Acne Treatment with medication
Treatment for acne depends on how severe it is. In many cases, medication can provide real relief from deep, painful breakouts.
The onset of acne is influenced by several factors, such as increased sebaceous gland activity, increased sebum production, abnormal follicular differentiation and increased cornification, as well as the increased bacterial colonisation. Each of these factors provides a potential target for treatment, while for the effective treatment of acne to be achieved; concomitant targeting of these factors is required. There are many medical products available, which are administered per os (by way of mouth). Among those, various antibiotics, retinoids, as well as hormonal therapies are included for adult women with acne.
Both in international and in national literature, there are many studies regarding the safety and effectiveness of oral medications for acne vulgaris. However, medical treatments have many disadvantages, such as:
- non-compliance to the therapeutic regimen by the patient
- the possibility of side effects
- the possibility of developing resistance to antibiotics, especially in cases of prolonged use
General principles of Acne Treatment with medication
Apart from the patient’s medical history, the dose, timing, combinations, side effects, and response to interventions should also be obtained. In addition, it is important to record the family history of acne and, if present, its tendency to scarring should be noted. With women, it is important to discuss possible menstrual irregularities and the level of hair growth, as well as the use of cosmetic products.
Furthermore, concrete and explicit instruction should be given. Patients should be aware of the difference of active inflammatory lesions and the purplish-red or hyperpigmented macules which have retreated. Topical application to the entire affected area rather than to specific lesions should be emphasised, as well as the fact that oral and topical medications should be used daily as the treatment’s nature is preventative.
Treatment failure may be due to drug interactions, already existing conditions, or antibiotic resistance. Nevertheless, the most common and important cause is lack of adherence to the treatment regimen. The use of medications that are well tolerated, have convenient dosing regimens, and are cosmetically acceptable will help, but thorough patient education is essential.
The use of antibiotics (orally administered) is suitable for:
- moderate to severe acne
- for the acne treatment of the chest, back or shoulders
- for patients with inflammatory disease in whom combinations of topical agents have failed or are not tolerated
- for patients in whom absolute control of the situation is mandatory like those who develop scars or inflammatory hyperpigmentation
Generally, it takes 6-8 weeks to evaluate the efficacy. Starting at a high dose and gradually reducing is preferred once control of acne has been achieved. Combination therapy, that is antibiotics with topical retinoids or retinoid-benzoyl peroxide is ideal. The duration of most oral therapy regimen is at least 3-6 months.
Tetracycline is the safest choice. It is usually administered 1 to 4 times daily with gradual dose reduction depending on clinical response. Tetracycline is combined with calcium or iron in food supplements, thus reducing absorption by as much as half.
It causes anti-inflammatory activity and due to the fact that the dose administered is low, it does not cause antibiotic resistance.
Minocycline is the most effective oral antibiotic for the treatment of acne vulgaris. It constitutes an alternative treatment with patients with resistant to tetracyclines P. acnes.
People who cannot take tetracyclines due to their side effects or women who are pregnant but should take oral antibiotic therapy, have the option of erythromycin.
Clindamycin responses excellently in acne treatment. However, its use has been limited significantly due to the possibility of development of pseudomembranous colitis and the availability of retinoids.
- Other Antibiotics
In certain cases, sulfonamides are prescribed. Nevertheless, their use is quite limited due to the potential development of severe rashes. Administration of trimethoprim can also be helpful. Amoxicillin is another alternative choice which may be useful during pregnancy. Although, rarely used today, dapsone has been demonstrated to be effective in severe acne conglobate.
Bacterial Resistance to antibiotics
The antimicrobial resistance of P. acnes constitutes a clinically relevant problem. P. acnes antibiotic resistance prevention strategies include:
- limiting the duration of treatment
- stressing the importance of adherence to the treatment regimen
- restricting the use of antibiotics in cases of inflammatory acne
- encouraging retreatment with the same antibiotic unless it is no longer effective
- avoiding the simultaneous use of different oral and topical antibiotics agents
- using isotretinoin if not responding to appropriate antibiotics, antibiotic oral treatment
Retinoids (oral administration)
Isotretinoin is a reliable treatment method for patients with severe cystic acne. However, it is useful in less severe forms of acne in order to prevent the need for continuous treatment and repeated visits to the dermatologist required by many patients.
