CLINICAL PRACTICE Managing acne vulgaris Update effectively The management of acne is a gratifying experience. Available treatments are effective, relatively nontoxic and generally safe. However, there is no quick fix. Antibiotics, hormone therapies and topical therapies are maintenance treatments. Isotretinoin can induce remission, as can some of the newer physical modalities of lights, lasers and radiofrequency devices. Effective management of acne often requires using a combination of treatments that act on different parts of Greg Goodman the pathogenic process of acne development. MBBS, FACD, GradDipClinEpi, is Senior Lecturer, Department of Community Medicine, Monash University, Victoria. The pathogenesis of acne is thought to be an Topical retinoids [email protected] interplay between a number of factors including hyperkeratinisation with occlusion of the follicular Tretinoin (or all trans retinoic acid) is topical vitamin A acid. orifice; colonisation by pathogenic Propionobacterium In Australia tretinoin sells under the trade names Retin A, acnes and inflammation; excess androgenic stimulation; Stieva A, and Retrieve. This is probably the most potent of and sebum hypersecretion. the available keratolytic agents. Topical isotretinoin (Isotrex) is also available but is probably not as effective. Adapalene Although no treatment affects only one of these processes (Differin) has recently been introduced to the market and is exclusively, it is useful to group treatment by the target thought to be less irritant. Azarotene (Zorac) has also just most affected. Combination therapy is often chosen in an been released in Australia. attempt to provide additive therapeutic efficacy, taking from Tretinoin acts to normalise the turnover of follicular agents exerting their effects on different pathogenic factors. lining epithelial cells1 causing expulsion of comedones and Choice of therapy often depends on the patient’s age and inhibiting further comedone formation.2 Three aspects of pattern of the acne (Table 1). tretinoin have limited its widespread use: skin irritation, sun sensitivity, and initial flaring of acne. Reducing hyperkeratinisation of the hair Topical retinoids produce skin dryness or dermatitis follicle which patients find unpleasant. This can be minimised by Early or mild acne is often comedonal or papulopustular starting the treatment slowly and building up over a few with little inflammation. In this subgroup, the treating weeks, either by increasing the time tretinoin is on the practitioner should choose agents that will unblock and skin before washing it off, or by using it every second sterilise the follicle. night initially until the skin can be treated nightly. Another method is to start with a low concentration (0.025%) Physical treatments initially and increasing to 0.05% as and when tolerated. Manual extraction of impacted comedones by the treating Simultaneous use of other irritating chemicals should practitioner or a beauty therapist once or twice at monthly be avoided. intervals may be added to hasten resolution. Pharmacies Sun sensitivity from retinoids is really a photo- also carry a range of self administered acrylate glue based degradation of the tretinoin and the photoproducts induce material strips that may be used by the patient at home the sensitivity. Night usage and the use of a sunscreen (this is not the same as picking at the spots by the patient, usually avoids this problem. which carries the risk of scarring). Approximately 3 weeks after starting topical retinoid therapy there is a breakout of acne and a 'clearing out' of Keratolytic agents follicles.3 There is then a further delay of 2 months before Keratolytic agents are the most effective topical medications the retinoids exert their maximal effect.4 for comedonal and early acne targeting the abnormal Adapalene is a synthetic naphthoic acid derivative occlusion of the follicular orifice. Agents include: retinoids, and has both comedolytic and anti-inflammatory azelaic acid, and the alpha and beta-hydroxy acids (AHAs activities.5 It is probably equipotent to tretinoin in anti- and BHAs). acne activity.5,6 Reprinted from Australian Family Physician Vol. 35, No. 9, September 2006 705 CLINICAL PRACTICE Managing acne vulgaris effectively Azelaic acid Reducing P. acnes hydrophilic gels (Eryacne®). These agents reduce Azelaic acid is a naturally occurring dicarboxylic A change in the severity of acne occurs when numbers of P. acnes14 and may also be anti- acid and is not related to other acne medications. the noninflammatory comedone develops into inflammatory agents by inhibiting neutrophil Azelaic acid helps to normalise follicular an inflammatory papule or pustule. This usually chemotaxis. Topical erythromycin and clindamycin