Acne vulgaris severe

Acne is a polymorphic disease with a wide spectrum of severity. Severity of the disease varies markedly from one individual to the other depending upon the interplay of various factors involved in the development of acne vulgaris. Several methods have been proposed in order to standardize clinical evaluation of acne severity. Grading systems based on the clinical appearance of lesions as well as lesion counting are useful in assessing the severity of acne vulgaris. 

Fig. i6.i. Severe post-inflammatory hyperpigmentation caused by acne vulgaris... 

Tor the severe form of nodulocystic acne vulgaris, the first line of therapy is the systemic use of... 

Doxycycline is commonly used for moderate to severe acne vulgaris. It is more effective and produces less resistance than tetracycline. The initial dose is 100 or 200 mg daily, followed by 50 mg daily as a maintenance dose after improvement is seen. Doxycycline maybe given with food, but it is more effective when taken 30 minutes before meals. / Minocycline is also commonly used for moderate to severe acne vulgaris. It is more effective than tetracycline. It is dosed similar to doxycycline (100 mg/day or 50 mg twice daily) and on an indefinite basis in selected patients. Minocycline has the most reported adverse effects of the tetracyclines, some of which may be serious. 

Isotretinoin is most useful for the treatment of severe recalcitrant nodular acne vulgaris. It may also be... 

The past twenty years have witnessed considerable progress in the synthesis and use of other retinoid-like molecules related to vitamin A. The aromatic retinoid etretin (8.54) and its ester etretinate (8.55) had some effectiveness in the treatment of psoriasis, a disorder of skin. 13-cA-Retinoic acid (isotretinoin) produces sebaceous gland atrophy and could prove useful in the treatment of severe acne vulgaris. Although these compounds have toxic side effects and are not in regular use, they have opened up new therapeutic possibilities. Retinoic acid (tretinoin, 8.56) has been employed in the treatment of acne. 

Doxycydine (Adoxa, Periostal-, Oracea, Vibramycin, Vibra-Tabs) [Anribiotic/Tetracycline] Uses Broad-spectrum antibiotic acne vulgaris, uncomplicated GC, Chlamydia sp, PID, Lyme Dz, skin Infxns, anthrax, malaria prophylaxis Action Tetracycline bacteriostatic X- protein synth Dose Adults. 100 mg PO ql2h on 1st d, then 100 mg PO daily bid or 100 mg IV ql2h acne daily dosing, Chlamydia 7d, Lyme Dz 14—21 d, PID 14 d Peds >8 y 5 mg/kg/24 h PO, to a max of 200 mg/d - daily-bid Caution [D, +] Hepatic impair Contra Children <8 y, severe hepatic dysfxn Disp Tabs, caps, syrup, susp, inj SE D, GI disturbance, photosens Interactions T Effects OF digoxin, warfarin 1 effects W/ antacids, Fe, barbiturates, carbamazepine, phenytoins, food 4-effects OF penicillins EMS Monitor for signs of electrolyte disturbances and hypovolemia d/t D monitor for S/Sxs of super Infxn T risk of photosensitivity Rxns antibiotic of choice for the Tx and prophylaxis of anthrax exposure expired tetracyclines have been known to cause nephrotox OD May cause adverse GI effects symptomatic and supportive... 

Some women who use progestogen implants develop acne, because of the androgenic activity of levonorgestrel. Three women developed severe acne vulgaris within... 

Several systemic antibiotics that have traditionally been used in the treatment of acne vulgaris have been shown to be effective when applied topically. Currently, four antibiotics are so utilized clindamycin phosphate, erythromycin base, metronidazole, and sulfacetamide. The effectiveness of topical therapy is less than that achieved by systemic administration of the same antibiotic. Therefore, topical therapy is generally suitable in mild to moderate cases of inflammatory acne. 

Topical sulfacetamide is available alone as a 10% lotion (Klaron) and as a 10% wash (Ovace), and in several preparations in combination with sulfur for the treatment of acne vulgaris and acne rosacea. The mechanism of action is thought to be due to inhibition of P acnes by competitive inhibition of p-aminobenzoic acid utilization. Approximately 4% of topically applied sulfacetamide is absorbed percutaneously, and its use is therefore contraindicated in patients having a known hypersensitivity to sulfonamides. 

