Consistent approach, realistic expectations serve as acne management cornerstones

Many adolescents who experience acne cope with psychosocial symptoms that disproportionately outweigh physical aspects of the condition, often resulting in embarrassment, shame and social impairment, but informed pediatricians can help patients sort through the laundry list of available therapies to find the treatment that is right for them.

Over-the-counter formulations, topical retinoids, antibiotics, oral contraceptives, laser removal and special diets were among acne management strategies that Richard J. Antaya, MD, director of pediatric dermatology at Yale University School of Medicine discussed at the American Academy of Pediatrics 2009 National Conference and Exhibition in Washington this weekend.

Whatever treatment is chosen, adherence to the regimen and realistic expectations are critical for success, according to Antaya.

“You must treat acne every day without fail and if you look at all of the studies the best you are going to do is about 60% to 70% improvement with any individual medication,” Antaya said.

Using an acne grading scale based on the patient’s acne severity is a useful tool for guiding treatment, according to Antaya. For patients with very mild acne that is primarily comedonal and papulopustular, he suggests treatment with a topical retinoid such as tretinoin, adapalene or tazarotene either alone or in conjunction with an over-the-counter benzoyl peroxide. If improvement does not occur after 12 weeks, Antaya suggests adding a topical antibiotic.

Both topical retinoids and antibiotics come in multiple formulations (including cream or lotion, gel and solution) with each differing in potency. Antaya suggested starting on the lowest formulation possible. “You don’t want to start a patient on a formulation unless you know they can tolerate it,” he said.

Informing patients about associated adverse effects may make the difference between treatment success and failure. Drying, erythema and peeling are common with topical antibiotics, whereas retinoin can cause skin irritation, photosensitivity and transient worsening of acne in the first month after treatment commences.

Tazoratene often causes irritation and should not be prescribed for patients who are pregnant or breast-feeding; however, due to its extreme potency patients who experience irritation may still benefit from short contact therapy, Antaya said.

Patients with moderate acne characterized by papules, pustules, small nodules and mild scarring may benefit from the addition of an oral antibiotic to the above regimen. Tetracycline, doxycycline, minocycline, erythromycin, azithromycin or trimethoprim-sulfamethoxazole should be initiated for eight to 12 weeks and then tapered off to limit the development of antibiotic resistance, he said. Treatment with topical antibiotics should continue.

General adverse events associated with oral antibiotics include gastrointestinal upset, allergic reactions, vaginal candidiasis and esophageal ulceration. Antibiotic-specific adverse events include hyperpigmentation consisting of a bluish-brown discoloration with minocycline and photosensitivity, which is mostly a problem associated with doxycycline, followed by tetracycline and minocycline.

Antaya recommends referring patients with severe nodulocycstic acne and more significant scarring to a dermatologist for oral isotretinoin. – by Nicole Blazek

#F2132.