Treatment of Acne 3

B. Comedonal Acne

Treatment of acne is based on the type and severity of lesions. Comedones require treatment different from that of pustules and cystic lesions. In assessing severity, one must also take the sequelae of the lesions into account. Therefore, one must treat an individual who gets only two new lesions per month that scar or leave postinflammatory hyperpigmentation much more aggressively than a comparable patient whose lesions clear without sequelae. Soaps play little role in acne treatment, and unless the patient's skin is exceptionally oily, a mild soap should be used to avoid irritation that will limit the usefulness of other topicals, all of which are themselves somewhat irritating.

1. Topical retinoids —

Tretinoin is very effective for comedonal acne or for treatment of the comedonal component of more severe acne, but its usefulness is limited by irritation. Start with 0.025% cream (not gel) and have the patient use it at first twice weekly at night, then build up to as often as nightly. A few patients cannot use even this low-strength preparation more than three times weekly, but even that may cause improvement. A pea-sized amount is sufficient to cover half the entire face. To avoid irritation, have the patient wait 20 minutes after washing to apply. Adapalene gel 0.1% and reformulated tretinoin (Renova, Retin A Micro, Avita) are other options for patients irritated by standard tretinoin preparations. Some patients — especially teenagers — do best on 0.01% gel. Although the absorption of tretinoin is minimal, its use during pregnancy is contraindicated. Some patients report photosensitivity with tretinoin. Patients should be warned that they may flare in the first 4 weeks of treatment. Tazarotene gel (0.05% or 0.1%) (Tazorac), a topical retinoid approved for treatment of psoriasis and acne, may also be effective.

2. Benzoyl peroxide —

Benzoyl peroxide products are available in concentrations of 2.5%, 4%, 5%, 8%, and 10%, but it appears that 2.5% is as effective as 10% and less irritating. In general, water-based and not alcohol-based gels should be used to decrease irritation.

3. Antibiotics —

Use of topical antibiotics (see below) has been demonstrated to decrease comedonal lesions.

4. Comedo extraction —

Open and closed comedones may be removed with a comedo extractor but will recur if not prevented by treatment.