Acne is the most common skin disorder seen in the United States, affecting approximately 17 million persons. Acne can persist into mid-adulthood in some persons, and can also present initially in adulthood. Overall, acne affects approximately ten percent of the U.S. population. Acne was the most common reason for visits to dermatologists over the two year period from 1989 to 1990, accounting for 16.6 percent of all visits. Although acne is not associated with severe morbidity, mortality, or disability, it can produce psychological effects. Furthermore, in severe cases, acne can lead to physical scarring which may exacerbate the emotional effects of the disease.

Treatment

Medical treatment of acne is determined by the extent and severity of disease, prior treatments, and therapeutic goals. Each regimen must be followed for a minimum of four to six weeks before determining whether it is effective. The following table lists guidelines to be used in the treatment of acne.

Benzoyl Peroxide and Tretinoin (Retin-A)

Topical keratolytic therapy is recommended as the primary treatment for comedonal acne to prevent new acne lesions as well as to treat preexisting ones. Two classes of keratolytics, tretinoin (retin A) and benzoyl peroxide, can be used alone or in combination with each other and will control 80 to 85 percent of acne. Cream preparations of both tretinoin and benzoyl peroxide should be used because they are less irritating to the skin than gel forms. Tretinoin has a propensity to severely irritate the skin if used incorrectly. To avoid irritation, a low strength Tretinoin Cream 0.025%, or Tretinoin Cream 0.05% should be applied every other night for one week and then nightly. In addition, because skin treated with tretinoin is more sensitive to sun exposure, sunscreen should be used. Tretinoin should be avoided during pregnancy because of the potential of photoisomerization to isotretinoin, a teratogen. Improvement of acne after treatment of tretinoin can take six to 12 weeks and flare-ups of acne can occur during the first few weeks due to surfacing of the lesions onto the skin. Benzoyl peroxide is available over-the-counter in various strengths and applications (gels, creams, lotions, or soaps). All concentrations seem to be therapeutically equivalent. Mild redness and scaling of the skin may occur during the first week of use.

Topical Antibiotics

Topical antibiotics decrease the quantity of P. acnes in the hair follicles. However, they are less effective than oral antibiotics because of their difficulty in penetrating sebum-filled follicules. Topical erythromycin and clindamycin are similar in effectiveness and can be used once or twice a day. Some percutaneous absorption may rarely occur with clindamycin, resulting in diarrhea and colitis. Topical antibiotics are frequently used in combination with keratolytics and are most useful for maintenance therapy if improvement after one to two months of oral antibiotics is observed.

Oral Antibiotics

Patients with moderate to severe inflammatory acne will require oral antibiotics in addition to topical therapy (Indicator 2). Tetracycline and Erythromycin are the most commonly used systemic antibiotics. Minocycline is also effective with more convenient dosing; however, its cost limits its use to those patients with severe or recalcitrant acne.

Isotretinoin

The oral retinoid isotretinoin (Accutane) has been very efficacious in nodulocystic acne resistant to standard therapeutic regimens. In appropriate regimens, isotretinoin has resulted in long-term remission of acne in approximately 60 percent of patients treated. Because of its severe teratogenicity, isotretinoin should be avoided during pregnancy. Side effects of isotretinoin include dryness and scaliness of the skin, dry lips and occasionally dry eyes and nose. It can also cause decreased night vision, hypertriglyceridemia, abnormal liver function, electrolyte imbalance, and elevated platelet count. Up to 10 percent of patients experience mild hair loss, but the effect is reversible. Because of the seriousness of these side effects, isotretinoin should be reserved for patients with severe acne who have failed previous therapy (Indicator 3).

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