Acne Vulgaris: Management

Acne Grading - Severity Score Showdown

• Classification by Predominant Lesion:
  • Comedonal: Non-inflammatory.
  • Papulopustular: Inflammatory.
  • Nodulocystic: Severe inflammatory, scarring.
• Severity (Investigator's Global Assessment - IGA):
  • Mild (IGA Grade 2): Few comedones/papulopustules. No nodules.
  • Moderate (IGA Grade 3): Many comedones/papulopustules. Few (<5) nodules.
  • Severe (IGA Grade 4): Extensive papulopustules/nodules (≥5). Scarring.

⭐ Acne conglobata, a severe form, is part of the follicular occlusion tetrad (with hidradenitis suppurativa, dissecting cellulitis, pilonidal sinus).

Topical Treatments - Pimple Patrol Power

• Retinoids (Adapalene 0.1%, 0.3%; Tretinoin): MOA: Comedolytic, anti-inflammatory. SE: Irritation, photosensitivity.

  ⭐ Topical retinoids are comedolytic and anti-inflammatory, forming the cornerstone of acne therapy for both treatment and maintenance.

• BPO (2.5%, 5%, 10%): MOA: Antibacterial (no resistance!), keratolytic. SE: Irritation, bleaching (fabric/hair).
• Topical Antibiotics (Clindamycin 1%): MOA: ↓P. acnes, anti-inflammatory. 📌 Combine with BPO (↓resistance); avoid monotherapy.
• Azelaic Acid (15%, 20%): MOA: Antibacterial, comedolytic, anti-inflammatory. Helps PIH.
• Salicylic Acid (0.5%-2%): MOA: Keratolytic, comedolytic. Milder.
• Dapsone Gel (5%, 7.5%): MOA: Anti-inflammatory. SE: Staining with BPO; rare G6PD risk (topical).

Systemic Attack - Zit Zapping Internally

For moderate-severe or resistant acne.

• Oral Antibiotics (Limit use to 3-6 months to ↓resistance)

  • Doxycycline: 100mg OD/BD. SE: Photosensitivity.
  • Minocycline: 50-100mg OD/BD. SE: Pigmentation, vestibular.
  • Azithromycin: 500mg 3x/week (pulse).

  ⭐ Gram-negative folliculitis: complication of long-term antibiotics; new pustules/papules (nose, chin).

• Oral Isotretinoin (Severe/scarring/resistant acne)

  • Dose: 0.5-1 mg/kg/day; cumulative 120-150 mg/kg.
  • MOA: ↓Sebum, ↓comedones, ↓P. acnes, ↓inflammation.
  • ⚠️ Teratogenic! Strict contraception. Monitor LFTs, lipids.
  • SE: 📌 CHEID (Cheilitis, Hyperlipidemia, Elevated LFTs, Teratogenicity [Strict Precautions], Depression).

Hormonal & Adjuvants - Balancing Act & Boosters

• Hormonal Therapy (Females):
  • OCPs: ↓ovarian androgens, ↑SHBG (Sex Hormone Binding Globulin).

    ⭐ Combined oral contraceptives containing drospirenone or cyproterone acetate are particularly effective for hormonal acne in females due to their anti-androgenic properties.

  • Spironolactone: Androgen receptor blocker. Dose: 50-200 mg/day. SE: hyperkalemia, menstrual irregularities.
• Corticosteroids:
  • Intralesional: Triamcinolone 2.5-5 mg/mL for nodules/cysts.
  • Oral (short-course): For severe inflammation.
• Light/Laser Therapy:
  • Blue light: Targets P. acnes.
  • Photodynamic Therapy (PDT): For severe acne.
• Dietary Factors:
  • Consider avoiding: High glycemic index foods, dairy products (association debated).

Maintenance & Scarring - Long Haul & Leftovers

• Maintenance Therapy: Key to prevent relapse.
  • Topical retinoids (e.g., adapalene, tretinoin)
  • Benzoyl Peroxide (BPO)
  • Azelaic acid
  • Adherence is crucial.
• Acne Scarring Types:
  • Atrophic: Icepick, boxcar, rolling.
  • Hypertrophic/Keloidal.
• Scar Treatment Overview:
  • Chemical peels
  • Microneedling
  • Lasers (e.g., CO2, Er:YAG)
  • Subcision
  • Fillers

⭐ Topical retinoids are the gold standard for maintenance therapy in acne to prevent relapses and can also improve atrophic scarring over time.

High‑Yield Points - ⚡ Biggest Takeaways

• Topical retinoids are first-line for comedonal and mild-moderate inflammatory acne.
• Benzoyl peroxide is key: antimicrobial, comedolytic, prevents antibiotic resistance.
• Combine topical antibiotics (clindamycin) with benzoyl peroxide to reduce resistance.
• Oral antibiotics (doxycycline) for moderate-severe acne; avoid tetracyclines in pregnancy & children <8 years.
• Oral isotretinoin for severe/refractory acne; highly teratogenic, strict contraception essential.
• Hormonal therapy (OCPs, spironolactone) for females with hormonal acne.
• Maintenance with topical retinoids prevents relapse_._