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How to Treat Acne. Keeping It Clear To avoid further clogging of your pores, all cosmetics, lotions, and sunscreens should be oil-free! Medications Benzoyl Peroxide Benzoyl peroxide can be found in many over the counter acne medications. Directions: Start conservatively, with 5 percent gel or lotion once a day such as after you wash your face to go to bed. After one week, increase use to twice a day if you are not using another medication.
If your acne is not better after 4 to 6 weeks, try a 10 percent solution. It is now available over-the-counter without a doctor's prescription. Be sure to get the pure form: you may want to ask the pharmacist for the type that used to be available by prescription only. Retin-A Retin-A is available with a doctor's prescription, as well as in over-the-counter solutions at your local drug store.
Directions: Retin-A may cause your skin to become very red and dry, and may cause peeling.
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Newer medications have milder side effects. You should ask your doctor to switch your medication if you suffer some of these side effects. As your doctor will tell you, Retin-A should only be used at night, because it makes your skin more sensitive to the sun and more susceptible to sunburn. Use extra sunscreen and sun protection when outdoors. It may take two to three months to see improvement in your skin. Be patient, follow your doctor's instructions and remember to stick with the program. Acne may get worse before it gets better. Antibiotics Antibiotics are available with a doctor's prescription only.
Directions: Be sure to follow your doctor's instructions. Take the antibiotic pills with plenty of water. Some antibiotics may increase your skin's sensitivity to the sun, wear sunscreen when outdoors. Accutane Accutane is available with a doctor's prescription only. Directions: Blood testing is done frequently when taking Accutane, as it can affect blood cell count and levels.
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Some physicians will not prescribe Accutane. Last Reviewed : October Related Articles. More Resources. Drug Guide Look up prescription and over-the-counter drug information. Medical Library Look up information helpful health information. Diseases and Conditions See our full library of diseases and conditions. Patient Information Practical info for Sutter patients. Tools and Quizzes Online tools to help you make decisions about your health. Tetracycline agents should not be used during pregnancy because use during the second and third trimester is known to cause discoloration of the teeth and bones.
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However, there is no firm evidence that first-trimester use is associated with major birth defects Kong and Tey, , Meredith and Ormerod, Cases of maternal liver toxicity that is associated with the use of tetracycline agents during the third trimester have been reported Hale and Pomeranz, , Rothman and Pochi, , Wenk et al.
Although there is a theoretical risk of bone and teeth malformation if tetracycline is administered during lactation, low concentrations of neonatal absorption are expected because of its strong binding with calcium ions in breast milk. Tetracycline is generally considered safe for use during breast feeding Spencer et al. Doxycycline appears to be effective for patients with AV in the 1. Subantimicrobial dosing of doxycycline i. Issues to consider when prescribing doxycycline include the fact that doxycycline is more photosensitizing than minocycline Zaenglein et al.
To mitigate these side effects, patients should be counseled to use sunscreen lotion and other photoprotective measures to decrease the risk of sunburns, take doxycycline with a meal or a full glass of water, and not take doxycycline less than 1 hour prior to bedtime. Additionally, absorption is decreased with the concomitant intake of iron and calcium. The hyclate version of doxycycline tends to have greater gastrointestinal side effects compared with the monohydrate form. Doxycycline is primarily metabolized by the liver and can be used safely in most patients with renal disease Zaenglein et al.
Previously, treatment with minocycline was thought to be superior to doxycycline in reducing P. However, a recent Cochrane review found that minocycline was effective to treat patients with AV but was not superior to other antibiotic medications Garner et al. For practical purposes, minocycline is generally dosed at 50 to mg twice daily. Compared with doxycycline, minocycline tends to have lower rates of gastrointestinal side effects but is associated with tinnitus, dizziness, and pigment deposition within the skin, mucous membranes, and teeth.
Minocycline-associated pigmentation is more common in patients who take higher doses for longer periods of time Zaenglein et al. Rare, serious, immune-mediated events have also been associated with minocycline including drug-induced hypersensitivity syndrome or a drug reaction with eosinophilia and systemic symptoms, drug-induced lupus, and other hypersensitivity reactions Kermani et al.
Macrolide medications including erythromycin and azithromycin have been used in the treatment of patients with acne but recently have fallen out of favor as first-line treatment. Macrolide agents are considered alternative therapy when traditional antibiotic medications cannot be used. As with tetracycline, macrolide has some anti-inflammatory properties but the specific mechanism of action in acne is unknown.
The most common side effect is gastrointestinal disturbances Zaenglein et al. Macrolide medications occasionally can cause cardiac conduction abnormalities and rarely cause hepatotoxicity Zaenglein et al. Erythromycin is the traditional oral antibiotic medication of choice when a systemic antibiotic treatment is needed for acne while a patient is pregnant Hale and Pomeranz, , Koren et al.
Due to increasing bacterial resistance, erythromycin should be combined with a topical preparation such as BP Meredith and Ormerod, Due to the differences in absorption, mg erythromycin ethyl succinate produces the same serum levels as mg erythromycin base or stearate. For the erythromycin base, dosing ranges from to mg twice daily. For erythromycin ethyl succinate, dosing ranges from to mg twice daily. Oral erythromycin is classified as FDA pregnancy category B. Erythromycin is more commonly used during pregnancy to treat other infections, which resulted in larger retrospective studies on pregnancy outcomes Romoren et al.
Although erythromycin is largely considered safe for use during pregnancy, reports of fetal cardiac malformation exist Kallen et al. Azithromycin is an azalide antibiotic agent that is derived from erythromycin Meredith and Ormerod, and tends to be better tolerated compared with erythromycin Kong and Tey, Azithromycin has been studied in varying doses from 3 times a week to 4 days a month with varying efficacy in patients with AV and all trials used pulse-dosing regimens Antonio et al.
Trial doses have included mg once daily for 4 consecutive days per month for 2 consecutive months Babaeinejad et al. One study from showed that azithromycin is as effective to treat patients with AV as doxycycline Kus et al. A more recent, randomized, controlled trial that compared treatment with azithromycin 3 days per month to daily doxycycline showed the superiority of doxycycline Ullah et al.
As with erythromycin, azithromycin is classified as FDA pregnancy category B. The usual dosing for patients with AV is one double-strength tablet twice daily. These risks are increased among women who do not use a multivitamin that contains folic acid Hernandez-Diaz et al. Additionally, exposure during the third trimester of pregnancy is small for gestational age infants as well as associated with hyperbilirubinemia Ho and Juurlink, Penicillin and cephalosporin are well established as safe for use during pregnancy and lactation Hale and Pomeranz, However, they are rarely used to treat patients with acne because information with regard to efficacy is sparse.
Penicillin and cephalosporin can be used as an alternative to conventional antibiotic medications, especially during pregnancy or with allergies to other classes of antibiotic treatments Zaenglein et al. Side effects include risk of hypersensitivity reactions that range from mild drug eruptions to anaphylaxis and gastrointestinal disturbances i. The recommended dosing for amoxicillin is mg twice daily up to mg three times daily.
Cephalosporin has in vitro activity against P. Isotretionoin is an important nonhormonal and nonantimicrobial treatment option for adult women with acne Gollnick et al. Oral isotretinoin is FDA-approved for the treatment of severe recalcitrant AV but can also be used to treat patients with moderate acne that is either treatment-resistant or relapses quickly after discontinuation of oral antibiotic therapy Agarwal et al.
Several studies have shown that isotretinoin effectively decreases sebum production, the number of acne lesions, and acne scarring Amichai et al. According to the AAD working group, isotretinoin is also indicated for the treatment of patients with moderate inflammatory acne that is either treatment-resistant or produces physical scarring or significant psychosocial distress Zaenglein et al.
Isotretinoin is usually initiated at a starting dose of 0. In very severe cases, lower initial doses in addition to oral corticosteroid medications may be needed. Low-dose isotretinoin 0. However, intermittent dosing is not as effective as daily dosing and exhibits higher relapse rates Agarwal et al. Absorption of isotretinoin is increased with fatty foods and isotretinoin is recommended to be taken with meals Strauss et al.
The lidose formulation Absorica has absorption profiles that are not dependent on fat intake. The most prevalent side effects of isotretinoin mimic symptoms of hypervitaminosis A Zaenglein et al. With standard dosing, these side effects resolve after discontinuation of therapy Zaenglein et al.
