EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY Information Leaflet for Patients ACNE: HOW TO TREAT IT The aim of this leaflet This leaflet is designed to help you understand more about acne vulgaris and in particoular it tells you about different types of treatments for acne. ACNE: HOW How can your acne be treated? TO TREAT IT Type of acne Mild acne Moderate acne Severe acne 1st choice Topical retinoid Fixed combination Oral isotretinoin of Topical retinoid, Benzoyl peroxide, topical antibiotic variably combined 2nd choice Topical retinoid and/ Systemic antibiotic Systemic antibiotic or Benzoyl peroxide + Fixed combination + Fixed combination and/or Azelaic of Topical retinoid + of Topical retinoid + acid / and Topical Benzoyl peroxide Benzoyl peroxide antibiotic Possible addition Combined oral Combined oral in female contraceptives or contraceptives or patients antiandrogens antiandrogens TOPICAL PRODUCTS found. Topical retinoids are used alone in cases of acne where non-inflammatory Topical drugs are of major importance and lesions (comedones) largely prevail over widely prescribed in acne therapy. The most effective topical treatments in acne are inflammatory lesions (papules and pustules; retinoids, benzoyl peroxide, antibiotics and see leaflet 1 for complete definitions), or azelaic acid. They are indicated in mild to when the aim is to prevent recurrences moderate acne, and also in moderate to after “clearing” or disappearance of acne severe acne in association with systemic lesions (maintenance therapy). They are treatments. frequently used in combination with other topical products like benzoyl peroxide and What are the main topical antibiotics, with improvement in terms of retinoids, their efficacy, and side efficacy. They should be used preferentially effects? at night. Topical retinoids, such as tretinoin, About one-third to over half (30-60%) of adapalene, isotretinoin, and tazarotene, acne lesions decrease after 3 months of are unanimously considered to be the topical use alone. core of topical acne therapy thanks to Allergic contact dermatitis: negligible/ their effects on: 1) reducing comedones very rare occurrence. (non-inflammatory lesions, also called “blackheads” and “whiteheads”) that Irritative contact dermatitis: quite are already present, 2) preventing the frequent during the first weeks of development of new comedones, and 3) application. It appears with redness, burning reducing skin inflammation. sensation, and skin peeling. It is usually They have an effect on both inflammatory mild and subsides within 2-4 weeks. The and non-inflammatory acne lesions, and most tolerable formulations are creams and no direct effects on sebum production (by aqueous gels that contain no drug/active sebaceous glands) and C. acnes have been substance. EADV INFORMATION LEAFLET FOR PATIENTS I ACNE What strategies can be used during the About one-third to over half (30-60%) of first weeks of topical retinoid application to acne lesions decrease after 3 months of avoid or minimize irritation? being used alone. • before application, use a non-aggressive Allergic contact dermatitis: rare cleanser and avoid over-cleansing occurrence. • dab instead of rubbing to dry the skin Irritative contact dermatitis: quite frequent during the first weeks of • wait a few minutes after cleansing before application. Using a moisturizer is advisable. applying the product Systemic absorption: none. The use • the most tolerable version of the retinoid during pregnancy is allowed. (i.e. lowest concentration is usually better) should be selected according to skin type Use in summer: allowed with caution. It and environmental factors (temperature, must be used in the evening. It makes the humidity, etc.) skin more sensitive to sunrays so adequate sun protection is necessary. • apply the product in a thin layer Other precautions: Benzoyl peroxide may • if irritation is most likely to occur, begin bleach clothes and hair. to apply the retinoid every other day or two non-consecutive days per week, or What are the main topical for a short time (30-60 min per day), then wash off antibiotics, their efficacy, and side effects? • after absorption of the active agent, apply a moisturizing product The most effective topical antibiotics are clindamycin 1% and erythromycin 2-4%. • use an appropriate sunscreen during Their effect is both antibacterial, reducing C. summertime. acnes, and anti-inflammatory. Its use alone Systemic absorption: negligible, but use is not advisable for the risk of inducing during pregnancy is not allowed. antibiotic resistance. Fixed combinations, with retinoids or benzoyl peroxide, are Use in summer: allowed with caution. It more effective, better tolerated and provide must be used in the evening. It makes the