Inflammatory acne

In some patients, hyperpigmented macules may persist following resolution of inflammatory acne lesions. These dark areas have to be considered as healing lesions and not active acne. Post-inflammatory hyperpigmentation generally resolves, even if the resolution time may be very long. 

Systemic antibiotics are indicated for moderate-severe inflammatory acne not responding to topical treatments. Systemic antibiotics act on 1) suppression of P. acnes growth 2) inhibition of bacterial lipases 3) reduction of free fatty acids and 4) reduction of inflammation. Oxytetracycline and its derivatives are the most commonly used oral antibiotics. Second-generation tetracyclines such as minocycline, doxy-cycline and lymecycline present longer half-lives, enhanced bacterial activity and lower... 

Spironolactone is an antiandrogen which blocks androgen-receptors, alters steroidogenesis by adrenals and gonads and inhibits 5-a reductase. In doses of 100-200 mg daily it reduces sebum production and improves inflammatory acne in women. During treatment, birth control measures are required due to the risk of male fetus feminization. 

Propionibacterium acnes (P. acnes), an anaerobic organism, is also found in the normal flora of the skin. This bacteria proliferates in the mixture of sebum and keratinocytes and can result in an inflammatory response producing a closed comedo or whitehead. More severe acne lesions such as pustules, papules, and nodules can also form with inflammatory acne and result in significant scarring if treated inadequately (Fig. 62-2). 

Scars inflammatory acne can result in permanent scarring that ranges from small depressed pits to large elevated blemishes Hyperpigmentation inflammatory acne may cause hyperpigmentation of the skin that can last for weeks to months... 

Retinoids, which are highly effective in the treatment of acne, stimulate epithelial cell turnover and aid in unclogging blocked pores. Retinoids also exhibit anti-inflammatory properties through the inhibition of neutrophil and monocyte chemotaxis.8 Because of these comedolytic and antiinflammatory effects, topical retinoids are recommended as first-line treatment for mild to moderate comedonal and inflammatory acne.3 While success is seen with monotherapy, using a retinoid in combination with benzoyl peroxide or topical antibacterials is also an appropriate and effective therapeutic treatment option.3 Tretinoin, adapalene, and tazarotene are topical retinoids available for use in the treatment of acne. Table 62-2 describes the strengths and formulations of these agents. 

Topical antibacterials directly suppress P. acnes and are also first-line agents used in the treatment of mild to moderate inflammatory acne.3,16... 

Adverse effects are generally mild and include dryness, erythema, and itching.18 Although rare and seen most often with oral therapy, pseudomembranous colitis can occur with the use of topical clindamycin.19 As with any antibacterial agent, the possibility of resistance exists with the use of topical erythromycin. However, co-administration of erythromycin and benzoyl peroxide has been shown to decrease the incidence of resistance, as well as to improve symptoms of mild to moderate inflammatory acne.20... 

Hormonal therapy can be an effective treatment in females affected by inflammatory acne. Different varieties of hormonal therapies are... 

Benzoyl peroxide may be used to treat superficial inflammatory acne. It is a nonantibiotic antibacterial that is bacteriostatic against P. acnes. It is decomposed on the skin by cysteine, liberating free oxygen radicals that oxidize... 

Erythromycin in concentrations of 1% to 4% with or without zinc is effective against inflammatory acne. Zinc combination products may enhance penetration of erythromycin into the pilosebaceous unit. 

Azithromycin is a safe and effective alternative for moderate to severe inflammatory acne. Its long half-life permits intermittent dosing three times a week. 

Mild, moderate, or severe prostate, urinary tract, and CNS infections (excluding meningitis)-, uncomplicated gonorrhea inflammatory acne Brucellosis skin granulomas cholera trachoma nocardiasis yaws and syphilis when penicillins are contraindicated PO... 

Treatment of inflammatory acne, anthrax, gonorrhea, skin infections, urinary tract infection (UTI) IM 250 mg/day or 300 mg/day divided q8-12h Dosage in renal impairment ... 

Inflammatory acne vulgaris, Lyme disease, mycoplasmal disease, Legionella infections. Rocky Mountain spotted fever, chlamydial infections in patients with gonorrhea PO... 

Several systemic antibiotics that have traditionally been used in the treatment of acnevulgaris 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 only in mild to moderate cases of inflammatory acne. 

Topical treatment of inflammatory acne vulgaris Benzoyl peroxide Clindamycin phosphate Duac Carbomer 940/sodium hydroxide Aqueous... 

In topical preparations, the base of erythromycin rather than a salt is used to facilitate penetration. Although the mechanism of action of topical erythromycin in inflammatory acne vulgaris is unknown, it is presumed to be due to its inhibitory effects on P acnes. One of the possible complications of topical therapy is the development of antibiotic-resistant strains of organisms, including staphylococci. If this occurs in association with a clinical infection, topical erythromycin should be discontinued and appropriate systemic antibiotic therapy started. Adverse local reactions... 

When treating the back, a concentration of 50% is not enough, and concentrations of 70% should be used for 4—10 minutes. If frosting occurs on the back, it is a sign of greater effectiveness, in contrast to facial treatment. Maximum effectiveness is achieved when treating active inflammatory acne. 

Inflammation may be a consequence of increased sebum production, keratinocyte sloughing, and bacterial growth. Also, P. acnes may trigger inflammatory acne lesions by producing biologically active mediators and promoting proinflammatory cytokine release. " ... 

Permanent scars may occur as a result of inflammatory acne lesions. 

Inflammatory acne lesions may trigger noticeable byperpig-mentation that may persist weeks to months after resolution of the lesion. ... 

Inflammatory acne with scarring, after conventional therapy has failed... 

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