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Continuity Clinic Notebook:

 Chapter III. Adolescent Issues

Chapter 3 Index

A. General

B. Skin

  

Acne: Treatment

Introduction: Teenagers do not want to know what causes acne, they just want to get rid of it.  Many preparations are over the counter and can be used; each MD needs to develop a plan of Rx

Etiology: Excessive sebum accumulates and obstructs sebaceous follicles colonized by 3 types of organisms: an anaerobic diphtheroid (P.acnes), coag neg Staph epidermis, and a yeast.

Mild Acne: Open and closed comedones (plugged sebaceous follicles) - little erythema

Treatment: 2-4 weeks topical benzoyl peroxide, topical antibiotics

Moderate Acne: Pustules, papules, and erythema with early scar formation.

Treatment: topical retinoid with topical or systemic antibiotic for 4-5 months

Severe Acne: Multiple inflamed nodules with significant scarring; may have cysts.

Treatment: Systemic Isotretinoin for 4-5 months

Treatment of Acne: No topical therapies influence sebum production.

I. General measures: Diet plays NO part in the pathogenesis of acne.  Climate: worse in summer; cleanse regularly with soap and water, do not manipulate, or squeeze.  Soaps, detergents, astringents, abrasive cleaners, and mechanical devices should be avoided.  A facial moisturizer with sunscreen is helpful in reducing chafing with all therapies.

II. Medical therapy: Become familiar with a few preparations, and use only those.

Treatment Mechanism Mild Mod Severe
Benzoyl Peroxide reduces bacteria   x   x  
(2.5-10%) BID produces desquamation      
         
Retinoic Acid (retinA) produces desquamation   x   x  
(0.025-0.1 cream) reduces comedones      
         
Topical Antibiotics reduces infection   x   x  
(Erythro,Clindamycin, Tetracycline)        
         
Oral antibiotics reduces infection     x  
Tetracycline, Erythro, mino and doxycycline)        
         
13-cis Retinoic Acid (Accutane) reduces size and scarring of nodules       x*
Steroids-intralesional reduces inflammation       x*
Estrogen or anti-androgen         x*

* Should only be prescribed by dermatologist familiar with side effects

Specific Preparations of Each Type of Medication: Dosage Included:

1. Benzoyl Peroxide: Use Once or Twice Each Day

a. gels: 2.5%, 5%, and 10%: all three supplied in 60g or 90g tubes
b. wash 2.5%, 5%, 10%: all three in 8-ounce bottles
c. water based gel: 2.5%, 5%, 10%: all in 60 g and 90g tubes - used for sensitive skin.

2. Retinoic Acid: Apply Once a Day Very Lightly.  Wash off in the Morning. Results: in 2-5 Weeks. May Need to Use a Sunscreen When Using This Medication.

a. gel: 0.01%, 0.025%: supplied as 15g and 45 g tubes
b. Cream: 0.025%, 0.5%, 0.1%: supplied as 20g and 45 g tubes

3. Topical Antibiotics: Use Once or Twice a Day: Can be Combined With Above Meds.

a. Erythromycin: -(T-Stat): 2.0% solution in 60cc bottle. Use once or twice/day. Can be obtained in pads: 60 disposable pads:-(A/T/S): 2% solution in 60 cc bottle. Use once or twice/day Can also be obtained in applicator or pads.
b. Clindamycin:  - (Cleocin T): topical solution: supplied 30 cc and 60cc bottles, topical gel: supplied 7.5gm, 30gm tubes, topical lotion: supplied 60cc bottle - probably active against Propionibacterium acnes.
c. Tetracycline: (Topicycline) supplied in single container with powder and liquid which must be combined.  An 8-week supply.

4. Oral Antibiotics: Suppress Flora by Effect on P. Acnes ALWAYS GIVE WITH TOPICAL RX

a. Tetracycline: 1 gm/d x 4 weeks, then 250 mgm bid for 4-6 months
b. Erythromycin: as above

5. Isotretinoin (Accutane): Only for Disfiguring Cystic Acne Resistent to Other Treatment. Because of its teratogenic effects, must have a negative serum pregnancy test within two weeks before starting treatment.  May need a consent form.

  • dosage: 0.5 to 2 mg/kg given in two divided doses daily for 4-5 months.
  • start out at lower dose and build up to higher dose. 

Unless you are in an unusual practice situation, this prescription should be done by dermatologists.  Side Effects: teratogenicity in fetuses; cheilitis, dry skin, irritability, muscle soreness; can have elevated ESRs and triglycerides which return to normal after medication stopped.

6. Steroid Injection: Used for larger inflammatory lesions (dermatologist)

7. Estrogen therapy: If unresponsive to therapy with other methods, women can take estrogens.

Reference: NEJM 1997;336;1156-1162

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004