Acne and Rosacea
Treatment of acne should be commenced early to prevent scarring. Patients should be counselled that an improvement may not be seen for at least a couple of months. The choice of treatment depends on whether the acne is predominantly inflammatory or comedonal and its severity.
Mild to moderate acne is generally treated with topical preparations. Systemic treatment with oral antibacterials is generally used for moderate to severe acne or where topical preparations are not tolerated or are ineffective or where application to the site is difficult. Another oral preparation used for acne is the hormone treatment co-cyprindiol (cyproterone acetate with ethinylestradiol); it is for women only. Severe acne, acne unresponsive to prolonged courses of oral antibacterials, scarring, or acne associated with psychological problems calls for early referral to a consultant dermatologist who may prescribe isotretinoin for administration by mouth. Rosacea is not comedonal (but may exist with acne which may be comedonal). The pustules and papules of rosacea respond to topical metronidazole or to topical azelaic acid. Alternatively, oral administration of oxytetracycline or tetracycline 500 mg twice daily or of erythromycin 500 mg twice daily can be used; courses usually last 6–12 weeks and are repeated intermittently. Doxycycline in a dose of 100 mg once daily can be used if oxytetracycline or tetracycline is inappropriate (e.g. in renal impairment). Isotretinoin is occasionally given in refractory cases [unlicensed indication]. Camouflagers may be required for the redness.
Topical preparations for acne
In mild to moderate acne, comedones and inflamed lesions respond well to benzoyl peroxide or to a topical retinoid. Alternatively, topical application of an antibacterial such as erythromycin or clindamycin may be effective for inflammatory acne. If topical preparations prove inadequate, oral preparations may be needed.
BENZOYL PEROXIDE:
Indications: Acne vulgaris.
Contraindications: Patients with a known sensitivity to Benzoyl Peroxide should not employ this medication.
Dose and Administration: Apply the product carefully to the affected areas once daily and allow remaining for 2 hours. Remove with water, and continue this treatment for 2 to 4 days. If no discomfort is felt, apply once daily for 4 hours for the next 4 days. If there is still no discomfort, apply at bedtime and leave the product on all night. For severe conditions the product may be used in the morning, again after 5 to 6 hours and again at night.
AZELAIC ACID:
Indications: Acne vulgaris.
Contraindications: Hypersensitivity to Skinoren Acne Cream (propylene glycol). Safety in pregnancy and lactation has not been established.
Dose and Administration: Before Cream is applied, the skin must be thoroughly cleansed with clear water or, if necessary, with a mild cleansing agent. In general, Cream should be applied in adequate amounts to the affected areas of the skin twice a day (mornings and evenings) and should be rubbed in well. The amount of Cream to be applied will depend on the size of the affected area. As a guide, a daily dose of 2 g (1 g per application) will be sufficient for the treatment of the entire facial area (1 g = 4 cm cream). If other areas of acne, in addition to the face, require treatment, for example the chest and back, a daily dose of 10 g of cream should not, in general, be exceeded.
CLINDAMYCIN PHOSPHATE:
Indications: Acne vulgaris.
Contraindications: Topical clindamycin is contraindicated in individuals with a history of hypersensitivity to clindamycin or lincomycin. Clindamycin topical is contraindicated in individuals with a history of inflammatory bowel disease or a history of antibiotic-associated colitis
Dose and Administration: Apply a thin film of Solution or Lotion twice daily to the affected area.
ADAPALENE
Indications: Differin Cream is proposed for the cutaneous treatment of mild to moderate acne vulgaris where comedones, papules and pustules predominate. Differin Cream is best suited for use on dry and fair skin. Acne of the face, chest or back is appropriate for treatment.
Contraindications: Hypersensitivity to any ingredient of the product.
Dose and Administration: Cream or gel should be applied to the acne-affected areas once a day before retiring and after washing. A thin film of cream should be applied, with the fingertips, avoiding the eyes and lip. Ensure that the affected areas are dry before application.
TRETINOIN:
Indications: indicated for topical application in the treatment of hyperkeratotic follicular and related conditions such as acne vulgaris, primarily grades 1-111 in which comedones, papules and pustules predominate. It is not effective in most cases of severe pustular and deep cystic nodular varieties (acne conglobata).
Contraindications: Sould be discontinued if hypersensitivity to any of the ingredients is noted.
Dose and Administration: should be applied once or twice daily to the area of skin where the acne lesions occur.
ISOTRETINOIN:
Indications: treatment of mild to moderate inflammatory and non-inflammatory acne vulgaris.
Contraindications: Sould be discontinued if hypersensitivity to any of the ingredients is noted also should not be used in patients with a personal or family history of cutaneous epithelioma.
Dose and Administration: Apply sparingly over the whole affected area once or twice daily. Patients should be advised that 6-8 weeks of treatment might be required before a therapeutic effect is observed.
ISOTRETINOIN-ERYTHROMYCIN:
Indications: treatment of mild to moderate inflammatory and non-inflammatory acne vulgaris.
Contraindications: Sould be discontinued if hypersensitivity to any of the ingredients is noted also should not be used patients with acute eczema, rosacea and perioral dermatitis. Isotrexin is contraindicated in pregnancy, in women intending to conceive and in lactation.
Dose and Administration: Apply sparingly over the whole affected area once or twice daily. Patients should be advised that 6-8 weeks of treatment might be required before a therapeutic effect is observed.
Oral preparations for acne
Systemic antibacterial treatment is useful for inflammatory acne if topical treatment is not adequately effective or if it is inappropriate. Anticomedonal treatment (e.g. with topical benzoyl peroxide) may also be required. Cocyprindiol (cyproterone acetate with ethinylestradiol) contains an anti-androgen. It is no more effective than an oral broad-spectrum antibacterial but is useful in women who also wish to receive oral contraception. The retinoid isotretinoin reduces sebum secretion. It is used for the systemic treatment of nodulo-cystic and conglobate acne, severe acne, scarring, acne which has not responded to an
adequate course of a systemic antibacterial, or acne which is associated with psychological problems. It is also useful in women who develop acne in the third or fourth decades of life, since late onset acne is frequently unresponsive to antibacterials.
ISOTRETINOIN:
Indications: Severe forms of acne (such as nodular or conglobate acne or acne at risk of permanent scarring) resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy.
Contraindications: Isotretinoin is contraindicated in women who are pregnant or breastfeeding. Isotretinoin is contraindicated in women of childbearing potential unless all of the conditions of the Pregnancy Prevention Programme are met. Isotretinoin is also contraindicated in patients with hypersensitivity to isotretinoin or to any of the excipients. Isotretinoin is also contraindicated in patients With hepatic insufficiency, With excessively elevated blood lipid values. Dose and Administration: 500 micrograms/kg daily increased if necessary to 1 mg/kg (in 1–2 divided doses) for 16–24 weeks (8 weeks if failure or relapse after first course); max. cumulative dose 150 mg/kg per course; child not recommended.