Although many small case reports and series show that isotretinoin has no negative effect on mood, memory, attention, or executive function Alhusayen et al. Food and Drug Administration, In the FDA case series, patients recovered after isotretinoin was discontinued and had a recurrence of symptoms after reinitiating isotretinoin. When patients were rechallenged, the time to onset of the psychiatric symptoms was on average shorter, and 10 patients had persistent psychiatric symptoms after isotretinoin discontinuation. As of December 31, , isotretinoin users worldwide have committed suicide while taking isotretinoin or within a few months of discontinuation of treatment and another patients have been hospitalized for severe depression or attempted suicide Duenwald, However, some have argued that the number of reported cases of depression among isotretinoin users is no greater than in the general population Lamberg, The AAD working group recommends that prescribing physicians monitor patients for any indication of depressive symptoms and educate patients on the potential risks of treatment with isotretinoin.
Laboratory test result monitoring for patients on isotretinoin varies widely among practitioners. Serum cholesterol, triglycerides, and transaminases are known to increase in some patients who take oral isotretinoin Bershad et al.
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Routine monitoring of serum lipid profiles and liver function studies are recommended to be done regularly but the interval varies Bershad et al. Some practitioners monitor laboratory test results monthly, but others only check at baseline and after dosing changes. Hansen et al. If the findings are normal, no further testing may be required. The AAD working group did not find any evidence-based reason to warrant routine monitoring of complete blood cell counts Zaenglein et al.
Pregnancy testing is required for female patients of childbearing potential at baseline, monthly during therapy, and 1 month after completion of isotretinoin treatment. The use of oral isotretinoin during pregnancy is absolutely contraindicated FDA pregnancy category X due to its known severe teratogenicity including craniofacial, cardiac, and thymic malformations Lammer et al. As a result of these serious effects, the manufacturers of oral isotretinoin have developed pregnancy prevention programs where preferably two forms of contraception are recommended Goodfield et al.
Currently, the United States and United Kingdom require enrollment in these pregnancy prevention programs to receive oral isotretinoin. Dermatologists should counsel women that they should not become pregnant 1 month before, during, or within 1 month after completion of isotretinoin therapy. The following therapies have limited evidence for their efficacy in the treatment of patients with AV.
Some of these modalities may be helpful to treat acne scarring as well. These treatments include comedo extraction Meredith and Ormerod, , Zaenglein et al. Many patients wish to use more natural treatments and may look to herbal and alternative agents for treatment.
Although most of these agents are generally well tolerated, there are limited data with regard to efficacy and safety. Additionally, the specific ingredients, concentrations, and potential adulteration with other unwanted chemicals is not well regulated and sometimes cannot be confirmed. These complementary and alternative therapies include tea tree oil Bassett et al. Other complementary and alternative medicines Fox et al.
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New therapies to treat patients with AV continue to be developed. Many of these new therapies are in various stages of testing, and although the ultimate efficacy is difficult to predict, preliminary studies show promising results. Oral minocycline has been shown to be effective in the treatment of patients with AV; however, systemic side effects including abnormal mucocutaneous pigmentation and autoimmune reactions may limit its use Kircik, , Smith and Leyden, The significant reduction in lesions were observed as early as week 3 and persisted until the end of the study at week Treatment was well tolerated and safe with no drug-related systemic side effects or serious adverse events.
Nitric oxide NO has been shown to have broad-spectrum antimicrobial, wound-healing, and immunomodulatory properties Friedman and Friedman, , Martinez et al. Qin et al. Both concentrations were safe and well-tolerated by patients. Systemic anti-androgens such as spironolactone and combination oral contraceptive medications can be used in the effective treatment of patients with AV Kong and Tey, , Meredith and Ormerod, , Thiboutot and Chen, , Zaenglein et al. However, systemic use of anti-androgens is limited to women who wish to conceive or have other endocrine disorders or contraindications Chen et al.
A topical anti-androgen treatment has not been made available for use to date. A myriad of treatment choices is available to treat adult female patients with acne. A relatively limited number of options are available for the management of acne during pregnancy and lactation.
