Severe Acne Vulgaris Management

Aka: Severe Acne Vulgaris Management, Cystic Acne, Systemic Acne Vulgaris Management, Systemic Antibiotics in Acne Vulgaris

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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 Topical 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 expect 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)
        1. Avoid in Acne Vulgaris, unless Tetracyclines are contraindicated
      3. Pregnancy Category B
  3. Alternative agents
    1. Indicated if first-line agents not tolerated
    2. Seysara (Tetracycline)
      1. Released in 2019 at $860/month compared with $30 for generic Doxycycline
      2. Difficult to see the benefit of an older, Generic Drug remarketed at 100x the original cost
      3. (2019) Presc Lett 26(3): 16
    3. Trimethoprim-Sulfamethoxazole (Bactrim, Septra)
      1. Dose: 160/800 (DS) twice daily
      2. Risk of sulfa Allergic Reaction
      3. Avoid in Acne Vulgaris, unless Tetracyclines and Macrolides are contraindicated
      4. Pregnancy Category C
    4. Trimethoprim
      1. Dose: 300 mg bid
      2. Avoid in Acne Vulgaris, unless Tetracyclines and Macrolides are contraindicated
      3. Pregnancy Category C
  4. Second Line
    1. Minocycline
      1. Dose: 50-200 mg/day in divided doses
      2. Considered first-line therapy by American Academy of Dermatology
      3. Risk of serious adverse effects (e.g. lupus-like reaction, Pseudotumor Cerebri)
      4. 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. Start 0.25 to 0.4 mg/kg/day (or 0.5 mg/kg/day if severe)
      2. Titrate to 1 mg/kg/day as tolerated after the first month
      3. Continue 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

VI. References

  1. (2017) Presc Lett 24(12): 69
  2. Habif (2004) Dermatology, Mosby, p. 162-94
  3. Parker in Noble (2001) Primary Care p. 758-60
  4. Feldman (2004) Am Fam Physician 69:2123-56 [PubMed]
  5. Gollnick (2003) J Am Acad Dermatol 49:S1-37 [PubMed]
  6. James (2005) N Engl J Med 352(14):1463-72 [PubMed]
  7. Oge (2019) Am Fam Physician 100(8): 475-84 [PubMed]
  8. Strauss (2007) J Am Acad Dermatol 56(4): 651-63 [PubMed]
  9. Tan (2003) Am J Clin Dermatol 4:307-14 [PubMed]
  10. Titus (2012) Am Fam Physician 86(8): 734-40 [PubMed]

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