CASE c Tam T. Nguyen, MD San Joaquin General Acne treatment: Easy ways Hospital Family Medicine Residency Program, French Camp, Calif to improve your care [email protected] The author reported no For patients of any age, facial lesions can cause potential conflict of interest relevant to this article. considerable embarrassment and distress. Read on to discover what key component of acne treatment you should be using (but probably aren’t) and which dosage you can safely lower. c Practice CASE Janis S, an otherwise healthy 19-year-old, is in your recommendations office, seeking treatment for acne. She reports she has tried various over-the-counter (oTc) creams in recent months, but › Use a classification system, has seen little improvement. The acne first appeared about such as that of the American 5 years ago, and her pediatrician prescribed topical adapalene Academy of Dermatol- and doxycycline. The treatment helped, but she says her face ogy, to assess the severity never fully cleared up; over the past year, the acne has gotten of acne vulgaris. A worse. › Treat inflamma- on examination, you find several nodules and comedones tory lesions aggressively on the patient’s face, chest, and back. ms. S confides in you to prevent scarring. A that the acne—particularly on her face—kept her from going › When isotretinoin is to the senior prom. indicated, consider prescrib- ing a lower dosage (but ore than 80% of adolescents and adults develop longer duration) than the acne vulgaris at some point in their lives, and in traditional regimen. B at least 15% to 20% of cases, the acne is moderate M1 Strength of recommendation (SOR) to severe. Although acne typically starts in early puberty, it 2 A Good-quality patient-oriented can continue well into adulthood. Females typically develop evidence acne at an earlier age than males. There are no other sex or Inconsistent or limited-quality B 3 patient-oriented evidence racial differences. C Consensus, usual practice, Regardless of the age at which acne develops, it has opinion, disease-oriented evidence, case series substantial psychological effects, including embarrassment, shame, depression, anxiety, social isolation—and in extreme cases, suicidal ideation.4 This evidence-based update will better prepare you to provide optimal medical therapy—and alleviate patients’ emotional distress—without delay. The pathophysiology of acne vulgaris The American Academy of Dermatology (AAD) defines acne as a “chronic inflammatory dermatosis which is notable for open and/or closed comedones (blackheads and white- 82 The Journal of family PracTice | february 2013 | Vol 62, no 2 Because most patients have both inflammatory and bacterial lesions, it is important to use combined therapies to treat P acnes and inflammation. clockwise, from top: closed comedones; open comedones; pustules; and scarring. heads) and inflammatory lesions, including are modulated by insulinlike-growth factor 1 papules, pustules, and nodules….”5 The under- (IGF-1) and insulin.8,9 Research to determine lying etiology is best described as a cascade of whether these receptors can be influenced by events involving the pilosebaceous unit. diet and melanocortins is ongoing.8,10 Normally, single keratinocytes are shed Evidence has also shown that inflam- into the follicular lumen for excretion. In mation around the follicles and follicular dif- acne, this process is disrupted and the kera- ferentiation precede bacterial overgrowth,7 tinocytes accumulate, becoming interwoven and that P acnes overgrowth exacerbates the with monofilaments and lipid droplets. The blockage and inflammation by creating a bio- lipids, cellular debris, and excessive sebum, film that plugs the follicles. Inflammation is as well as the overgrowth of Propionibacte- one of the main complications of acne, caus- rium acnes, block the follicles;6 the bacterial ing hyperpigmentation and scarring. overgrowth can generate inflammation, as well.7 Areas rich in sebaceous glands, such as These factors increase the risk the face, neck, chest, upper arms, and back, There are numerous risk factors for acne, are the sites at which acne is most likely to ranging from genetics to stress to certain develop. medications (TABLE 1).11 Although the exact genetic penetrance is unknown, acne often af- Androgen receptors play a role fects multiple family members;1,12 genetics is For many years, the underlying pathophysiol- also associated with an increase in androgens, ogy of acne vulgaris was thought to be lesion such as that found in patients with Cushing progression, with microcomedone forma- syndrome, polycystic ovary syndrome (PCOS), i mage © tion leading to both closed and open come- and congenital adrenal hyperplasia.13 dones. Emerging evidence has led to a deeper Emotional and physical stress can in- J oe gorman understanding of acne development. Sebum crease the risk for acne,14 with the latter of- is now known to have androgen receptors ten related to excessive friction on the skin (nuclear transcription factor Fox O1), which caused by sweat bands or helmet strips. Cos- JfPonline.com Vol 