Acne - treatment, complications, prognosis and prevention

The mainstays of treatment of acne are topical keratolytic agents and topical antibiotics. Creams, lotions, gels, foams, and solutions are available. Gels and solutions are commonly used because acne skin is generally greasier and these agents tend to be drying, but they have the tendency to be irritating and may not be as well tolerated. Creams and lotions are better tolerated but may not be as effective. The keratolytic agents (salicylic acid, azelaic acid, tretinoin, adapalene, tazarotene) produce superficial desquamation and, subsequently, relieve follicular obstruction. They are a mainstay of first-line therapy. The topical retinoids (tretinoin, adapalene, tazarotene) are based on the vitamin A molecule. They decrease keratin and sebum production and have some anti-inflammatory and antibacterial activity; thus they can be the most effective when used as monotherapy. Topical antimicrobials (benzoyl peroxide, dapsone, sulfur- sulfacetamide) and topical antibiotics (erythromycin, clindamycin) are anti-inflammatory and inhibit P. acnes proliferation. Erythromycin efficacy has decreased as P. acnes has become increasingly resistant to this antibiotic; topical antibiotics should be combined with an antimicrobial such as benzoyl peroxide to prevent the development of resistance. Combination therapy of a topical keratolytic agent and a topical antimicrobial is more effective than either agent alone for inflammatory acne. Oral antibiotics (tetracycline, doxycycline, minocycline) are typically used for deeper cystic lesions but should always be used in combination with a topical regimen. Tetracyclines are the most effective antibiotics because of their significant anti-inflammatory activity. As with topical erythromycin, oral erythromycin is rarely used because of bacterial resistance. For recalcitrant or severe nodulocystic acne, oral isotretinoin may be instituted. Isotretinoin, an oral analog of vitamin A, normalizes follicular keratinization, reduces sebum production, and decreases 5α-dihydrotestosterone formation and androgen receptor–binding capacity. A course of isotretinoin (0.5 to 1 mg/kg/day to reach a cumulative dose of 120 mg/kg) is the only medication that can permanently alter the course of acne
and induce a durable remission. Because of the high incidence of adverse effects, it should be used only by physicians familiar with this medication. Isotretinoin therapy requires careful patient selection, pretreatment counseling, and monthly laboratory monitoring. It is teratogenic and must not be used immediately before or during pregnancy.
Complications:  Acne has significant and frequently devastating effects on an adolescent’s body image and self-esteem. There may be little correlation between severity and psychosocial impact. Scarring may result in permanent morbidity.
Prognosis: Classically, acne lasts 3 to 5 years, although some individuals may have disease for 15 to 20 years. Only early treatment with isotretinoin may alter the natural course of acne. Acne lesions often heal with temporary postinflammatory erythema and hyperpigmentation. Depending on the severity, chronicity, and depth of involvement, pitted, atrophic, or hypertrophic scars may develop. Cystic acne has the highest incidence of scarring because rupture of a deep cyst induces the greatest
inflammation, though scarring may be caused by milder pustular or even comedonal acne.
Prevention:  Greasy hair and cosmetic preparations should be avoided because they exacerbate preexisting acne. There are no effective means for preventing acne, and there is little evidence that diet is associated with acne. Repetitive cleansing with soap and water or use of astringents or abrasives removes only surface lipids. Their use makes the skin appear less oily but does not prevent formation of microcomedones and may paradoxically worsen acne.