Tretinoin Retin A

a. Prescription retinoids remain the premier agents for both inflammatory and noninflammatory acne. Tretinoin loosens and removes comedones. The agent is available in six different strengths and formulations: a cream (0.025%, 0.05%, 0.1%), a gel (0.01%, 0.025%), and liquid (0.05%).

b. Fair-skinned patients may begin by applying the 0.025% cream shortly after washing nightly. The quantity of tretinoin applied may be gradually increased as tolerated, and twice-daily applications may be appropriate. The cream is best for dry skin; the gel is best for oily skin.

c. It should be applied once a day at bedtime after washing.

d. Retin-A cream (0.025, 0.05, 0.1%) [20, 45 g]; Retin-A gel (0.01,

0.025%) [15, 45 g]; or Retin-A liquid (0.05%) [28 mL]. e. Mild redness and peeling is common. Excessive sun exposure should be avoided, and sunscreen and protective clothing should be used.

4. Adapalene (Differin) is also a topical retinoid, available as a 0.1% gel. It functions in a manner similar to that of tretinoin. Adapalene works slightly better and faster and causes less irritation than tretinoin. Apply once a day to affected areas after washing qhs.

5. Azelaic acid cream (Azelex) is indicated for the treatment of acne in patients who cannot tolerate topical tretinoin. Azelaic acid is as effective as tretinoin but with less drying side effects. The 20% cream is applied bid [30 gm].

B. Treatment of pustular acne

1. Moderate or severe inflammatory acne requires oral antibiotics in addition to topical therapy. Side effects of oral antibiotics include gastrointestinal distress and vaginal candidiasis.

2. Tetracycline a. Tetracycline is an effective and low cost oral antibiotic. Starting dosage is 250 mg qid or 500 mg bid, 1 hour before or 2 hours after meals; after 1-2 months reduce to 250 mg PO qd.

b. Antacids or dairy products can interfere with absorption; can cause dental discoloration; contraindicated in pregnancy or in children <12 years; photosensitizing.

3. Minocycline (Minocin). Highly effective because of lipid solubility and good absorption with food. The usual starting dose is 50 mg bid or 100 mg qd [50,100 mg].

4. Doxycycline. Less expensive than minocycline and is very effective. 100 mg once daily; photosensitivity, gastrointestinal distress may occur.

5. Erythromycin. Starting dosage is 250 mg qid or 500 mg bid. Propionibacterium acnes bacteria are more resistant to erythromycin than tetracycline; gastrointestinal side effects.

6. Topical Antibiotics. Propionibacterium acnes is often resistant to topical antibiotics. Clindamycin is available in 1% solution, lotion or gel (Cleocin-T) for bid application.

7. Hormone therapy a. In women desiring birth control, an oral contraceptive may mitigate the inflammatory component of acne.

b. The newer progestins (desogestrel, norgestimate, gestodene) offer exceptional benefits. Ortho Tri-Cyclen and Ortho-Cyclen have an approved indication for moderate acne.

c. The aldosterone antagonist spironolactone (Aldactone) may provide significant relief for women with hormonal imbalances. At low doses (50 mg/day) it may reduce premenstrual flares.

8. Isotretinoin (Accutane)

a. Isotretinoin is the most potent agent available for treating acne. It decreases sebum production and reverses abnormal epithelial desquamation. Usage is restricted to acne that has not responded to other agents.

b. Teratogenicity. Isotretinoin has the potential to cause severe fetal malformations; therefore, pregnancy must be excluded and contraception is mandatory.

c. Initial dose. 0.5-1.0 mg/kg, or 40-80 mg/day [10,20,40 mg]. Response rate is 90%.

References: See page 195.

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