Acne care

TOPICAL TREATMENTS: 1 **See end of document for important information - numbered citations**

 Morning Routine:
 Wash your face with a mild soap such as “Dove”.
 Wait 3-5 minutes, then apply a pea size amount of morning medication to the affected
area. Overuse of medication will cause dryness, peeling, and irritation.
 Morning medication:
□ Benzoyl Peroxide 10% gel 60g tube
□ Clindamycin 1% gel 30g tube
□ Azelaic Acid 20% cream 30g tube
 You may apply an oil free moisturizer or makeup on top if needed.
 Evening Routine:
 Wash your face with a mild soap such as “Dove”.
 Wait 3-5 minutes, then apply a pea size amount of the Retinoid (your evening
medication) to each affected area e.g., face, chest, back.
□ Tretinoin 0.025% cream (25g tube)
□ Tretinoin 0.05% cream (25g tube)
□ Tretinoin 0.1% cream (25g tube)
 You should start using the Retinoid every 3rd night per week for 2 weeks, then 2nd night
per week for 2 weeks, then every night to allow your skin to adapt.
 Expect your skin to be red and irritated in the beginning it will get better .
 Expect significant improvement in acne at 2 months.
 Does not treat current acne, treats future acne.
***** Once under control treatment can often be decreased to every other day*****

ORAL TREATMENTS:
□ Doxycycline2 100mg orally twice per day for at least 3 months then follow up.
 Remain sitting up after taking for 15 minutes & drink full glass of water may irritate the
throat or stomach otherwise.
 Will make you sensitive to the sun.
 After 3 months can decrease frequency and strength to lowest effective or switch to
topicals only.
□ Oral Contraceptive Pill:3 □ Yaz (Drospirenone 3mg /EE 20 mcg)
□ Yazmin (Drospirenone 3mg /EE 30 mcg)
□ Ortho Tri-Cyclen (Norgestimate Triphasic/ EE 35 mcg)
4
□ Spironolactone: _____ mg orally each morning. (Start 25mg, max 200mg/d)

Diet:
Research suggests consuming a low-glycemic diet may decrease acne. Also consuming cow’s milk may
increase acne. Needs to be better studied to confirm both.

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Herbal Supplements:
Tea Tree Oil, Ayurvedic, Barberry Extract, Gluconolactone, and Zinc may help, but data and studies very
limited and often not in medical literature or are not of high quality with large numbers of patients.

Recommendations:
 Avoid using hot water on face.
 Do not use scrubs as they can irritate the skin.
 Do not use any other over the counter acne products alongside prescribed medications.
 You must wear sunscreen (SPF 50+ applied every 2 hours while out in
the sun).
 Use only unscented, hypoallergenic lotions.
 Acne friendly Make-Up is available and should state Non-Condom Forming or Similar. However,
often is not long-wear type or waterproof.

Dos and Don’ts:

 Do not “scrub” or use abrasives on your face. These cause inflammation and make acne worse.
 Do not use hot water. You should use lukewarm water and pat dry with a soft towel.
 Avoiding moisturizers. Non-comedogenic moisturizers and cosmetics are OK.
 Popping pimples. This spreads the bacteria that causes pimps and causes more pimps.
 Acne treatments take 8-12 weeks to be effective do not give up too soon.
 Do not use too many different products with too many different ingredients at one time this can
lead to over drying and increased breakouts.
 Constant washing does not improve acne as it is not because of poor hygiene.
 Do not wash more than 2 times per day.
 Smoking and Vaping may make acne worse.

What Causes Acne:

Acne is a chronic inflammatory disease of the sebaceous glands of the skin. At the microscopic level the
skin undergoes increased lipid (oil) production, abnormal keratin changes, overgrowth of the bacteria P.
acnes, and inflammation. Causes of these changes include stress, diet, genetics, elevated male hormone
levels, repetitive mechanical injury of the skin, and insulin resistance. Smoking causes a unique for acne
called atypical post-adolescent acne. BMI has show conflicting results in relation to acne in research
studies.

*** Mild Acne is characterized by scattered, 5mm or less lesions, conedomes (blocked pores or hair
follicles without pain or inflammation), inflamed papules (red, irritated, and/or swollen lesions) or
pustules (puss fill lesion, maybe painful, hard or soft, also called cystic acne). Mild Acne is non-scaring
and usually only on head/face.***

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*** Moderate to Severe Acne is characterized by many, lesions greater than 5mm, very prominent
acne, conedomes, inflamed papules, and/or pustules. Nodules (a solid or cystic raised bump wider than
1cm) are almost always present as well. Can involve multiple body areas. This is scarring acne also called
nodular cystic acne.

