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Seventy patients with grade 3 and 4 acne according to the US FDA global score were included in the study between October and December These patients were treated with a combination of low-dose isotretinoin 0.
Response to treatment was assessed at monthly intervals and was recorded as a percentage decrease in overall severity of disease. Treatment was continued to complete clearance of lesions or to 16 weeks, whichever came later. Results: Sixty-two Take Time to Talk Prior to acne treatment, time must be spent with the patient to fully explain the disease, the typical course of treatment, the possible side effects and the need for patience. This is critical for compliance, especially in young patients.
However, you must point out that there is a risk that sun exposure can make acne worse in some patients. Sometimes a few spots are very important to the patient. The aggressiveness of the treatment should be based not only on the severity of the acne, but also on the psychological impact of the disease. Do not reject cosmetics because in many cases cosmetics are essential for the successful treatment of acne in that they maximize compliance.
Topical cosmetics, especially non-comedogenic and non-greasy make-up, can be effectively used to cover irritant dermatitis or flare ups after treatment with retinoids. There are also many prescription products available to treat acne patients. Katsambas, tetracycline and erythromycin should be given at 1 gram per day for 4 to 6 months. Instruct patients to take tetracycline and erythromycin at least a half an hour before a meal.
Also, patients taking tetracycline should avoid the sun. Minocycline Dynacin, Minocin and doxycycline Monodox, Vibramycin, Adoxa should be given at mg per day for 4 to 6 months. Administer isotretinoin Accutane, Amnesteem, Claravis, Sotret for 4 to 8 months, at a minimum cumulative dose not less than mg per kilogram of weight, or there will be a high possibility of relapse.
If relapse occurs, repeat treatment with a proper dose. Combining tetracycline and isotretinoin can cause headaches and dizziness pseudotumor cerebri. Topicals must be applied to the entire area and not just on acne spots. Otherwise, treatment will fail. Also, topical retinoids work best on dry skin.
Warn patients that benzoyl peroxide will bleach clothing. If this is the case, then switch to either minocycline or isotretinoin. Double the dose of the antibiotic to mg per day of minocycline or mg a day of doxycycline. Consider switching to isotretinoin or, in women, consider administering estrogens and antiandrogens that minimize the sebum excretion rate. In all cases, you must extend treatment well beyond what constitutes a normal course of treatment, because ending treatment too soon will cause a relapse.
Gram-negative folliculitis is a rare phenomenon that typically occurs in patients doing well with antibiotic treatment who suddenly deteriorate and develop pustules. Also, a recent study in the Journal of the American Medical Association showed evidence of link between antibiotics and an increased risk of breast cancer. Researchers concluded that the more antibiotics the women in the study used, the higher their risk for breast cancer. The study showed that women who took antibiotics for more than days or who had more than 25 prescriptions over an average of 17 years had more than twice the risk of breast cancer as women who had not taken any antibiotics.
The risk was smaller for women who took antibiotics for fewer days. For patients with many microcomedones and microcysts, isotretinoin is much less effective. For these patients, excise or cauterize the microcomedones and microcysts under topical anesthesia — then resume isotretinoin. According to Dr.
Katsambas, the most important reason for failure of isotretinoin treatment in women is endocrine problems, women suffering with polycystic ovarian syndrome or late onset of adrenal hyperplasia. If acne returns in these patients, test for hyperandrogenism, especially in female acne patients with irregular menses, hirsutism, sicca syndrome, seborrhea, acne, hirsutism or thinning hair. To manage this, Dr. Katsambas recommends oral estrogens alone or in combination with anti-androgens given with, or just after, isotretinoin treatment.
For teenage patients who relapse after isotretinoin, repeat the treatment. You can repeat treatment with isotretinoin as many as four times without any problem. Almost every patient suffers some level of the common side effects of isotretinoin, including dermatitis and dry or cracked lips.
Patients should use an emollient and lip balm and in severe cases, hydrocortisone cream for a very short period of time. Sometimes, Staphylococcus aureus boils occur, which can be treated with erythromycin. Severe joint and muscle pain can also occur with isotretinoin. If this occurs, lower the dose or discontinue isotretinoin, depending upon the severity of the pain. A rare but real side effect of isotretinoin is mild depression.
Isotretinoin-induced depression occurs almost immediately after starting the drug. If the depression is a result of the medication and not incidental to the general state of mind of the patient, then discontinue isotretinoin immediately and have the patient seek psychiatric treatment. Or, use a less irritating topical retinoid like adapalene Differin and isotretinoin gel.
Adapalene gel 0. If dealing with an extreme acne flare, a single cortisone injection will reduce the symptoms. Problems with Minocycline Minocycline can cause benign intracranial hypertension, causing dizziness and headache pseudotumor cerebri. If this should occur, lower the dose or to switch to doxycycline.