hyperkeratinisation2 and may also have a direct signifies the presence of P. acnes. Traditional appear equivalent in efficacy, but probably anti-inflammatory effect through inhibition of treatments in the inflammatory phase are mixtures of these agents with benzoyl peroxide hydroxy and superoxide radical production by topical and systemic antibiotics acting as both are better than either alone15 and may help in neutrophils. It also has antimicrobial effects, being antimicrobial and anti-inflammatory agents. decreasing the incidence of antibiotic resistance. bacteriostatic against P. acnes.7 It is only available Recently a combined agent with clindamycin Benzoyl peroxide as a 15% gel (Finacea). It is reasonably tolerated and benzoyl peroxide has become available in clinically and may have similar efficacy to other Benzoyl peroxide is a potent bactericidal drug Australia (Duac). Most often therapies are topical medications.8,9 Local itching and burning available as an over-the-counter preparation. combined in an attempt to approach the problem sensations are occasionally observed. Trade examples include Panoxyl®, Benoxyl®, from more than one vantage point, so a topical BenzacAC®, and Brevoxyl®. This preparation is antibiotic or benzoyl peroxide is used in the Alpha- and B-hydroxy acids starting to appear in cleansers and combination morning and a keratolytic agent applied at night Alpha hydroxyacids occur naturally in sugar therapies with topical antibiotics in an effort Oral antibiotics cane, fruits, and milk products. Most commonly to both increase efficacy and limit antibiotic glycolic, lactic, citric and gluconic acids are resistance.12 Concentrations of 2.5–10.0% Oral therapy is indicated for moderate to severe used. Alpha hydroxyacids cause stratum may reduce comedones, but its primary role and widespread forms of acne, particularly those corneum desquamation10 and have action as a seems to be its ability to sterilise the follicle patients who are at risk of scarring. Effective comedolytic aiding the treatment of comedonal by combating P. acnes therefore effectively systemic therapies for acne include: tetracyclines acne.11 Examples of these agents include reducing acne.13 The metabolic by-product (including its relatives minocycline and Elucent®, Glyderm®, and MD formulations®. benzoic acid is harmless, however the parent doxycycline), erythromycin and trimethoprim alone They are only mildly effective as a home topical compound commonly causes dry skin and or in combination with sulfamethoxazole. Full dose treatment and probably have more efficacy occasionally allergy. It inactivates topical retinoic antibiotic treatment should be given until the acne as an in office peeling agent.7 Beta hydroxyacids acid when used concurrently and may cause is under control and then may be pulled back to (salicylic acid) are comedolytic agents with skin bleaching. a lower maintenance dose. Each oral medication a long history of dermatological use in has known side effects. All oral antibiotics Topical antibiotics acne which seem to be making a resurgence predispose to candida infections, particularly both in topical applications (eg. Acnederm®, The topical antibiotics clindamycin and vaginitis. Tetracyclines, especially doxycycline Clearasil Acne Treatment/Facewash®, Salact®) erythromycin are available as topical (but less so minocycline) induce phototoxicity. and office procedures. hydroalcoholic solutions (Clindatech®) and Minocycline produces a dose related ‘vertigo-like’ Table 1. Acne patterns, demographics and treatment Typical age Usual patient acne subtype Likely treatment Issues Peripubertal, teenage, Comedonal disease Comedolytics (adapalene, Young age, compliance with young adult retinoic acid, AHAs and BHAs), probable long term treatment, benzoyl peroxide and azelaic avoidance of comedogenic products acid, light or laser treatments Teenage, young adult Facial and truncal Topical therapies (antibiotics, Relative ineffectiveness of topical papulopustular disease retinoids, benzoyl peroxide), long therapy term antibiotics, hormone therapy Long term nature of therapy (OCP, antiandrogens), blue light (alternative may be light/laser and photodynamic therapy based therapies) Older teenager Nodulocystic disease Long term antibiotics, isotretinoin Unpredictable adverse reactions to antibiotics, predictable adverse reactions to isotretinoin Women Acne tarda papulopustular Topical antibiotics, hormone Hormone therapy in child bearing occasionally nodulocystic therapy, light and laser treatments age group or women in their 30s along jawline and neck 706 Reprinted from Australian Family Physician Vol. 35, No. 9, September 2006 Managing acne vulgaris effectively CLINICAL PRACTICE dizziness which patients seem to acclimatise