However, the level of evidence on the safety of any therapies during pregnancy and lactation is low. National Center for Biotechnology Information , U. Int J Womens Dermatol. Published online Dec Paller , MD. Author information Article notes Copyright and License information Disclaimer. Tan: ude. Published by Elsevier Inc.
This article has been cited by other articles in PMC. Abstract This review focuses on the treatment options for adult female patients with acne. Introduction Acne vulgaris AV is a disease of the pilosebaceous unit that causes noninflammatory lesions open and closed comedones , inflammatory lesions papules, pustules, and nodules , and varying degrees of scarring. Pathogenesis Four key pathogenic processes lead to the formation of acne lesions: alteration of follicular keratinization that leads to comedones; increased and altered sebum production under androgen control; follicular colonization by Propionibacterium acnes ; and complex inflammatory mechanisms that involve both innate and acquired immunity Williams et al.
Clinical presentation Acne in women can occur at any age and with varying degrees of severity. Open in a separate window. Figure 1. Comedones with post-inflammatory hyperpigmentation. Figure 2. Inflammatory papules and pustules. Figure 3. Acne Nodules and Cysts. Evaluation considerations The evaluation of any patient with acne should include a thorough medical history and physical examination. Table 1 Differential diagnosis of acne vulgaris. Table 2 Causative agents of drug-induced acneiform eruptions. Class of agent Examples Hormones Corticosteroids and corticotropin Androgens and anabolic Steroid medications Hormonal contraceptive medications Neuropsychotherapeutic drugs Tricyclic antidepressant medications Lithium Antiepileptic drugs Aripiprazole Selective serotonin reuptake inhibitors Vitamins Vitamins B1, B6, and B12 Cytostatic drugs Dactinomycin actinomycin D Immunomodulating molecules Cyclosporine Sirolimus Antituberculosis drugs Isoniazid Rifampin Ethionamide Halogens Iodine Bromine Chlorine Targeted therapies Epidermal growth factor receptor inhibitors Multitargeted tyrosine kinase inhibitors Vascular endothelial growth factor inhibitor Proteasome inhibitor Tumor necrosis factor alfa inhibitors Histone deacetylase inhibitor.
Further testing Microbiologic testing P. Endocrine testing The role of androgens in acne is well established. Treatment of acne vulgaris Table 3 shows the various treatments for patients with AV, along with the strength of recommendations from the AAD working group but modified to include pregnancy and lactation ratings. Table 3 AAD Working Group strength of recommendations for the management and treatment of patients with acne vulgaris a. The strength of the recommendation was ranked as follows: A.
Recommendation based on consistent and good-quality patient-oriented evidence; B. Recommendation based on inconsistent or limited-quality patient-oriented evidence; C. Recommendation based on consensus, opinion, case studies, or disease-oriented evidence. Good-quality, patient-oriented evidence; II. Limited-quality, patient-oriented evidence; III.
Other evidence including consensus guidelines, opinion, case studies, or disease-oriented evidence. National Library of Medicine. Table 4 American Academy of Dermatology Working Group treatment algorithm for the management of adolescents and young adults with acne vulgaris a. BP, benzoyl peroxide. Treatment of acne vulgaris in adult women The central tenets of acne management as displayed in Table 4 should be followed in the treatment of adult female patients. Treatment of acne vulgaris during pregnancy and lactation Women of childbearing potential should also be asked about their plans for reproduction, and treatment should be tailored for safety, whether the patients are actively trying to conceive, pregnant, or lactating Table 3.
Table 5 Summary of U. Category Description A Controlled studies show no risk. Adequate, well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester of pregnancy. B No evidence of risk in humans. Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities despite adverse findings in animals. The chance of fetal harm is remote but remains a possibility C Risk cannot be ruled out. Adequate, well-controlled human studies are lacking and animal studies have shown a risk to the fetus or are lacking as well.
There is a chance of fetal harm if the drug is administered during pregnancy but the potential benefits may outweigh the potential risk D Positive evidence of risk. Studies in humans or investigational or post-marketing data have demonstrated fetal risk. Nevertheless, potential benefits from the use of the drug may outweigh the potential risk.