Minocycline can also cause hyper-pigmentation, which, though rare, can last for many months or even years. You can see minocycline brown patches or even darkening of the nails. If this occurs, discontinue minocycline immediately because there is no treatment. Its mechanism of action is believed to involve reduction in the amount of sebum produced by sebaceous glands on the skin's surface.
Erythromycin is a bacteriostatic macrolide antibiotic used to treat bacterial infections, including the inhibition of bacteria linked with acne, such Cutibacterium acnes. The mechanism of action is poorly understood.
Most side effects affect the skin and have only a local effect to the place of application. Some of the side effects are related to vitamin A toxicity. From Wikipedia, the free encyclopedia. Topical gel.
According to Andreas Katsambas, professor and chairman of the department of dermatology at the University of Athens in Greece, there are a number of reasons for this, some having to do with the physician, some with the treatment and some with the patient. The Role of Dermatologists According to Dr. There are many dermatologists who still insist on diet restrictions, forbidding patients to eat things like chocolate or sweets.
Some use unnecessary methods like ultraviolet light, massage, etc. Dermatologists must do more to keep up with the latest developments. Often the least effective dermatologist in treating acne is the well-trained, experienced, but busy, dermatologist. There are also some dermatologists who are often too concerned about and who exaggerate side effects, instead of simply and properly explaining them. Fearing side effects, a dermatologist may use too low a dose, making the treatment ineffective.
Take Time to Talk Prior to acne treatment, time must be spent with the patient to fully explain the disease, the typical course of treatment, the possible side effects and the need for patience.
This is critical for compliance, especially in young patients. However, you must point out that there is a risk that sun exposure can make acne worse in some patients. Sometimes a few spots are very important to the patient. The aggressiveness of the treatment should be based not only on the severity of the acne, but also on the psychological impact of the disease.
Do not reject cosmetics because in many cases cosmetics are essential for the successful treatment of acne in that they maximize compliance. Topical cosmetics, especially non-comedogenic and non-greasy make-up, can be effectively used to cover irritant dermatitis or flare ups after treatment with retinoids.
There are also many prescription products available to treat acne patients. Katsambas, tetracycline and erythromycin should be given at 1 gram per day for 4 to 6 months. Instruct patients to take tetracycline and erythromycin at least a half an hour before a meal. Also, patients taking tetracycline should avoid the sun. Minocycline Dynacin, Minocin and doxycycline Monodox, Vibramycin, Adoxa should be given at mg per day for 4 to 6 months.
Administer isotretinoin Accutane, Amnesteem, Claravis, Sotret for 4 to 8 months, at a minimum cumulative dose not less than mg per kilogram of weight, or there will be a high possibility of relapse. If relapse occurs, repeat treatment with a proper dose.
Combining tetracycline and isotretinoin can cause headaches and dizziness pseudotumor cerebri. Topicals must be applied to the entire area and not just on acne spots. Otherwise, treatment will fail. Also, topical retinoids work best on dry skin. Warn patients that benzoyl peroxide will bleach clothing. If this is the case, then switch to either minocycline or isotretinoin. Double the dose of the antibiotic to mg per day of minocycline or mg a day of doxycycline.
Consider switching to isotretinoin or, in women, consider administering estrogens and antiandrogens that minimize the sebum excretion rate. In all cases, you must extend treatment well beyond what constitutes a normal course of treatment, because ending treatment too soon will cause a relapse. Gram-negative folliculitis is a rare phenomenon that typically occurs in patients doing well with antibiotic treatment who suddenly deteriorate and develop pustules.
Also, a recent study in the Journal of the American Medical Association showed evidence of link between antibiotics and an increased risk of breast cancer. Researchers concluded that the more antibiotics the women in the study used, the higher their risk for breast cancer. The study showed that women who took antibiotics for more than days or who had more than 25 prescriptions over an average of 17 years had more than twice the risk of breast cancer as women who had not taken any antibiotics.
The risk was smaller for women who took antibiotics for fewer days. For patients with many microcomedones and microcysts, isotretinoin is much less effective. For these patients, excise or cauterize the microcomedones and microcysts under topical anesthesia — then resume isotretinoin.
According to Dr. Katsambas, the most important reason for failure of isotretinoin treatment in women is endocrine problems, women suffering with polycystic ovarian syndrome or late onset of adrenal hyperplasia. If acne returns in these patients, test for hyperandrogenism, especially in female acne patients with irregular menses, hirsutism, sicca syndrome, seborrhea, acne, hirsutism or thinning hair.
