Dermatology Book

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Severe Acne Vulgaris Management

Aka: Severe Acne Vulgaris Management, Cystic Acne
  1. See Also
    1. Acne Vulgaris
    2. Acne Vulgaris Pathophysiology
    3. Acne Vulgaris Management
    4. Adjunctive Acne Vulgaris Management
    5. Moderate 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. See Moderate Acne Vulgaris Management
    2. Continue Benzoyl Peroxide
    3. Continue Comedolytic (e.g. Retin A)
    4. Continue topical antibiotic (e.g. Cleocin T)
      1. May combine with Benzoyl Peroxide (e.g. Benzaclin)
    5. Consider Adjunctive Acne Vulgaris Management
  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
      3. Benzoyl Peroxide should be used with all antibiotic regimens to prevent Antibiotic Resistance
    2. First Line
      1. Doxycycline
        1. Dose: 50-100 mg once to twice daily
        2. May substitute Tetracycline 250 to 500 mg daily to twice daily
          1. Doxycycline replaces Tetracycline as first-line therapy as of the 2007 AAD guidelines
        3. Pregnancy Category D
      2. Erythromycin
        1. Dose: 1 g/day in 2-4 divided doses
        2. Increasing resistance decreases its efficacy (compared with Tetracyclines)
        3. Pregnancy Category B
    3. Alternative agents
      1. Indicated if first-line agents not tolerated
      2. Trimethoprim-Sulfamethoxazole (Bactrim, Septra)
        1. Dose: 160/800 (DS) twice daily
        2. Risk of sulfa Allergic Reaction
        3. Pregnancy Category C
      3. Trimethoprim
        1. Dose: 300 mg bid
        2. Pregnancy Category C
    4. Second Line
      1. Minocycline
        1. Dose: 50-200 mg/day in divided doses
        2. Risk of serious adverse effects (e.g. lupus-like reaction, Pseudotumor Cerebri)
        3. Pregnancy Category D
  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 (iPLEDGE)
      4. Adverse effects
        1. Extremely Teratogenic
        2. Monitor Triglycerides and Liver Function Tests and Complete Blood Count
        3. Major Depression and increased Suicidality
    2. Light and laser therapy
      1. Awaiting larger, more definitive studies as to efficacy
  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 69:2123-56 [PubMed]
    4. Gollnick (2003) J Am Acad Dermatol 49:S1-37 [PubMed]
    5. James (2005) N Engl J Med 352(14):1463-72 [PubMed]
    6. Strauss (2007) J Am Acad Dermatol 56(4): 651-63 [PubMed]
    7. Tan (2003) Am J Clin Dermatol 4:307-14 [PubMed]
    8. Titus (2012) Am Fam Physician 86(8): 734-40 [PubMed]

Cystic acne (C0010666)

Concepts Disease or Syndrome (T047)
SnomedCT 13277001
Italian Acne cistica
German zystische Akne, AKNE CYSTICA, Akne cystica
Japanese 嚢胞性ざ瘡, ノウホウセイザソウ
English ACNE CYSTIC, cystic acne (diagnosis), cystic acne, Acne cystic, acne cystic, Acne;conglobate (cystic), acne vulgaris cystic, Acne cystica, Cystic acne, Cystic acne vulgaris, Cystic acne (disorder), cystic; acne, acne; cystic, Acne, cystic
French ACNE KYSTIQUE, Acné kystique
Portuguese ACNE QUISTICO, Acne quística
Czech Cystická forma akné
Hungarian Cisztikus akne, Cystikus acne
Dutch acne; cysteus, cysteus; acne, blaasjes acne
Spanish acné quística (trastorno), acné quística, Acné quístico
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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