Acne Vulgaris - Choosing a Treatment 2

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  Michelle A  Acne Vulgaris €Choosing a Treatment Option Michelle A. Stewart Pharm.D.Candidate, 2016April 10, 2016 What treatment options are available? 1 Acne VulgarisMild to ModerateModerateto SevereOTC € Benzoyl peroxide E ffective when used daily N o more than 2.5% M ay use in combination with Rx products € Salicylic acid E ffective when used daily M ay use in combination but may increase dryness & irritation RX Topical Antibiotics € Topical clindamycin  A vailable as foam, gel, lotion C oncentration: 1% € Topical erythromycin  A vailable as gel, ointment, pads, or solution C oncentration: 2%   RX Topical Retinoids € Adapalene  A vailable cream, gel, lotion C oncentration: 0.1%, 0.3% € Tretinoin  A vailable as cream, gel C oncentration: 0.025%, 0.05%, 0.1%   Systemic Antibiotics € Minocycline M ay be superior to doxycycline P atients 12 years and older D ose: 100mg PO BID € Doxycycline P atients 12 years and older D ose: 100mg PO QD € Bactrim U se when there is an allergy or intolerance to TCN class D ose: 800/160mg PO BID   Systemic Retinoids € Isotretinoin F or use in refractory, cystic acne where the benefits outweigh the risks of therapy i PLEDGE program enrollment  D ose: 0.5-1mg/kg/day PO in two divided doses for a 15 to 20 week course of therapy (severe scarring acne or truck acne may require a dose increase to 2mg/kg/day)  Michelle A Mild to Moderate Acne OTC Topicals : Benzoyl peroxide and salicylic acid € Readily availableOTC in a variety of formulations o Select a product that best suits patient’s needs € Effective if used in combination, especially with the systemic antibiotics as resistance does develop RX Topicals : The guidelines recommend either topical antibiotics or  topical retinoidsas first line prescription-strength therapies for acne. Table 1: Topical Abx Comparative Efficacy   2 ↓ Inlammatory Lesions↓ Non-Inflammatory LesionsClindamycin 1.0%59% reduction from baseline ( ~7 lesions)39% reduction from baseline ( ~11 lesions)Erythromycin 2.0%62% reduction from baseline ( ~9 lesions)43% reduction from baseline ( ~12 lesions) € No one treatment is significantly better at improving acne € Clindamycin > Erythromycin –cheaper and has fewer reports of treatment resistance over time Table 2: Topical Retinoid Comparative Efficacy  3 ↓ Total Lesions↓ Inlammatory LesionsAdapalene 0.1%28% reduction from baseline32% reduction from baselineTretinoin 0.025%22% reduction from baseline17% reduction from baselineTazarotene 0.1%“Similar to tretinoin”“Similar to tretinoin” € Tazarotene is costly and just as effectiveas tretinoin € Not listed in treatment algorithm Moderate to Severe Acne Systemic Antibiotics : € Minocycline > doxycycline –partly based on observational data € Allergy to tetracyclines € sulfamethoxazole/trimethoprim DS € Caution against using systemic erythromycin due to high rates of bacterial resistance( P. acnes ) Systemic Retinoid : Table 3: Systemic Retinoid Efficacy 4 Remission or Marked Improvement Relapse RatesIsotretinoin0.5mg –1mg/kg/day84% in fourmonths28% (ANY cyst) € None of the side effects reported were life-threatening. Reports of inflammatory bowel disease and psychiatric issues have been mentioned in case reports but do not present in clinical trials. Miscellaneous Therapies 1 Hormonal therapy: estrogen containing oral contraceptives € FDA approved for treatment of acne: Ortho Tri-cyclen and Estrostep € Evidence to support other estrogen containing OCPs but no evidence to support vaginal rings, patches, etc.Spironolactone: dosages of 50-200mg shown to be effective with average duration of therapy lasting 10 months   References1. Strauss J, Krowchuk D, Leyden J et al. Guidelines of Care for Acne Vulgaris Management. J Am Acad Dermatol. 2007 Feb;56:651-63.2. Shalita AR, Smith EB, Bauer E. Topical erythromycin vs. clindamycin therapy for acne. Arch Dermatol. 1984;120:351-5.3. Grosshans E etal. Evaluation of clinical efficacy and safety of adapalene vs. tretinoin in the treatment of acne vulgaris. Br J Dermatol. 1998;139(suppl52):26-33.4. Peck GL et al. Isotretinoin vs placebo in the treatment of cystic acne. J Am Acad Dermatol. 1982; 6:735-45.
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