Acne management 2017
Antibiotic resistance is increasing and antibiotics becoming less effective
o Ideally, topical benzoyl peroxide should be used in combination with a topical retinoid in preference to topical antibiotics to minimise the impact of bacterial resistance
Oral antibiotics still have a role in the treatment of moderate to severe acne BUT
They should always be used in combination with a topical retinoid or benzoyl peroxide or
both
Ideally they should not be used for more than 3 months
To limit resistance, benzoyl peroxide should always be added when long term oral
antibiotics are deemed necessary
Do not underestimate the impact of acne on patient quality of life and mental health
Topical retinoids are the mainstay of treatment, and they are recommended now for all cases of
acne (except when oral retinoids used)
Adapelene is the best tolerated retinoid
Maximal benefit is seen after 3 to 4 months
Women of child bearing age should be counselled re the need for contraception even with topical retinoids
Azelaic acid is an alternative to retinoids with anti-comedone and anti-inflammatory properties which is well tolerated, but with less evidence to support it. Beware its skin
bleaching effect in dark skinned people.
Avoid prolonged antibiotic courses and antibiotic monotherapy because of the development of resistance
Always use antibiotics with a topical retinoid or benzoyl peroxide to limit resistance, review after 8 weeks to consider whether to continue or change.
When possible limit antibiotics to 12 weeks duration, and avoid combining oral and topical antibiotics
Contraception
The evidence shows few differences between different types (including co-cyprindiol) but progesterone only contraceptives may worsen acne.
Is co-cyprindiol safe? - small but increased risk of VTE comparable to levonorgestrel pills (1.5 to 2 times increased relative risk), evidence suggests that the DVT risks are similar to newer generation pills containing desogestrel, gestodene or drospirenone.
Review
They advise a minimum of 3 months to control acne and then the need to continue treatment should be evaluated periodically by the physician and individualised decisions made
To lower threshold for referring for oral isotretinoin
Combined products have potential benefits of complementary mechanisms and reducing resistance and improved adherence, but are of course more expensive….
There is no evidence that stronger preparations of benzoyl peroxide are any more effective than 2.5%, and irritation improves with continued use
o As it bactericidal expect rapid improvements in inflammatory acne and it helps prevent development of resistance
o If acne is just comedonal with little inflammation, then retinoid alone may be sufficient
What will you do differently in future?:
Use a single topical agent
comedonal, topical retinoid
inflammatory,benzoyl peroxide 2.5%
mixed, combination of the two.
If one not tolerated,switch to other. If both not tolerated try azelaic acid.
consider a standard COCP if contraception needed
Consider combination of:
BP plus topical antibiotic (predom inflammatory)
BP plus topical retinoid (predomcomedonal)
Oral antibiotic if extensive (always use with topical BP or retinoid, and never with topical antibiotic, to reduce resistance).
REFER if no response after 6/12 of trying in primary care
In meantime, commence treatment with oral antibiotic and BP + topical retinoid
consider a COCP (standard or co-cyprindiol)
Consider co-cyprindiol when topical treatment or systemic antibiotics has failed.