To manage this, Dr. Katsambas recommends oral estrogens alone or in combination with anti-androgens given with, or just after, isotretinoin treatment. For teenage patients who relapse after isotretinoin, repeat the treatment. You can repeat treatment with isotretinoin as many as four times without any problem. Almost every patient suffers some level of the common side effects of isotretinoin, including dermatitis and dry or cracked lips.
Patients should use an emollient and lip balm and in severe cases, hydrocortisone cream for a very short period of time. Sometimes, Staphylococcus aureus boils occur, which can be treated with erythromycin. Severe joint and muscle pain can also occur with isotretinoin. If this occurs, lower the dose or discontinue isotretinoin, depending upon the severity of the pain. A rare but real side effect of isotretinoin is mild depression. Isotretinoin-induced depression occurs almost immediately after starting the drug.
If the depression is a result of the medication and not incidental to the general state of mind of the patient, then discontinue isotretinoin immediately and have the patient seek psychiatric treatment.
Or, use a less irritating topical retinoid like adapalene Differin and isotretinoin gel. Adapalene gel 0. If dealing with an extreme acne flare, a single cortisone injection will reduce the symptoms.
Problems with Minocycline Minocycline can cause benign intracranial hypertension, causing dizziness and headache pseudotumor cerebri. If this should occur, lower the dose or to switch to doxycycline. Minocycline can also cause hyper-pigmentation, which, though rare, can last for many months or even years. You can see minocycline brown patches or even darkening of the nails. If this occurs, discontinue minocycline immediately because there is no treatment.
Minocycline has also been associated with a rare occurrence of lupus-like symptoms. Acne Variants and Cystic Acne A poor response can occur in patients with acne variants and cystic acne, like pyoderma faciale, acne fulminans or cystic acne. Pyoderma faciale occurs in women 25 to 40 years of age who suddenly develop devastating acne-like symptoms.
Katsambas recommends isotretinoin 1 mg per day. For acne fulminans, which occurs primarily in men and appears suddenly as severe acne primarily on the trunk often with fever and polyarthropathy, treat with erythromycin, isotretinoin and prednisone at 40 mg a day.
Cystic acne can respond poorly to treatment, especially with whiteheads behind the ear or inflamed cysts. You must extract these whiteheads with light cautery under topical anesthesia. If the patient has cysts, administer isotretinoin 1 mg per day and intralesional therapy with steroids. For older cysts more than 3 weeksyou should remove with liquid nitrogen. Patient-Related Problems Sometimes a poor response to treatment is directly related to the state of mind of the patient.
You can have cases of acne excoriee — acne caused by the patient. It is most common in women, and occurs when they scratch. If you must treat the acne, use only a systemic treatment, or even isotretinoin. For some of these patients, no treatment outcome is satisfactory. For these patients, set realistic expectations and use an aggressive systemic treatment, such as isotretinoin, even for minimal acne.
Making Treatment Work Despite the problems that can occur, a proper response can almost always result in improvement for the patient. With the wide variety of treatment options, a little patience and a willingness to try other methods if one fails can go a long way toward achieving a satisfactory result.
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Erythromycin/isotretinoin (trade name Isotrexin) is a topical gel with two active ingredients: erythromycin 2% w/w and isotretinoin % w/w with a primary. Such flares can be avoided or controlled by overlapping the initiation of isotretinoin therapy with oral erythromycin for up to 2 months. A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and. Do not take any extra medication that may interact with Accutane. you are taking Accutane Other antibiotics such as Penicillin, Erythromycin, Bactrim. Interactions between your drugs . Email Address.Background: The conventionally used dose of isotretinoin in acne causes significant dose-related adverse effects. Low-dose isotretinoin has been used successfully in mild to moderate papulopustular acne. Although isotretinoin acts against all mechanisms of acne formation, it has no significant direct antimicrobial effect. Objective: To test whether the addition of an antibacterial enables use of isotretinoin in low doses even in moderate to severe acne.
Methods: This was a preliminary open-label, prospective, non-comparative, single-centre study carried out in a tertiary-care referral hospital. Seventy patients with grade 3 and 4 acne according to the US FDA global score were included in the study between October and December These patients were treated with a combination of low-dose isotretinoin 0. Response to treatment was assessed at monthly intervals and was recorded as a percentage decrease in overall severity of disease.
Treatment was continued to complete clearance of lesions or to 16 weeks, whichever came later. Results: Sixty-two The mean total cumulative dose of isotretinoin was Seven Fifty-three adverse effects were observed. Three patients had initial aggravation of disease that was managed with prednisolone and disappeared with continuation of treatment.
Conclusion: A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and low post-treatment relapse rates.
Abstract Background: The conventionally used dose of isotretinoin in acne causes significant dose-related adverse effects. Publication types Clinical Trial.
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