Dermatology Book

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Severe Acne Vulgaris Management

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  1. See Also
    1. Adjunctive Acne Vulgaris Management
  2. Indications
    1. Moderate to severe Acne Vulgaris
    2. Nodular, pustular, or cystic Acne Vulgaris
  3. Step 1: Incorporate Moderate Acne Vulgaris Management
    1. Initiate Comedolytic (e.g. Retin A)
    2. Initiate topical antibiotic (e.g. Cleocin T)
  4. Step 2: Start Oral Antibiotics
    1. General
      1. Do not anticipate an effect for 6 to 8 weeks
      2. Continue antibiotic for minimum of 6 months
    2. First Line
      1. Tetracycline 1 g/day given in 2-4 divided doses
      2. Erythromycin 1 g/day in 2-4 divided doses
        1. Increasing resistance decreases its efficacy
    3. Second Line
      1. Doxycycline 100-200 mg/day in divided doses
      2. Trimethoprim 300 mg bid
    4. Third Line (risk of serious adverse effects)
      1. Minocycline 50-200 mg/day in divided doses
  5. Step 3: Maximal medical therapy (cystic or refractory acne)
    1. Isotretinoin (Accutane)
      1. Consider in all patients with resistant or cystic acne (scarring)
      2. Dose: 1 mg/kg/day for 20 weeks
      3. Only qualified clinicians may prescribe
      4. Adverse effects
        1. Extremely Teratogenic
        2. Monitor Triglycerides and Liver Function Tests
  6. References
    1. Habif (2004) Dermatology, Mosby, p. 162-94
    2. Parker in Noble (2001) Primary Care p. 758-60
    3. Feldman (2004) Am Fam Physician 69:2123
    4. Gollnick (2003) J Am Acad Dermatol 49:S1
    5. Tan (2003) Am J Clin Dermatol 4:307

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