• Sodium sulfacetamide 10% and sulfur 5% (Plexion® topical suspension, cleanser, and cleansing cloths; Rosanil® cleanser)
• 1% clindamycin / 5% benzoyl peroxide (Duac® topical gel 45 gm or BenzaClin® 50 gm).
• Benzoyl peroxide gels can also be used without combination with an antibiotic: 2.5%, 3%, 4%, 5%, 6%, 9% or 10% gel depending on skin dryness. (Use milder strengths when the skin is dry and higher concentrations on very oily skin.)

Topical antibiotics alone can be less costly than antibiotic-benzoyl peroxide combination products. To reduce the emergence of antibiotic resistance, they are best used with a benzoyl peroxide product. Examples are clindamycin 1% solution (Cleocin® lotion) or 1% clindamycin phosphate (Clindets® Pledgets), erythromycin 2% gel or solution, Akne-mycin 2% ointment (well-tolerated by those with easily irritated skin) and sodium sulfacetamide 10% with 5% sulfur (Klaron®, Novacet®, Sulfacet-R®, Plexion®).

Many exfoliant agents are available over the counter with sulfur, salicylic acid, or resorcinol; they are less effective than retinoids and, while sometimes helpful for mild acne, can add an irritant factor if used in addition to the above prescription agents.

When there are inflammatory papules or deeper-seated lesions, use or add an oral medication: Start with tetracycline 500 mg twice daily. If there is no response to tetracycline after 2–3 months, consider doxycycline 100 mg twice daily or minocycline 100 mg twice daily. Trimethoprim-sulfamethoxazole has also been used and is particularly useful if gram-negative organisms evolve. Caution the patient regarding photosensitivity while taking tetracyclines, and advise patients to use sunscreens (SPF 30) when anticipating sun exposure.

Isotretinoin should be considered in cases of severe acne or moderate acne that has failed more conservative measures. Due to the drug's teratogenicity, patients and prescribers are required to be registered with the iPLEDGE program. Female patients should use 2 forms of birth control while taking isotretinoin and for 30 days after treatment has ended, and they need to have a documented negative pregnancy test prior to the initiation of therapy. Pregnancy testing continues monthly during therapy and at 1 month after the patient has stopped taking the drug. Patients are usually started on a dose of 0.5 mg/kg/day, which is increased to 1 mg/kg/day after 1 month. Blood work is required before and after the course of treatment.

For acne control in women, estrogen-containing oral conceptives are often used (eg, Ortho Tri-Cyclen®, Yasmin®), as is spironolactone (100–200 mg/day) particularly in hirsute women with acne.

Note: Patients taking spironolactone will need their serum electrolytes monitored and should avoid becoming pregnant.

Other treatment modalities:

• Subpurpuric pulsed dye laser
• Red (660 nm) and blue (415 nm) light therapy

Thiboutot DM. Overview of acne and its treatment. Cutis. 2008 Jan;81(1 Suppl):3-7. PubMed Id: 18338651

Zaenglein AL, Graber EM, Thiboutot DM, Strauss JS. Acne Vulgaris and acneiform eruptions. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:690-701.

Campbell JL. A comparative review of the efficacy and tolerability of retinoid-containing combination regimens for the treatment of acne vulgaris. J Drugs Dermatol. 2007 Jun;6(6):625-9. PubMed Id: 17668528

Krakowski AC, Eichenfield LF. Pediatric acne: clinical presentations, evaluation, and management. J Drugs Dermatol. 2007 Jun;6(6):589-93. PubMed Id: 17668524

Tanghetti E, Abramovits W, Solomon B, Loven K, Shalita A. Tazarotene versus tazarotene plus clindamycin/benzoyl peroxide in the treatment of acne vulgaris: a multicenter, double-blind, randomized parallel-group trial. J Drugs Dermatol. 2006 Mar;5(3):256-61. PubMed Id: 16573259

Leyden JJ. Meta-analysis of topical tazarotene in the treatment of mild to moderate acne. Cutis. 2004 Oct;74(4 Suppl):9-15. PubMed Id: 15543714

Haider A, Shaw JC. Treatment of acne vulgaris. JAMA. 2004 Aug 11;292(6):726-35. PubMed Id: 15304471

Leyden JJ. A review of the use of combination therapies for the treatment of acne vulgaris. J Am Acad Dermatol. 2003 Sep;49(3 Suppl):S200-10. PubMed Id: 12963896

Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, Shalita AR, Thiboutot D, Global Alliance to Improve Outcomes in Acne. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003 Jul;49(1 Suppl):S1-37. PubMed Id: 12833004

Madden WS, Landells ID, Poulin Y, Searles GE, Smith KC, Tan JK, Toole J, Zip CM, Degreef H. Treatment of acne vulgaris and prevention of acne scarring: canadian consensus guidelines. J Cutan Med Surg. 2000 Jun;4 Suppl 1:S2-13. PubMed Id: 11749902

Leyden JJ. Therapy for acne vulgaris. N Engl J Med. 1997 Apr 17;336(16):1156-62. PubMed Id: 9099661

American Academy of Dermatology. Guidelines of care for acne vulgaris. J Am Acad Dermatol. 1990 Apr;22(4):676-80. PubMed Id: 2138639

Appearance
No Acute Distress

Body Location
Cheek
Chin
Ear
Earlobe
Face
Forehead
Nose
Superior Chest
Tragus of Ear
Upper Back

Configuration
Follicular Configuration

Distribution
Primarily Truncal

Lesion
Cyst
Excoriated
Hyperpigmented Macule
Open Comedone
Papule
Pustule

Medications
Albuterol
Allopurinol
Aminophylline
Androgen
Aripiprazole
Bevacizumab
Carbamazepine
Cetuximab
Cimetidine
Ciprofloxacin
Cyanocobalamin
Cyclosporine
Dactinomycin
Dasatinib
Dexamethasone
Erlotinib
Ethionamide
GCSF
Gefitinib
Haloperidol
Infliximab
Isoniazid
Isotretinoin
Levonorgestrel
Lithium
Matuzumab
Methyltestosterone
Oral Contraceptives
Panitumumab
Penicillin
Phenobarbital
Phenytoin
Potassium Iodide
Prednisolone
Prednisone
Progesterone
Propranolol
Quinidine
Retinoid
Rifampin
Sirolimus
Stanozolol
Testosterone

Occupations
Military

Signs and Symptoms
No Fever (Afebrile, Apyrexial)

Social History
Middle/High School (6-12)

Temporal
Developed Chronically Lasting Months to Years
Developed Steadily Over Weeks to Months
Eruption 6 to 30 Days After Drug