The pathogenesis of acne is multifactorial: increased sebum production, hyperkeratinization of the follicular infundibulum, inflammation, and the presence of the bacterium Cutibacterium acnes (formerly Propionibacterium acnes).
Twin studies have shown that acne is highly heritable.
In the article estet-portal.com you can learn in detail effective methods of acne management: systemic antibiotics, hormone therapy, antiandrogenic spironolactone, isotretinoin.
Method #1 — Systemic antibiotics
Oral antibiotics are widely used in acne patients to control inflammation in moderate to severe acne. Antibiotics should be used in combination with topical retinoid and benzoyl peroxide.
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Given concerns about increasing antibiotic resistance, current acne treatment guidelines recommend limiting the use of oral antibiotics to 3-4 months whenever possible. Clinical improvement should be maintained with continued use of a topical retinoid with or without benzoyl peroxide, depending on the type of lesion.
In clinical trials evaluating the effectiveness of combination therapy, the total number of lesions decreased by approximately 60% after 3 months. In a trial of maintenance therapy after a course of antibiotic therapy using 0.1% adapalene gel, 75% of patients maintained clinical improvement with adapalene alone, compared with 54% of those using placebo gel.
Which antibiotic to prefer
Tetracyclines are generally prescribed to treat acne because they reduce C. acnes, but they also have an anti-inflammatory effect. They reduce the degradation of enzymes, are antioxidants, and also regulate cell proliferation.
In the US, minocycline is the most commonly used antibiotic for acne, followed by doxycycline. Tetracycline is used less frequently due to limited bioavailability and the need to take it on an empty stomach.
Sunscreen should be used in patients with post-inflammatory hyperpigmentation to prevent further aggravation.
In patients with moderate to severe acne, modified-release doxycycline 40 mg daily showed similar efficacy to doxycycline 100 mg daily and both were superior to placebo. Side effects, especially gastrointestinal disturbances, were less frequent in patients who received 40 mg per day than in those who received 100 mg.
Other antibiotics that are used to treat acne include trimethoprim-sulfamethoxazole, penicillins, cephalosporins, and macrolides. However, data are limited regarding their effects in patients with acne, and their use should only be limited to patients who cannot take tetracycline.
Method #2 — Hormone Therapy
Combined oral contraceptive pills containing estrogen and progestin have been shown to be as effective as oral antibiotics in controlling inflammatory lesions in adult women with acne, although patients take longer to clinically improve.
In a meta-analysis of 32 randomized trials, the use of combined oral contraceptives resulted in a 62% reduction in inflammatory elements from baseline at 6 months.
Combined oral contraceptives are often used as second-line therapy in adults or adolescents, including those with polycystic ovary syndrome.
First generation progestins such as norethindrone and norgestrel are androgenic and therefore may exacerbate acne.
Method #3 — Antiandrogenic spironolactone
The antiandrogenic spironolactone is also helpful for women with acne. Although data from randomized trials of this agent are limited, some retrospective studies and observational data have shown that the use of spironolactone was associated with significant clinical improvement in women with acne.
Adult women in general and adolescents with PCOS may be of particular benefit.
To mitigate the side effects of breast tenderness and menstrual irregularities, spironolactone is often given with a third or fourth generation combined oral contraceptive.
Spironolactone is contraindicated during pregnancy due to possible feminization of the male fetus.
Hyperkalemia is rare, although it is a concern in women with kidney disease or who are taking potassium-sparing diuretics.
Method #4 — Isotretinoin
Isotretinoin is a systemic retinoid that is very effective in the treatment of recurrent nodulocystic acne. It is also the therapy of choice for patients with moderate to severe acne who have not responded to other therapy, including systemic antibiotics.
The specific mechanism of action remains unknown, but isotretinoin reduces sebum production, C. acnes levels, inflammation, and has a strong comedolytic effect.
This is a powerful teratogen and there are various programs around the world to prevent pregnancy while taking isotretinoin.
Common skin side effects of isotretinoin include dry skin and mucous membranes. Increases in serum triglycerides, low-density lipoprotein cholesterol and aminotransferases may be observed, although these are usually mild. Routine monitoring of lipids and liver function is recommended at baseline and after reaching the maximum therapeutic dose.
Acne Treatment: Modern and Effective Therapeutic Approaches
One of the major concerns is the possible link between isotretinoin use and depression, suicide.
Practical Guidelines for Acne Therapy for the Clinician
Thus, modern recommendations state the need to prescribe topical methods in conjunction with systemic therapy. Combination therapy should be started with topical adapalene 0.1% gel or tretinoin 0.025% cream in the evening, OTC benzoyl peroxide every day in the shower, and doxycycline 100 mg daily.
If significant clinical improvement is noted, discontinue doxycycline after 3 months and continue with retinoid and benzoyl peroxide for maintenance therapy.
If acne is poorly controlled at follow-up, alternative therapy should be considered, such as a combined oral contraceptive with or without spironolactone, or possibly isotretinoin.
Thank you for staying with estet-portal.com. Read other interesting articles in the "Dermatology" section. You may be interested in Retinoid use: to be or not to be
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