Systemic Therapies for Acne
Individuals with moderate-to-severe inflammatory acne may warrant systemic therapies, especially if they are unresponsive to topical treatments, or have significant quality of life decrements, which is not uncommon in this population. Specific clinical fe
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Systemic Therapies for Acne Marisa Kardos Garshick, Alexa Kimball, and Lynn Drake
4.1
Introduction
Individuals with moderate-to-severe inflammatory acne may warrant systemic therapies, especially if they are unresponsive to topical treatments, or have significant quality of life decrements, which is not uncommon in this population. Specific clinical features, including the type and severity of acne, the presence of scarring, and the association with abnormal menses, can help guide the appropriate course of treatment. All dosages mentioned in this section must be adjusted according to the individual patient.
4.2
Oral Antibiotics
Oral antibiotics used for the treatment of moderate-to-severe inflammatory acne work by inhibiting the growth of P. acnes, or by anti-inflammatory effects [1]. Due to the widespread use of antibiotics, there is an increasing concern about antibiotic resistance. Given this, antibiotics are initially prescribed for a limited course. In the absence of clinical improvement after 6–8 weeks, a change in the antibiotic or other treatments may be considered. If partial improvement is observed, response to therapy should be reassessed after 6–8 weeks [2]. Using topical benzoyl peroxide or other topicals in combination with antibiotics may decrease the emergence of resistance [3]. Once acne is improved, oral antibiotics are often discontinued and patients should continue topical therapies for long-term maintenance as acne tends to flare in the absence of treatment.
M.K. Garshick, B.S. (*) • A. Kimball, M.D., M.P.H. • L. Drake, M.D. Department of Dermatology, Massachusetts General Hospital, 50 Staniford Street Suite 240, Boston, MA 02114, USA e-mail: [email protected] J.A. Zeichner (ed.), Acneiform Eruptions in Dermatology: A Differential Diagnosis, DOI 10.1007/978-1-4614-8344-1_4, © Springer Science+Business Media New York 2014
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4.2.1
M.K. Garshick et al.
Macrolides
Erythromycin is not commonly used given the incidence of treatment failure perhaps due to the development of P. acnes antibiotic resistance or the low level of antiinflammatory activity. Erythromycin is usually recommended when tetracycline derivatives are contraindicated [4]. A common acne dose is 500 mg twice daily. Side effects may include gastrointestinal (GI) distress, which might be reduced if administered with food. Azithromycin has been reported as effective in the treatment of acne, though there is little consensus for its use and optimum dosing [5–7]. Given its role in the treatment of respiratory infections and as an alternative treatment for patients allergic to beta-lactam antibiotics, there is concern with increasing resistance. Azithromycin does not usually cause GI upset and should be taken on an empty stomach to enhance GI absorption.
4.2.2
Tetracyclines
The tetracyclines are probably the most commonly used antibiotics, and they have both antibiotic and anti-inflammatory properties. The newer generation tetracyclines (doxycycline and minocycline) are often preferred over tetracycline, due to dec
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