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Merec bulletin: vol10 n08
Contents: The treatment of acne vulgaris: an update
The treatment of acne vulgaris: an update
While acne vulgaris affects 80%
of adolescents, it can also occur
later in life.1 It may lead to
* The main aims of acne treatment are to reduce the
scarring or hyperpigmentation
number of lesions, reduce the impact of psychological
and substantial disfigurement.2
Acne sufferers are also more
stress and prevent scarring. Patient counselling is an
likely to be depressed or anx-
important part of disease management.
ious.1 This Bulletin discusses
the general approach to acne
* Treatment should be started as early as possible with
management and considers
patients reassessed every two to three months initially.
recent issues surrounding
treatment. It will not attempt
A response may take months and in some cases
to evaluate every possible
treatment may need to be continued for several years.
drug combination in acne.
* Early referral of patients with severe acne, for treatment
by a dermatologist, may help to prevent scarring.
What causes acne?
* Mild acne should initially be treated with topical
agents. Drug choice depends on whether comedonal
or inflammatory lesions predominate. Benzoyl
or a topical retinoid
are first choice agents,
sebum production and keratinousdebris cause a blockage of
depending on tolerance, formulation and cost.
the pilosebaceous duct. Thisproduces a lesion called a
* Oral antibiotics
should be added to topical therapy
in moderate to severe acne. Tetracycline
are first choice agents as they are
(whitehead). Some comedonesevolve into inflammatory lesions
effective and inexpensive. An adequate dose of an oral
antibiotic should be given for at least three months
before deciding a patient has failed to respond.
Inflammation may be causedby proliferation of the anaerobe
* Minocycline and doxycycline have not been shown to
.3Diet (e.g. chocolate) or poor skin
be more effective than tetracycline or oxytetracycline
cleansing do not
and are more expensive. As reports of P. acnes
resistance to minocycline are rare, it may be tried inpatients who fail to repond to first choice agents.
How should acne be managed?
* Erythromycin is best reserved for patients in whom
other antibiotics are unsuitable, as propionibacterial
resistance to this drug is relatively common.
management of acne requires anunderstanding of the cause, the
topical antibiotics. Tetracycline
Limitations of evidence
and isotretinoin10 to be aseffective as tretinoin. However,
evidence for azelaic acid
, their place in
compared benzoyl peroxide
gel for four weeks) and tretinoin
(0.1% cream, not available in theUK) in 147 patients with acne
Choice of topical agent
are first choice agents
is the topical
agent of choice. The place in
therapy of topical antibiotics
How should mild acne be treated?
not well defined. Some specialistsrecommend using a topical
acne consists of open and
Topical benzoyl peroxide
(see table 1
). Patients with mild
How should moderate to severe
While topical antibiotics
acne be treated?
numbers of P. acnes
within hairfollicles, their precise mechanism
The topical retinoids
acne also includes
causes a low-grade
mainstay of systemic therapy.
• P. acnes
resistance to antibiotics has been associated with a poor treatment
• In 1996, a GP study of 1,000 skin swabs taken from acne patients found that 25%
of swabs had strains of P. acnes
which were resistant to antibiotics.
• Most data on resistance relate to in vitro
measurements and are difficult to interpret
in terms of clinical effect. Minocycline is unstable in bacteriological culture medium
and so measurement of resistance to minocycline is unreliable. Reported resist-
• Most tetracycline resistant strains of P. acnes
are cross-resistant to doxycycline.
Most erythromycin resistant strains are cross-resistant to clindamycin.
Measures to minimise antibiotic resistance
• Do not prescribe antibiotics if a non-antibiotic topical preparation will suffice.
•. Use adequate doses of antibiotics.
• Avoid concomitant oral and topical use of antibiotics from different classes.