*** Acne Fulminans and Ane Conglobata are rare severe very severe forms of acne and should be
referred to a Dermatologist immediately. ***

Import to know:
1) Prior to treatment acne should be assessed Type, Severity, Presence of Complications, Potential
Contributing Factors, and Medication Interactions with current medications. For Mild Acne 1st line
treatment is always a topical retinoid. For Moderate to Severe Acne 1st line treatment should consist of
an oral therapy in combination with topical therapy with antibiotics, contraceptives, spironolactone, or
oral isotretinoin (Accutane, see #6 below before taking this medication) 6. In female some of
these oral treatments can be combined. Early referral to Dermatology may be indicated. There are some
procedural therapies such as UV treatments that maybe adjunctively used by your Dermatologist.
2) procedural therapies such as UV treatments maybe adjunctively used by the Dermatologist.
3) Doxycycline is the best tolerated with least side-effects of the tetracycline class of medications and least
expensive. Minocycline is the 2nd line choice. It’s the most effective of tetracyclines but has more toxicity
concerns. Sarecycine is still investigational, comparative strength is unknown (maybe more effective) and
is narrow spectrum (has less resistance and disruption of good gut bacteria) no generic so is expensive.
Tetracyclines should not be used in children younger than 9 years old, may discolor teeth, and cause blue
tinged skin or cartilage.
4) Combined Oral Contraceptive medications may only be used in female patients. Estrogen containing
contraceptives are contraindicated in Migraine Disorders, Smokers 35 or older, and Estrogen sensitive
cancers.
5) Spironolactone should be used for acne only in Females. May help with male pattern hair loss in females.
As a diuretic watch for common side-effects: electrolyte issues, increase urination. male characteristics to
develop in Female patients, gynecological issues like amenorrhea, and most common side-effect of
Gynecomastia.
6) *** For Moderate to Severe Acne that will not respond to other treatments an oral retinoid Isotretinoin
(Accutane) can be prescribed. It is well known to cause always cause severe and potentially fatal birth
defects such as Anencephaly (a child born without a brain and skull or partially without them). It is FDA X
Class medication and requires the physician to be certified in how to prescribe it, to have a special DEA (X
class) License, and patients and physicians must both enroll in the FDA’s iPLEDGE program. Only certified
pharmacies may issue this drug and only a 30 day supply may be given. It may not be written as a future
prescription (do not dispense to after). Distributors must also be certified. IT IS NEVER RECOMMENDED
AS A FIRST LINE THERAPY BY ANY US DERMTOLOGIC ORGANIZATION. Patients must be 12 or older, non-
pregnant, have multiple inflammatory nodules greater than 5 mm, and must be categorized as severe
nodular acne at minimum. Dosing once per day and long-term use is NOT recommended. A normal course
of treatment is 15-20-weeks on the medication, 2 months off, and if reoccurring a 2nd 15–20-week
treatment may be used. Pregnancy testing is required at initial prescription, each month on the
medication, and for 1 month after stopping Accutane. Labs for cholesterol and liver function must always
be draw on all patients prior to starting. It can cause several potential permanent or fatal side-effects such
as Suicide, intracranial hypertension, sluffing of the skin, pancreatitis, liver failure, stunting of growth, and
loss of vision. New on sit Diabetes is all possible. It will also react badly to Vitamin A (NO MULIVITAMINS)

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and any tetracycline. Accutane with cause birth defects even if the male is the only one taking the
medication. More information is available at www.drugs.com, WWW.ipledgeprogram.com, or 1-866-495-
0654.

Additional thoughts and points of interest:

*** Alternative antibiotics for individuals with moderate to severe side-effects to the tetracyclines are
Azithromycin and Erythromycin, they have high resistance rates and less supporting research. ***
*** Some oral treatments maybe combined in females, i.e. contraceptives and antibiotics. ***
*** Oral steroids and Flutamide may potential work (not FDA approved) but have potentially fatal side-
effects and little good research. ***

*** The following medications or classes of medications are known to be associated with drug-induced
acne. ***

1. Vitamin B2, B6, and B12 – in multivitamins and supplements

2. Glucocorticoids - prednisone, white stuff for joint injections, numerous conditions
3. Phenytoin – anti-seizure medication
4. Lithium – Bipolar medication
5. Isoniazid – tuberculosis treatment
6. Epidermal growth factor receptor inhibitors - a type of anti-cancer medication
7. Iodides – psoriasis medications, and Tincture (brown liquid doctor puts on for butterfly stitches)
8. Bromides – example include medications for myasthenia gravis
9. Androgens – testosterone
10. Progestin-only contraceptives – over the counter birth control, minipill, Plan-B, Depo-Provera
11. Corticotropin – used in rheumatologic disorders and multiple sclerosis
12. Cyclosporin – type of steroid often used for dry eye
13. Disulfiram – old generation alcohol treatment medication
14. Psoralens – vitiligo reversal medication
15. Thiourea – anti-thyroid medications
16. Azathioprine - a transplant anti-rejection medication
17. Janus kinase inhibitors - type of myelofibrosis medication