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 (high risk!)
    1. Antiandrogen: Spironolactone 150-200 mg/d
    2. Isotretinoin (Accutane) 1 mg/kg/day for 20 weeks
      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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