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Source: Sibbald DJ. Acne Vulgaris. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed May 27, 2012.

  • Acne

  • A common, usually self-limiting disease involving inflammation of sebaceous follicles of face and upper trunk.

  • Genetic, racial, hormonal, dietary, and environmental factors

  • Increased sebum production, hyperproliferation of ductal epidermis, bacterial colonization of ducts, and inflammation
  • Androgens cause sebaceous glands to increase size and activity.
  • Increased keratinization of epidermal cells and development of obstructed sebaceous follicles (microcomedones)
  • The anaerobic bacterium Propionibacterium acnes causes T cell–mediated inflammation.
  • Acne characterized by open and closed comedones is termed non-inflammatory acne.
  • Inflammatory lesions—including pustules, nodules, and cysts—may form that lead to scarring.

  • Lifetime prevalence is approximately 90%.
  • Affects 79–95% of the adolescent population in Western countries.

  • Family history of acne
  • Adolescence
  • Elevated testosterone levels

Signs and Symptoms

  • Lesions occur on face, back, upper chest, and shoulders.
  • Categorized as mild, moderate, or severe, depending on type and severity of lesions.
  • Lesions may take months to heal completely; fibrosis may lead to permanent scarring.

  • Established by patient assessment, including observation of lesions and excluding other potential causes (e.g., drug-induced acne).

  • Reduce number and severity of lesions.
  • Slow disease progression.
  • Limit disease duration.
  • Prevent formation of new lesions.
  • Prevent scarring and hyperpigmentation.

  • Select treatments appropriate for severity of clinical presentation.
  • Taper effective treatment over time, adjusting to response.
  • Use smallest number of agents at lowest effective doses.
  • After control is achieved, simplify regimen but continue with some suppressive therapy.
  • First line for mild–moderate acne: Exfoliative agents (benzoyl peroxide, topical retinoids, salicylic acid)
  • For moderate–severe acne with inflammatory lesions and scars: Reduce P. acnes with benzoyl peroxide, topical antibiotics (alone or with benzoyl peroxide), oral antibiotics (e.g., minocycline), retinoids (tretinoin, adapalene, tazarotene), azelaic acid.
  • For severe acne with extensive nodules, cysts, and scars, or resistant acne: Add antiandrogens, isotretinoin, or topical and oral antibiotics.

  • Encourage patients to avoid aggravating factors, maintain balanced diet, and control stress.
  • Patients should wash no more than twice daily with mild soap or soapless cleanser. Minimize scrubbing to prevent follicular rupture.

  • Topical Pharmacotherapy
    • Exfoliants
      • Salicylic acid products (up to 2% nonprescription, 5–10% prescription) for mild acne. Start with low concentration and increase as tolerated.
      • Resorcinol 2% and resorcinol monoacetate 3% in combination with sulfur 3–8%. Do not apply to large areas or on broken skin.
      • Sulfur in precipitated or colloidal form 2–10%. Often combined with salicylic acid or resorcinol but has limited efficacy and offensive odor.
    • Topical Retinoids
      • First step in moderate acne, alone or in combination with antibiotics and benzoyl peroxide.
      • Tretinoin (0.05% solution; 0.01% and 0.025% gels; 0.025%, 0.05%, 0.1% creams). Avoid in pregnant women because of risk to fetus.
      • Adapalene (Differin 0.1% gel, cream, ...

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