62, no 2 | february 2013 | The Journal of family PracTice 83 TABLE 1 lar, nodulocystic), while others also consider Drugs that are potential the number of each type of lesion and areas affected.15 In 2002, the US Food and Drug Ad- acne triggers ministration (FDA) defined the components of a Global Acne Severity Scale as having common drugs/drug classes 6 grades (0-5), with 0 for normal skin and 5 anabolic steroids representing a predominance of highly in- (eg, danazol and testosterone) flammatory lesions with a variable number of bromides and iodides papules/pustules and nodulocystic lesions.16 corticosteroids (eg, prednisone) The AAD’S classification system has only corticotropin 3 grades—mild, moderate, and severe—and is one of the easiest to use: isoniazid and ethionamide • Mild cases have few to several papules lithium and barbiturates and pustules, but no nodules Phenytoin and trimethadione • Moderate cases have more papules less common drugs and pustules, with a few nodules • Severe cases have numerous papules, azathioprine pustules, and nodules.5 cyclosporine Disulfiram CASE c ms. S is in obvious emotional distress, Phenobarbital and her acne needs to be treated aggressively. Quinidine because of the emotional impact and the fact that she has lesions on several body parts, her Adapted from: Sterry W, et al. Dermatology. Thieme Clinical Companions. 2006.11 case is classified as severe (and would be even instanT if her face had only a few lesions). Poll metics that plug the follicles are a risk factor Treatment: Prevention Do you for acne, as well. of new lesions is paramount recommend Preventing new formations is a key focus of topical retinoids acne therapy, and patients should be ad- and benzoyl The patient has acne, vised that it may take weeks for results to be peroxide for but how severe? seen. Nonetheless, aggressive treatment of patients with Because acne is often diagnosed clinically, inflammatory lesions is necessary to prevent acne? there is often no need for routine testing. Nor scarring. Because most patients have both n Yes, on a routine is a bacterial culture for P acnes necessary. inflammatory and bacterial lesions, it is im- basis If the patient has signs and symp- portant to use combined therapies, including toms suggestive of an endocrine disorder, topical or oral antibiotics, to treat P acnes and n Yes, if the acne however—eg, infertility, PCOS, or hirsut- inflammation (TABLE 2).13,17-23 is moderate to severe ism—consider checking free testosterone, dehydroepiandrosterone sulfate (DHEA), Topicals are the cornerstone of treatment n Only for patients luteinizing/follicle-stimulating hormones Retinoids and benzoyl peroxide topicals are who have not (LH/FSH), 17-alpha-progesterone, adreno- the foundation of therapy for both comedo- tried topicals 17 previously corticotropic hormone (ACTH), and/or dexa- nal and inflammatory acne, regardless of methasone suppression. Other indicators of severity. Both are recommended by the AAD. n Rarely; I’ve had a need for endocrine testing include male or But evidence suggests that only 55% of der- more success with female pattern balding, an abnormal men- matologists and 10% of primary care provid- other treatments strual cycle, acanthosis nigricans, and trun- ers recommend them.19,20 n Other __________ cal obesity.5,6 z retinoids inhibit microcomedone for- Numerous acne classification systems mation and regulate follicular keratinocytes, jfponline.com have been developed; some are based on the which have anti-inflammatory properties type of lesions (ie, comedonal, papulopustu- and help to prevent the formation of new le- 84 The Journal of family PracTice | february 2013 | Vol 62, no 2 improving acne treAtment sions. Patients should be warned that topical antibiotics have both antimicrobial and anti- retinoids can cause irritation, erythema, des- inflammatory properties. quamation, pruritus, and burning. To reduce Tetracycline antibiotics (ie, doxycycline the adverse effects, advise patients to start and minocycline) are first-line oral therapy.21 retinoid therapy slowly, at a reduced frequen- Minocycline has been found to be the most cy (eg, every other day or every third day) and potent agent in this drug class; tetracycline shorter contact (washing it off after one to 4 is the least.22 Tetracyclines can cause tooth hours for a week, then increasing the contact discoloration and inhibit skeletal growth, time). When it is clear that the medication is and are contraindicated for children younger well tolerated, the frequency and amount can than 10 years and pregnant women. be increased. Use of the topical, as tolerated, Photosensitivity is an adverse effect of should continue as long as the potential acne tetracycline antibiotics, so patients should be problem remains. advised to cover up and avoid sun exposure. There are 3 retinoid formulations on the Other adverse effects, particularly of minocy- market—adapalene, tretinoin, and tazaro- cline, include dizziness, lupus-like syndrome, tene—all of which have been shown to be ef- pseudotumor cerebri, skin and mucosal pig- fective.