Isotretinoin (brand name Accutane) is used to treat severe acne vulgaris, and it has been reported to cause depression, psychosis, and suicidal ideation. Therapists who treat teens and young adults should ask about medications used for any purpose, and if they take this medication for acne, they need to be referred to their physician for a change. 

Some women who use progestogen implants develop acne, because of the androgenic activity of levonor-gestrel. Three women developed severe acne vulgaris within several weeks to a few months after either insertion of a levonorgestrel lUCD (two women, 27 and 33 years of age) or subcutaneous implantation of etonogestrel (a 26-year-old woman) (31). 

Topical application of chndamycin to the skin has been used in acne vulgaris. However, percutaneous absorption can occur (SEDA-8, 160) and several cases of diarrhea have been reported, including cases of pseudomembranous cohtis (32). 

Resorcinol, which was formerly used to treat leg ulcers, is nowadays mainly used in the treatment of acne vulgaris as a peeling agent. In the older literature (1), several cases of systemic toxicity from percutaneous absorption were reported and there were deaths (2). The use of resorcinol in the treatment of acne is considered safe (SEDA-9, 142). 

Acne vulgaris is the result of several factors combined. The condition arises in the pilosebaceous units in the dermis, which consist of a hair follicle and associated sebaceous gland. These glands secrete sebum, a mixture of fats and waxes that protect the skin and hair by retarding water loss and forming a barrier against external agents. The hair follicle is lined with epithelial cells that become keratinised as they mature. 

Severity acne vulgaris is classified according to its clinical features ... 

Acne lesions typically occur on the face, back, upper chest, and shoulder area. Severity of the disease varies from a mild comedonal form to severe inflammatory necrotic acne. Acne vulgaris is described as mild, moderate, or severe, depending on the type and severity of lesions present. See Table 95-1 for descriptions of mild, moderate, and severe acne. 

Severity, lesion types, scarring, and skin discoloration, as well as previous treatment history, helps to determine a treatment approach to acne vulgaris (see Table 95-1). Most treatments reduce or prevent new eruptions and may take up to 8 weeks to produce visible results. During the first few weeks of therapy, acne may appear to worsen as existing acne lesions may resolve more rapidly. Patients must understand the need to continue therapy for optimal outcome. 

Adverse effects of tetracyclines include resistant bacteria, folliculitis, candidiasis, gastrointestinal upset, and phototoxic effects. Tetracyclines must not be combined with systemic retinoids because of the increased probability for development of intracranial hypertension. Tetracycline is used in the treatment of moderate to severe acne vulgaris. It is the least expensive of the tetracyclines and therefore often prescribed for initial therapy. A common initial approach includes tetracycline 1 g daily (500 mg twice daily), 1 hour before meals after 1 or 2 months, when marked improvement of inflammatory lesions is observed, the dose may be decreased to 500 mg every day, for another 1 or 2 months. Drawbacks to the use of tetracycline include also a drug-food interaction with dairy prodncts. 

Minocycline is another commonly prescribed oral antibiotic used in the treatment of moderate to severe acne vulgaris. It is more effective than tetracycline because of greater lipid solubility and enhanced penetration into tissne and sebaceons foUicles. It is dosed similarly to doxycycline (100 mg/day or 50 mg twice daily) and on an indefinite basis in selected patients. 

Chiu A, Chon SY, Kimball AB. The response of skin disease to stress changes in the severity of acne vulgaris as affected by examination stress. Arch Dermatol 2003 139 897-900. 

Oral isotretinoin (accutane) is approved for the treatment of severe nodulocystic acne vulgaris. The drug has remarkable efficacy in severe acne and may induce prolonged remissions after a single course of therapy. It normalizes keratinization in the sebaceous follicle, reduces sebocyte number with decreased sebum synthesis, and reduces Propionibacterium acnes, the organism that proves inflammation in acne. 

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