II. Indications

  1. Moderate to severe Acne Vulgaris
  2. Nodular, pustular, or cystic Acne Vulgaris

III. Management: Step 1 - Incorporate Moderate Acne Vulgaris Management

  1. See Moderate Acne Vulgaris Management
  2. Continue Benzoyl Peroxide
  3. Continue Comedolytic (e.g. Retin A)
  4. Continue topical antibiotic (e.g. Cleocin T)
    1. May combine with Benzoyl Peroxide (e.g. Benzaclin)
  5. Consider Adjunctive Acne Vulgaris Management

IV. Management: Step 2 - Start Oral Antibiotics

  1. General
    1. Do not anticipate an effect for 6 to 8 weeks
    2. Continue antibiotic for minimum of 6 months
    3. Benzoyl Peroxide should be used with all antibiotic regimens to prevent Antibiotic Resistance
    4. As with topical Antibiotic Resistance in acne, oral Antibiotic Resistance is also increasing
    5. Stop oral antibiotics after acne improves (after 3-4 months) and continue topical agents
  2. First Line
    1. Doxycycline
      1. Dose: 50-100 mg once to twice daily
      2. May substitute Tetracycline 250 to 500 mg daily to twice daily
        1. Doxycycline replaces Tetracycline as first-line therapy as of the 2007 AAD guidelines
      3. Pregnancy Category D
    2. Erythromycin
      1. Dose: 1 g/day in 2-4 divided doses
      2. Increasing resistance decreases its efficacy (compared with Tetracyclines)
      3. Pregnancy Category B
  3. Alternative agents
    1. Indicated if first-line agents not tolerated
    2. Trimethoprim-Sulfamethoxazole (Bactrim, Septra)
      1. Dose: 160/800 (DS) twice daily
      2. Risk of sulfa Allergic Reaction
      3. Pregnancy Category C
    3. Trimethoprim
      1. Dose: 300 mg bid
      2. Pregnancy Category C
  4. Second Line
    1. Minocycline
      1. Dose: 50-200 mg/day in divided doses
      2. Risk of serious adverse effects (e.g. lupus-like reaction, Pseudotumor Cerebri)
      3. Pregnancy Category D

V. Management: Step 3 - Maximal medical therapy (cystic or refractory acne)

  1. Isotretinoin (Accutane)
    1. Consider in all patients with resistant or Cystic Acne (scarring)
    2. Dose: 1 mg/kg/day for 20 weeks
    3. Only qualified clinicians may prescribe (iPLEDGE)
    4. Adverse effects
      1. Extremely Teratogenic
      2. Monitor Triglycerides and Liver Function Tests and Complete Blood Count
      3. Major Depression and increased Suicidality
  2. Light and laser therapy
    1. Awaiting larger, more definitive studies as to efficacy

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Ontology: Cystic acne (C0010666)

Concepts Disease or Syndrome (T047)
SnomedCT 13277001
Italian Acne cistica
German zystische Akne, AKNE CYSTICA, Akne cystica
Japanese 嚢胞性ざ瘡, ノウホウセイザソウ
English ACNE CYSTIC, cystic acne (diagnosis), cystic acne, Acne cystic, acne cystic, Acne;conglobate (cystic), acne vulgaris cystic, Acne cystica, Cystic acne, Cystic acne vulgaris, Cystic acne (disorder), cystic; acne, acne; cystic, Acne, cystic
French ACNE KYSTIQUE, Acné kystique
Portuguese ACNE QUISTICO, Acne quística
Czech Cystická forma akné
Hungarian Cisztikus akne, Cystikus acne
Dutch acne; cysteus, cysteus; acne, blaasjes acne
Spanish acné quística (trastorno), acné quística, Acné quístico