DJ. Acne Vulgaris. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR,
Wells BG, Posey LM, eds. Pharmacotherapy:
A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7998615.
Accessed May 27, 2012.
- A common, usually self-limiting disease involving inflammation
of sebaceous follicles of face and upper trunk.
- Genetic, racial, hormonal, dietary, and environmental
- 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
- 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
- Elevated testosterone levels
- 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
- 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
- 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
- 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
- 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, ...