higher adherence to the treatment than skin more sensitive to sunrays so adequate separated products. sun protection is necessary. About one-third to two-thirds (30-70%) of acne lesions decrease after 3 months What is benzoyl peroxide, its of being used in combination with other efficacy, and side effects? products. Benzoyl peroxide is an antimicrobial agent, Allergic contact dermatitis: negligible/ and it reduces C. acnes in number without very rare occurrence. creating resistant strains since it is not an antibiotic, but it has no effect on production Irritative contact dermatitis: negligible/ of sebum. rare occurrence. Its main clinical effect is on inflammatory Systemic absorption: minimal. The use of clindamycin and erythromycin during lesions (papules and pustules). It can be pregnancy is allowed. used alone, but it works better in a fixed combination (in the same product) with Use in summer: allowed. Evening use is topical retinoids or antibiotics. preferable in case of sun exposure. EADV INFORMATION LEAFLET FOR PATIENTS I ACNE ACNE: HOW What is azelaic acid, its efficacy, During pregnancy: erythromycin and and side effects? clindamycin are allowed, but tetracyclines are contraindicated. TO TREAT IT It reduces inflammation, levels of C. acnes, and comedones. No direct effect on sebum Sun exposure: it may lead to mild production has been shown. The more erythematous (reddening of the skin) relevant clinical effect is on inflammatory reactions in some patients using doxy- acne lesions, papules and pustules. cycline, which increases with higher doses. Photosensitivity (increased skin sensitivity About one-fourth to half (25-50%) of acne to the sun) has not been shown with lesions decrease after 3 months of being lymecycline, minocycline and macrolides. used alone. Allergic contact dermatitis: negligible/ What are the main hormones, rare occurrence. their role in female acne therapy, Irritative contact dermatitis: rare. their efficacy, and side effects? Systemic absorption: negligible. Use Male hormones (androgens) are strongly during pregnancy is allowed. involved in acne development. Hormonal Use in summer: allowed with caution therapy which counteract is indicated and at night. It makes the skin slightly in females with moderate-to-severe more sensitive to sunrays so adequate sun inflammatory acne: papular-pustular protection is necessary. (inflammatory lesions), nodular or cystic acne (with nodules or cysts). It is more effective in combination with topical SYSTEMIC THERAPY treatments or oral antibiotics rather than as a stand-alone therapy, and it works whether What are the main oral or not the blood levels of androgens are antibiotics, their efficacy, and increased. The most effective hormonal treatments for acne are combined oral side effects? contraceptives and spironolactone. Among Oral antibiotics act by reducing C. acnes the available combined oral contraceptives, and directly decreasing inflammation. They the ones containing progestins with an anti- are used for moderate and severe acne, and androgenic effect (like cyproterone acetate, also acne extending over the chest and/ drospirenone and chlormadinone acetate) or back. are preferred among patients with acne. Tetracyclines (like doxycycline, lymecycline Duration of treatment: on average, it and minocycline) are the first choice takes 3-4 months before you may see a before macrolides (like erythromycin and clinical improvement of your acne. The full azithromycin) due to fewer side effects, effect is expected to be seen at 6-9 months, including in particular antibiotic resistance. with a reduction of acne lesions by 30-70%. Their efficacy is increased when associated with topical treatments, such as retinoids, Side effects: mood changes, breast benzoyl peroxide, azelaic acid, and specific tenderness, decreased libido, irregular anti-acne oral contraceptives. The advisable menstrual bleeding, weight gain, and duration of the treatment is 6 to 12 weeks, headache may occur. A slightly increased and a longer period of treatment is rarely risk for blood clots should be considered. more beneficial. The use of oral antibiotics Contraindications for combined alone is not advisable. oral contraceptives: risk for deep vein About one-third to three-fourths (35-75%) of thrombosis (blood clots), blood coagulation inflammatory acne lesions decrease after 3 disorders, ischemic heart disease at a young months of being used in combination with age, estrogen-dependent cancer (breast), other topical products. strong smoking in over 35 years of age. EADV INFORMATION LEAFLET FOR PATIENTS I ACNE Use in summer: combined oral contra- their management facilitated. Laboratory ceptives may be used during summertime. tests, including a pregnancy test, must be done before, during,