• Do not continue treatment for longer than necessary (but give an adequate course
(100mg daily, in
• If acne returns, reuse the same drug if the previous response was satisfactory with
(100mg daily) are
more expensive (see table 2
• Stress to patients the importance of good compliance.
and have not been shown to bemore effective than tetracycline
or oxytetracycline. However, theymay be useful when compliance
). There is evidence that
.20 This is also the case for
has been the
effects, minocycline should be
reserved for patients who fail
to respond to tetracycline
years or more.8 An adequate
dose of oral antibiotic should
resistant strains of P. acnes
be given for at least three
months before deciding a
patient has failed to respond.
menstrual flare.2 Dianette
prescribe oral isotretinoin.
Treatment duration and referral
As it is highly teratogenic, womenof childbearing age should use
Other reasons for referralinclude: scarring, pigmentation,
Table 2. Comparative costs of some oral antibiotics for acne.
(Prices are based on Chemist & Druggist
and the Drug Tariff
, October 1999).
Cost of 28 days therapy
acne or unpleasant side-effectsfrom current acne therapy.
- 500mg twice a day
- 500mg twice a day
- 100mg once a day
likely timescale for improvementand that treatment may be needed
Vibramycin Acne Pack
dispersible tablets 100mg
Patients should avoid abrasive
100mg daily in one or two divided doses
cleansers and vigorous scrub-
bing, as this may worsen acne
by provoking inflammation.3
modified-release capsules 100mg
- 500mg twice a day
acceptable to the patient,otherwise they may not be used.
sensitive or dry skin. Creams
Doses quoted are those recommended in the BNF for acne treatment.
Sykes NL, Webster GF. Acne: a review of opt-
imum treatment. Drugs 1994; 48(1)
20 Eady EA, Bojar RA, et al
. The effects of acne
September 1999; 38
peroxide and erythromycin on skin carriage of
Cunliffe WJ, Poncet M, et al
. A comparison of
erythromycin-resistant propionibacteria. Br J
the efficacy and tolerability of adapalene 0.1%
Dermatol 1996; 134
gel versus tretinoin 0.025% gel in patients with
21 Chalker DK, Shalita A, et al
. A double-blind
study of the effectiveness of a 3% erythromycin
and 5% benzoyl peroxide combination in the
10 Dominguez J, Hojyo MT, et al
. Topical isotretin-
Dermatol 1983; 9
oin vs. topical retinoic acid in the treatment of
22 Draelos ZK. Patient compliance: enhancing
acne vulgaris. Int J Dermatol 1998; 37
clinician abilities and strategies. J Am Acad
11 Lyons RE. Comparative effectiveness of benzoyl
Dermatol 1995; 32
peroxide and tretinoin in acne vulgaris. Int J
Dermatol 1978; 17
12 Eady EA. Bacterial resistance in acne.
Useful information sources
Dermatology 1998; 196
13 Cunliffe W, Eady A. GP acne survey: results
Acne Support Group
and recommendations. Prescriber 1996; 7(4)
14 Cunliffe WJ. Rapid resolutions in the primary
care management of acne: Round table series
62, The Royal Society of Medicine Press Ltd,
15 Ferner RE, Moss C. Minocycline for acne: first
line antibacterial treatment of acne should be
Chu TC. Acne and other facial eruptions.
with tetracycline or oxytetracycline. BMJ 1996;
Medicine 1997; 25(9)
Brown SK, Shalita AR. Acne vulgaris. Lancet
16 Knowles SR, Shapiro L, Shear NH. Serious
adverse reactions induced by minocycline.
Leyden JJ. Therapy for acne vulgaris. N Engl J
Arch Dermatol 1996; 132
Med 1997; 336
17 Gough A, Chapman S, et al
Anon. Topical antibiotics for acne. Drug Ther
induced autoimmune hepatitis and systemic
Bull 1992; 30
Healy E, Simpson N. Acne vulgaris. BMJ 1994;
hyperpigmentation. Lancet 1997; 349
Date of preparation: September 1999
drug treatment in acne. Dermatology 1998;
19 Guillebaud J. Contraception your questions
The National Prescribing Centre, The Infirmary, 70 Pembroke Place, Liverpool, L69 3GF.
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