For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective. X Contraindicated in pregnancy. Studies in animals or humans or investigational or post-marketing reports have demonstrated positive evidence of fetal abnormalities or a risk that clearly outweighs any possible benefit to the patient N No pregnancy category has been assigned.
Topical therapies Topical therapies are considered one of the mainstay treatments for patients with mild-to-moderate acne Nast et al. Benzoyl peroxide BP is commonly used to treat patients with acne and is available in a variety of strengths 2. Salicylic acid SA is a comedolytic agent that is available over the counter in 0. Topical antibiotic medications Topical antibiotic medications are thought to accumulate in the follicle and may work through both anti-inflammatory and antibacterial effects Mills et al. Topical clindamycin Clindamycin is available in a gel, lotion, pledget, or topical solution and has been assigned FDA pregnancy category B.
Topical erythromycin Erythromycin is available as a gel, solution, ointment, pledget, or thin film. Topical retinoid medications Topical retinoid medications are vitamin A—derivative prescription agents Bradford and Montes, , Krishnan, , Lucky et al. Azelaic acid Azelaic acid acts as a comedolytic, antimicrobial, and anti-inflammatory agent Strauss et al.
Other topical agents The following topical agents lack evidence-based data for their use in patients with acne but have been demonstrated to be effective in clinical practice: sodium sulfacetamide Lebrun, , Tarimci et al. Systemic antibiotic medications Oral antibiotic medications are commonly prescribed as second-line therapy for patients with mild-to-moderate acne that is not adequately controlled with topical agents alone and are a mainstay of acne treatment in patients with moderate-to-severe inflammatory acne.
Doxycycline Doxycycline appears to be effective for patients with AV in the 1. Minocycline Previously, treatment with minocycline was thought to be superior to doxycycline in reducing P. Macrolides Macrolide medications including erythromycin and azithromycin have been used in the treatment of patients with acne but recently have fallen out of favor as first-line treatment. Erythromycin Erythromycin is the traditional oral antibiotic medication of choice when a systemic antibiotic treatment is needed for acne while a patient is pregnant Hale and Pomeranz, , Koren et al.
Azithromycin Azithromycin is an azalide antibiotic agent that is derived from erythromycin Meredith and Ormerod, and tends to be better tolerated compared with erythromycin Kong and Tey, Penicillin and cephalosporin Penicillin and cephalosporin are well established as safe for use during pregnancy and lactation Hale and Pomeranz, Isotretinoin Isotretionoin is an important nonhormonal and nonantimicrobial treatment option for adult women with acne Gollnick et al. Miscellaneous and adjuvant therapies The following therapies have limited evidence for their efficacy in the treatment of patients with AV.
Complementary and alternative therapies Many patients wish to use more natural treatments and may look to herbal and alternative agents for treatment. Novel therapies New therapies to treat patients with AV continue to be developed. Minocycline foam Oral minocycline has been shown to be effective in the treatment of patients with AV; however, systemic side effects including abnormal mucocutaneous pigmentation and autoimmune reactions may limit its use Kircik, , Smith and Leyden, Topical nitric-oxide P.
Conclusions A myriad of treatment choices is available to treat adult female patients with acne. References Adebamowo C. High school dietary dairy intake and teenage acne. J Am Acad Dermatol. Milk consumption and acne in adolescent girls. Dermatol Online J. Milk consumption and acne in teenaged boys.
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Reprod Toxicol. Acne in the adult female patient: a practical approach. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. Comparison with vehicle and topical tretinoin. The effectiveness of intermittent isotretinoin treatment in mild or moderate acne. Superficial chemical peels and microdermabrasion for acne vulgaris. Polyarteritis nodosa-like vasculitis in association with minocycline use: a single-center case series. Semin Arthritis Rheum. Effects of fish oil supplementation on inflammatory acne. Lipids Health Dis.
Anti-inflammatory effect of Keigai-rengyo-to extract and acupuncture in male patients with acne vulgaris: a randomized controlled pilot trial. J Altern Complement Med. A double-blind study of the effects of cis-retinoic acid on acne, sebum excretion rate and microbial population. Doxycycline and minocycline for the management of acne: a review of efficacy and safety with emphasis on clinical implications.
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