According to expert’s consensus, oral isotretinoin treatment for acne is justified in:
- severe acne
- poorly responsive acne with less than 50% improvement after 6 months of therapy combined with oral and topical agents’ administration,
- acne relapses off oral treatment
- acne scarring
- cases acne induces psychological distress
- gram-negative folliculitis, inflammatory rosacea, pyoderma faciale, acne fulminans and hidradenitis suppurativa
The major advantage of isotretinoin is that is the only acne therapy that can lead to a remission lasting for many months or years.
Around 40 – 60% of patients remain acne-free after a single course of isotretinoin. Approximately 1/3 of the relapsing patients will need only topical therapy, whilst the others oral treatments. Many patients in the second category prefer to be retreated with isotretinoin because of:
- its reliable efficacy.
- the ability to predict side effects, as they are similar to those experienced in the first therapeutic regimen.
Despite the fact that a patients’ tolerance and response to repeated courses are similar to their experience with the first course, adult women who relapse may be better managed with hormonal therapies, and mild acne treated with the standard, typical therapy.
In adult patients with acne, who are usually less tolerant to the side effects of isotretinoin, it is possible to administer lower doses and/or follow an intermittent treatment regime.
Isotretinoin and pregnancy
Women should not become pregnant until the discontinuation of their medication and for at least 1 month afterwards. The drug is not mutagenic and there is no risk of the fetus being conceived while the male partner is taking the drug.
Isotretinoin and Mental Health
While the usual outcome is an improvement of mood because of the acne’s improvement, studies have demonstrated that there are still a few patients who have developed depression.
Having said that, isotretinoin administration should be combined with:
- close monitoring for
- full information of the patient’s history for possible side effects.
- cooperation with a close friend or family member to monitor possible changes in the patient’s behavior.
Isotretinoin and other side effects
Other side effects of isotretinoin are dose-dependent and generally not serious. Up to 90% of patients present:
- dry eyes
- dry lips
- dry oral and nasal mucosa
The following may also occur:
- skin abscesses
- staphylococcal conjunctivitis (pus-filled abscesses)
- impetigo (bacterial infection)
- facial cellulite
- folliculitis (inflammation of hair follicles)
Arthralgias (pains in the joints) may also occur but treatment interruption is not necessary unless severe, as is the case with other side effects. Moreover, the monitoring of serum lipids is carried out since certain patients may develop hypertriglyceridemia. This means that patients must quit smoking and alcohol and also follow a low-fat diet. In addition, a liver function test should be performed on a regular basis, depending on the risk factors and the dose administrated.
Women who have normal laboratory values, as long as they can receive medication, respond well to hormonal therapy for acne. The first evidence of progress is evident within 3 months, while improvement continues for at least 6 months. Good candidates for hormonal acne treatment are:
- women with PCOS, late-onset adrenal hyperplasia or another endocrinologic condition.
- women with late-onset acne, severe acne, acne which has not responded to other oral or topical therapies, or acne with frequent relapses after isotretinoin treatment.
- women with acne on the lower part of the face and neck, as well as with deep-seated nodules that are painful and long-lasting.
- Oral contraceptives
Oral contraceptives block both the adrenal and the ovarian androgens. Certain contraceptives are especially effective for acne treatment, nevertheless, the patient should be informed about the side effects like nausea, vomiting, abnormal menses, melasma, weight gain, breast sensitivity and rarely in some rare cases, thrombophlebitis, pulmonary embolism and hypertension.
- Spironolactone is usually administered along with other topical or oral therapies for acne. Usually, several months of treatment is required to show a result and its side effects depend on the dose administered and include breast tenderness, headache, dizziness, fatigue, irregular menstrual periods and diuresis (a condition in which the kidneys filter too much bodily fluid).
Dexamethasone can lead to a reduction of androgen excess and may alleviate cystic acne. Corticosteroids are effective in the treatment of adult-onset adrenal hyperplasia, but antiandrogens are also used increasingly in this situation.
Despite the fact that steroids can produce acne, they constitute effective anti-inflammatory agents in cases of severe and persistent acne. Treatment with corticosteroids is effective for the management of severe cystic acne and acne conglobate. In general, they are prescribed only in patients with severe inflammatory acne during the first few weeks of isotretinoin treatment for the initial reduction of the inflammation and the minimisation of the flare ups caused by isotretinoin.
- Other Hormonal factors
Among the other hormonal agents that have been shown to have a beneficial effect on acne, finasteride, flutamide, estrogen, gonadotropin-releasing agonists, and metformin (testosterone levels’ reduction) are included.