Systemic therapy, acne

When treating acne vulgaris, topical and systemic therapies (if indicated) are initiated 2 to 4 weeks prior to peeling. Topical antibiotics and benzoyl peroxide based products can be used daily and discontinued 1 or 2 days prior to peeling. However, unless a deeper peel is desired, retinoids should be discontinued 7-10 days prior to salicylic acid peeling. Broad-spectrum sunscreens (UVA and UVB) should be worn daily (see Photo damage. Sunscreen section). 

Systemic therapy for acne includes antibiotics, isotretinoin and hormones (Tables 11.8 and 11.9). Oral treatment is indicated in cases of 1) moderate and severe acne 2) acne with tendency to scars development and 3) psychological distress related to acne. 

An increase in the frequency of attacks of familial Mediterranean fever has been reported after the start of systemic therapy with isotretinoin for nodulocystic acne (108). 

TABLE 20.1 Medication for Systemic Therapy for Acne Vulgaris... 

Resistant strains of P. acnes are emerging that may respond to jndicions nse of retinoids in combination with antibiotics. Commonly nsed topical antimicrobials in acne inclnde erythromycin, clindamycin (Cleocin-t), and benzoyl peroxide and antibiotic-benzoyl peroxide combinations (Benzamycin, Benzaclin, others). Other antimiaobials nsed in treating acne inclnde sulfacetamide (Klaron), sulfacetamide/sulfur combinations (Snlfacet-R), metronidawie (Metrocream, Metro-Gel, noritate), and azelaic acid (Azelex). Systemic therapy is prescribed for patients with more extensive disease and acne that is resistant to topical therapy. Effective agents inclnde tetracycline (snmycin, others), minocycline (MINO-CIN, others), erythromycin (ERYC, others), clindamycin (CLEOCIN), and trimethoprim-sulfamethoxazole (bactrim, others). Antibiotics nsnally are administered twice daily, and doses are tapered after control is achieved. 

Among retinoids, 13-cis-retinoic acid is known to have not only anti-inflammatory but also sebostatic effects. Therefore it is one of the most potent topical and also systemic agents for therapy of acne. 

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

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. 

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... 

After administration of a -trans-, 3-cis- or 9-cw-retinoic acid, the respective retinoyl glu-curonides (RAG) have been identified as the major metabolite in most mammal models including the human system. Like R A, RAG is biologically active in promoting the growth of vitamin A-deficient rats [187] and in the induction of differentiation of, e. g., HL-60 cells [188], but unlike RA, RAG is less cytotoxic and teratogenic. Like RA, RAG is also effective in the topical treatment of human acne [189], but unlike RA, it does not produce any side effects associated with RA therapy [189]. 

Systemic lupus erythematosus Malignant disease hormone Acne therapy Isotretinoin Other Interferon-beta-1 a... 

Initial treatment is armed at reducing lesion count and wrU vary in duration from a few months to a few years, depending on severity and response to treatment. Once control is achieved, chronic indefinite treatment may be required. Therapy with both topical and systemic antibiotics should be for the minimum duration necessary to achieve control of acne, in order to minimize the likelihood of resistance. Topical treatment forms include creams, lotions, solutions, gels, and disposable wipes. Responses to different formulations may be dependent on skin type and individual preferences ... 

Erythromycin can be used for patients who reqnire systemic antibiotics, but cannot tolerate tetracyclines, or who acqnire hacterial strains resistant to tetracyclines. The dosage is nsnally 1 g/day with meals to minimize gastrointestinal intolerance. Zinc combination products possibly enhance penetration of erythromycin into the pilosebaceous unit. Erythromycin s efficacy is similar to tetracycline, but it induces higher rates of bacterial resistance. - Development of erythromycin resistance by P. acnes may be rednced by combination therapy with BPO. 

Azithromycin, an azalide antibiotic and derivative of erythromycin, is a safe and effective alternate treatment of moderate to severe inflammatory acne. With a half-life of 68 hours, it may be intermittently dosed three times a week. One study using pulse therapy, 500 mg daily for 3 to 4 consecutive days every week for 4 weeks, demonstrated efficacy similar to other systemic antibacterial agents. Adherence is high with this regimen, and phototoxicity and resistance have not been reported. ... 

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. 

Tan HH. Antibacterial therapy for acne a guide to selection and use of systemic agents. Am J Clin Dermatol 2003 4 307-314. 

Kunynetz RA. A review of systemic retinoid therapy for acne and related conditions. Skin Therapy Lett 2004 9 1-4. 

Isotretinoin is administered orally. The recommended dose is 0.5 to 2 mg/kg per day for 15 to 20 weeks. Lower doses are effective but are associated with shorter remissions. The cumulative dose also is important, so smaller doses for longer periods can be used to achieve a total dose in the range of 120 mg/kg. Approximately 40% of patients will relapse, usually within 3 years of therapy, and may require retreatment. Preteens and patients with acne con-globata or androgen excess are at increased risk of relapse. However, mild relapses may respond to conventional management with topical and systemic antiacne agents. 

Acne vulgaris is the most common dermatologic disorder treated with either topical or systemic antibiotics. The anaerobe P. acnes is a component of normal skin flora that proliferates in the obstructed, lipid-rich lumen of the pdosebaceous unit, where tension is low. P. acnes generates free fatty acids that are irritants and may lead to microcomedo formation and result in the inflammatory lesions of acne. Suppression of cutaneous P. acnes with antibiotic therapy is correlated with clinical improvement. 

Reduces active acne and rosacea lesions and seborrhea. Accelerates efficacy of topical and systemic acne therapy. 

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