Acne
Differential diagnosis
Differential diagnosis
- Drug-induced acne
- Tropical acne - Extreme heat
- Acne aestivalis (Mallorca acne) - Sun exposure
- Rosacea - Late age onset, erythema, talengiectasia, papules, pustules, no comedones
- Periorificial dermatitis - Around mouth, nose or eyes sparing vermilion border
- Pseudo/Folliculitis, no comedones
- Keratosis pilaris - Follicular prominence and roughness (usually on arms, but may resemble acne on cheeks)
- Favre-Racouchot syndrome - Comedones on cheek due to sun damage
Treatment
Treatment
Comedonal
Comedonal
- Topical retinoids gel/cream (Tretinoin 0.025%, Adapalene 0.1%, Tazarotene 0.1%)
- Benzoyl peroxide (BPO) 2.5% or 5% gel or Azelaic acid (AA) 20% cream (possible better tolerability than BPO)
Mild-moderate papulopustular
Mild-moderate papulopustular
- Topical Retinoid + BPO or Topical Abx + BPO
- Adapalene 0.1% and BPO 2.5% (Tactupump)
- Clindamycin 1% and BPO 5%
- Treat with all three topicals (Retinoid, BPO, Abx) if no response x 3 months
- Combined OCP or systemic antibiotics
- High estrogen (ethinyl estradiol) concentration associated with decrease in inflammatory lesions
- Tetracycline (eg. doxycycline 100mg PO BID or daily x 3-4 months)
- Risk in pregnancy or <9yo (teeth discoloration/bone growth)
- Side effects: GI, photosensitivity
Severe papulopustular
Severe papulopustular
- Oral isotretinoin (pregnancy-prevention measures due to teratogenicity)
- 0.5-1mg/kg daily divided BID for 15-20 weeks or
- 0.5mg/kg daily divided BID for 1 month, then 1mg/kg/day divided BID, until a cumulative dose of 120-150 mg/kg
- Consider lower dose 20mg every alternate day or 0.25-0.4mg/kg/day for moderate
- Consider monitoring labs
- Fasting lipid and LFTs at 4 weeks and 8 weeks, and then stop if normal
Other
- Oral zinc has been shown to have effect against inflammatory lesions
- Diet: Some evidence for low glycemic index diet, lack of evidence concerning dairy consumption
- Chemical peels have minimal evidence but are safe and inexpensive
References:
- Asai Y, Baibergenova A, Dutil M, Humphrey S, Hull P, Lynde C, Poulin Y, Shear NH, Tan J, Toole J, Zip C. Management of acne: Canadian clinical practice guideline. CMAJ. 2016 Feb 2;188(2):118-26. doi: 10.1503/cmaj.140665. Epub 2015 Nov 16. http://www.cmaj.ca/content/188/2/118.full.pdf
- European Evidence-based (S3) Guideline for the Treatment of Acne (Update 2016). http://www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne