SKINIPEDIA - Skin Encyclopedia: Acne Vulgaris Medication
Acne Vulgaris by James Fulton Jr, MD, PhD,
ACNE TREATMENT: Medication
The goals of pharmacotherapy for acne vulgaris are to reduce morbidity and to prevent complications.
Retinoids
These agents decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and they may reduce the potential for malignant degeneration. They also modulate keratinocyte differentiation.
Isotretinoin (Accutane)
Most effective oral medication. Oral agent that treats serious dermatologic conditions. Isotretinoin is synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Decreases sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
An FDA-mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy. Female patients must sign an informed consent that they will use contraceptives during the treatment course and for 30 d after discontinuing therapy.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
Total cumulative dose of 120-150 mg/kg recommended; starting dose should be <0.5 mg/kg/d PO; dose may be increased to 1 mg/kg/d as tolerated
Pediatric
Not established
* Dosing
* Interactions
* Contraindications
* Precautions
Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Obtain 2 negative pregnancy test results in patients of childbearing potential prior to initiating therapy; pregnancy must be avoided during and for 1 mo after treatment, and monthly pregnancy test results must be documented; hyperlipidemia may develop; pseudotumor cerebri, vision impairment, headaches, myalgias, arthralgias, and depression have been reported; dry skin and cheilitis are nearly universal adverse effects.
Tretinoin (Retin-A, Retin-A Micro, Avita)
Inhibits microcomedo formation. Normalizes follicular epidermal differentiation and exhibits anti-inflammatory properties. Available as 0.01% and 0.025% gels. Cream formulas are avoided with acne patients because some ingredients may be comedogenic.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
Begin with lowest tretinoin formulation and increase as tolerated; apply hs or qod; lower frequency of application if irritation develops
Pediatric
<12 years: Not established
>12 years: Apply as in adults
* Dosing
* Interactions
* Contraindications
* Precautions
Coadministration with benzoyl peroxide may increase irritation; begin with 2 therapies slowly, such as qod
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with excessive sunlight exposure; erythema and peeling may occur (most prominent within first few wk of treatment)
Adapalene (Differin)
A naphthoic acid derivative that binds the retinoic acid receptor. Normalizes follicular epidermal differentiation and exhibits anti-inflammatory properties. Available in cream, gel, solution, and pledget formulations.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
Apply a small amount to involved skin qd
Pediatric
Not established
* Dosing
* Interactions
* Contraindications
* Precautions
None reported
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Erythema and peeling may occur in some individuals; avoid contact with mucous membranes, eyes, mouth, and nostrils; avoid exposure to sunlight and sunlamps; dryness of skin, scaling, erythema, burning, and pruritus may occur
Tazarotene (Tazorac, AVAGE)
Retinoid prodrug whose active metabolite modulates differentiation and proliferation of epithelial tissue; may also have anti-inflammatory and immunomodulatory properties. Available in 0.05% and 0.1% cream and gel formulations.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
Apply sparingly to affected area qd
Pediatric
Children: Not established
Adolescents: Administer as in adults
* Dosing
* Interactions
* Contraindications
* Precautions
Use cautiously with dermatologic drugs or cosmetics that have a strong drying effect on the skin (eg, salicylic acid, benzoyl peroxide, astringents)
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Erythema and peeling may occur at application site
Antibiotics
Topical and systemic antibiotics used in the treatment of acne vulgaris are directed at P acnes. They also have anti-inflammatory properties.
Minocycline (Dynacin, Minocin)
Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible chlamydial, rickettsial, and mycoplasmal organisms. Available in 50-, 75-, and 100-mg preparations.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
50-100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h
* Dosing
* Interactions
* Contraindications
* Precautions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity; severe hepatic dysfunction
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Antibacterial agent effective against gram-positive and gram-negative organisms. Available in 20-, 50-, and 100-mg preparations.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d
* Dosing
* Interactions
* Contraindications
* Precautions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity; severe hepatic dysfunction
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Tetracycline (Sumycin)
Antibacterial agent effective against gram-positive and gram-negative organisms.
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO divided qid
* Dosing
* Interactions
* Contraindications
* Precautions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
* Dosing
* Interactions
* Contraindications
* Precautions
Documented hypersensitivity
* Dosing
* Interactions
* Contraindications
* Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Antibiotic with activity against many gram-positive and gram-negative organisms. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Available as 80 mg trimethoprim and 400 mg sulfamethoxazole or as 160 mg trimethoprim and 800 mg sulfamethoxazole (double strength).
* Dosing
* Interactions
* Contraindications
* Precautions
Adult
160 mg TMP/800 mg SMZ PO q12h
Pediatric
8 mg/kg/d TMP/40 mg/kg/d SMZ PO/IV divided q12h