MANAGEMENT OF ACNE

By: Dr. YATIN SETHI

 JR1 Dermatology
MANAGEMENT OF ACNE
AIMS OF MANAGEMENT :

•ALLEVIATE SYMPTOMS
•CLEAR EXISTING LESIONS
•LIMIT DISEASE ACTIVITY BY
PREVENTING NEW LESIONS FORMING AS
WELL AS SCARS DEVELOPING
•AVOID NEGATIVE EFFECT ON QUALITY
OF LIFE.
 GENERAL PRINCIPLES OF
ACNE MANAGEMENT

•Patients should be reassured that effective treatments

are available but should be informed that response is
slow and resolution is directly linked to good adherence
•Therapy is largely determined by the severity and
extent of the disease but should be tempered by other
factors such as duration, response to previous
treatments, predisposition, to scarring, post
inflammatory erythema and pigmentation
Indications for topical therapy include mild acne ,
moderate acne, severe acne.

MILD ACNE consist of :

1. Comedonal
2. papular/pustular
 MODERATE ACNE consist of :
1. Papular/pustular
2. Nodular
 SEVERE ACNE consist of :
1. Nodular/conglobate
Treatment algorithm for comedonal
acne.
 Treatment of Comedonal acne:
1. Topical retinoids :
• All trans retinoic acid is available in 0.01 up to 0.05%
concentrations as either gel or cream.
• Iso tretinoin gel is a second generation retinoid.
• The third generation retinoid, adaplene 0.1% cream or gel , has
significant and rapid anti-inflammatory action and has a greater
benefit risk ratio that tretinoin
• Retinoid reduce abnormal growth and development of
keratinocytes within the pilosebaceous duct.
• The reversal of hypercornification within the follicular canal as
well as the induction of follicular epithelium helps to unplug the
follicle.
• This also inhibits the development of microcomedo and non-
inflamed lesions resulting in less anaerobic conditions for fewer
p.acnes
• Hence topical retinoids are recommended for comedonal acne.
2. Benzoyl peroxide :

•BPO is currently available in number of different

formulations and concentrations (2.5%, 5%, 10%) ,
some of which are available over the counter.
•BPO is a powerful anti- microbial and rapidly destroys
both surface and ductal p.acnes and yeasts.
•Once applied to the skin, it decomposes in the
sebaceous follicles to release free oxygen radicles with
potent bactericidal and anti-inflammatory activity
•Topical BPO has been noted to be superior to placebo
and topical antibiotics( clindamycin and erythromycin)
and equivalent to adaplene for the treatment of
comedonal acne.
3. Topical antibiotics:

•Topical clindamycin has been shown to be superior to

placevo when compared to vehicle for comedones but
inferior to tretinoin.
•BPO has been shown to be superior to all topic
antibiotics when used as a monotherapy for treating
comedonal lesions topical antibiotics as monotherapy are
not advocated for the teratement of comedones as there
are superior therapies avaialble.
4. Fixed combination therapy:
•Fixed combination clindamycin – BPO is equivalent to
BPO alone and superior to clindamycin alone for the
treatment of comedonal acne.
•Fixed dose adaplene- BPO is superior or equivalent to
BPO and adaplene alone for the treatment of
comedoneal acne.
•A fixed combination clindamycin- tretinoin recently
introduced has shown superior efficacy to its
component monotherapies with respect to comedonal
acnes.
 5. Azelaic acid
•Azelaic acid reduces comedones by normalising the
disturbed terminal differentiation of keratinocytes in
the follicle infundibulum; 20% azelaic acid cream has
shown superiority to placebo in the treatment of
comedonal acne.
Treatment algorithm for mild to
moderate papulo-pustular acne
 Treatment of mild to moderate
papulopustular acne

1. Topical retinoids :
• All topical retinoids were found to be superior to placebo or
vehclie in the treatment of papulo-pustular acne.
• The efficacy of adapelene was found to be equivalent to
BPO and tretinoin for the treatment of inflammatory lesions
• Tazarotene has been noted to be superior to vehicle for
inflammatory lesions and superior to or equivalent to
adapalene and tretinoin for the treatment of inflammatory
lesions.
 2. Benzoyl peroxide
•BPO is more effcacious than vehicle in the treatment of
papulo-pustular acne.
•It is equivalent to adapalene and conflicting evidence
exists regarding its equivalence to tretinoin for the
treatment of inflammatory lesions.
 3. Topical antibiotics

•Topical antibiotics demonstrate superior efficacy

compared to placebo in the management of
inflammatory acne.
•However, their use as monotherapy in acne is not
advocated due to risk of emerging bacterial resistance.
•BPO emerged as a successful treatment and appeared
similar in effectiveness to topical erythromycin and
clindamycin.
 Fixed dose combination topical therapy

 Fixed dose clindamycin - BPO is more efficacious than

BPO alone for papulopustular acne.
 Both clindamycin–BPO and adapalene–BPO are superior
to adapalene monotherapy and have been shown to be
equivalent in efficacy for the treatment of papulopustular
acne
 Fixed‐dose clindamycin–tretinoin gel is efficacious for
inflammatory acne and superior to vehicle, topical 1.2%
clindamycin and topical tretinoin 0.025% alone.
 There is also some evidence to suggest that clindamycin–
tretinoin gel is superior to once‐nightly 0.025% tretinoin
gel.
 5. Azelaic acid

•Azelaic acid (1 : 2 heptanedicarboxylic acid) is available

as a 20% cream for acne.
•In mild to moderate papulopustular acne, the studies would
suggest that 20% azelaic acid has equivalent efficacy to 5%
BPO, 0.05% tretinoin, adapalene and 2% topical
erythromycin at 5–6 months but inferior efficacy to
systemic tetracycline.
 Hormonal therapy in papulo-
pustular acne
Systemic hormone preparations are available for acne in female
patients. Indications for use include the following:

1. Failed standard antibiotic/combination regimens.

2. Menstrual control and/or contraception required alongside
acne therapy.
3. When oral isotretinoin is inappropriate or not available.

•Topical therapy can be prescribed in conjunction with hormonal regimens.

Potential hormonal treatments for acne include inhibitors of androgen
production by the ovary (oral contraceptives) or adrenal gland (low ‐dose
corticosteroids), androgen receptor blockers, and antiandrogens that block
the effect of androgens on the sebaceous gland.
1.Oestrogens and progestins
•COCs generally contain oestrogen (most commonly ethinyl
oestradiol) and a progestin. Oestrogens increase the
synthesis of sex hormone binding globulin (SHBG) leading
to increased binding of testosterone and reduced levels of
free circulating testosterone. Hence all oral contraceptives
potentially improve acne.
•In addition, oral contraceptives suppress ovulation by
inhibiting the production of ovarian androgens which results
in reduced serum androgens and lower sebum production.
•Drosperinone is a novel progestin derived from 17α‐
spironolactone and has antiandrogenic activity, making it
potentially helpful in acne.
2. Androgen receptor blocker

•Androgen receptor blockers suppress sebum so offer potenti

for the treatment of acne.
•Co‐cyprindiol (Dianette and Estelle‐35) is an oral
contraceptive that ameliorates acne.
3. Spironolactone in acne
•Spironolactone is reported in the literature as an effective
treatment for acne. It is usually prescribed at a dose of 50–10
mg daily with meals, but many women with sporadic
outbreaks do well with doses as low as 25 mg daily
Treatment algorithm for severe acne.
Treatment of severe acne

•Clinical evidence for the treatment of severe acne is

limited.
•Oral isotretinoin is regarded as the treatment of choice for
severe acne.
•However, if contraindicated or not acceptable, topical
adapalene or fixed‐dose BPO–adapalene may be used in
combination with systemic antibiotics with the best
evidence in support of doxycycline
1. Systemic antibiotics

•A combination of systemic antibiotic combined with BPO with

or without adapalene has been given a medium strength
recommendation for severe acne.

2. Hormonal therapy
Ethinyloestradiol/CPA is officially indicated for the
treatment of severe acne unresponsive to systemic antibiotics .

3. Oral isotretinoin

Oral isotretinoin (13‐cis‐retinoic acid) is a synthetic vitamin A analogue which was

first approved by the US Food and Drug administration (FDA) in 1982 for the
treatment of severe recalcitrant acne. Isotretinoin remains the most clinically effective
acne therapy, producing long‐term remission or significant improvement in many
patients. It is licensed for the treatment of severe acne that has failed to respond to
conventional antibiotic therapies.
Other therapies for acne:
1. Topical nicotinamide
• Topical nicotinamide 4% has anti‐inflammatory
actions and does not induce P. acnes resistance.
Double‐blind studies have shown it to be better than
vehicle alone against inflamed lesions, although the
improvement with the placebo was also considerable
•A comparison of 4% nicotinamide gel demonstrated
it to be similar in efficiency to 1% clindamycin gel.
•Salicylic acid 2% has been shown to be more effective in
reducing non‐inflammatory and inflammatory acne lesions than
alcoholic vehicle at 12 weeks in an RCT
3. Sulphur
•A longstanding antiacne therapy, which may be both
comedogenic and comedolytic , sulphur is unpopular because of
its smell, and is rarely used.
4. Corticosteroids
•A few topical preparations contain weak corticosteroids but
proof of their efficacy is lacking. Potent steroids such as
clobetasol propionate applied twice a day for 5 days can
dramatically reduce the inflammation in an active inflammatory
nodule.
DEVICES AND PHYSICAL MODALITIES FOR
TREATING ACNE:

•There are a variety of specially shaped tools available for

blackhead macrocomedo removal
•Light cautery or hyfrecation has been shown to help
patients with multiple macrocomedones; these are usually
whiteheads but occasionally blackheads (up to 1.5 mm
diameter)
•A topical anaesthetic preparation is applied beneath an
occlusive dressing. The cautery or hyfrecation should be
set as low as possible to produce little or no pain. The aim
is to produce very low‐grade thermal damage.
•The treatment of each lesion takes seconds and is
associated with very little scarring or post‐inflammatory
pigmentation. This therapy is more effective than topical
tretinoin for macrocomedones

Comedo
extracter
Lasers and photodynamic therapy:

•There has been increased interest in the use of lasers and

light‐based devices for acne over the last few years.
•Light therapy destroys propionibacteria by targeting
porphyrins produced by these bacteria.
Chemical peels :
•Chemical peels are believed to promote desquamation which
reduces corneocyte cohesion and keratinocyte plugging, so
enabling the extrusion of inflammatory contents. Peeling
agents include α‐hydroxy acids (glycolic acid), salicylic acid
and trichloroacetic acid.
THANKYOU LISTENERS