Solutions for cystic acne that is resistant to treatments:
Investigate compliance
Increase frequency of topical treatment
Begin or increase oral antibiotic dosage
Search for hormonal derangement
Begin oral isotretinoin therapy
Oral treatment:
Acne that is resistant to topical treatment requires oral antibiotics. Many
of the antibiotics useful in acne also have an anti-inflammatory activity,
which is nearly as important as their effect on the P acnes itself. Oral
erythromycin used to be a common treatment for acne, but the rise of
resistance has greatly reduced its utility. It is necessary to begin the
treatment with doxycycline or minocylcine.
Acquired resistance to minocycline and doxycycline is less
common than to erythromycin but is still a concern, and use of these drugs
should be limited to those patients who truly need them. Patients are
instructed to take the drug with food this minimises stomach complaints and
maximises compliance. If minocycline or doxycycline cannot be used,
alternatives include co-trimoxazole and
ciprofloxacin. Risk of acquiring resistance to these drugs after long-term
use has not been studied, but the use of these drugs should be minimised. In
general, cephalosporins and penicillins are not very effective in treating
acne. The increased cost of some of these newer drugs may make using
isotretinoin an attractive option in the long-term treatment.
Hormonal treatment:
It is wrong to assume that any woman with acne have a hormonal derangement.
In fact, androgen levels do not correlate with acne severity among people
with acne. Acne resistant to treatment, especially in a woman with irregular
menses, should be investigated. Measurements of total and free testosterone
as well as dehydroepiandrosterone sulphate. If these levels are raised, four
approaches may be taken: suppression with low dose oral corticosteroid, oral
contraception, cyproterone acetate or spironolactone.
Isotretinoin revolutionised the treatment of severe acne. It is used in case
of severe nodular acne, but it is commonly used for severe acne that is
resistant to oral antibiotics as well. Patients should be monitored
routinely.
Acne and pregnancy:
Erythromycin, topical or oral, is safe in
pregnancy, although oral erythromycin
is often poorly tolerated in patients whose lower oesophageal sphincter is
already relaxed by pregnancy. Benzoyl peroxide is also safe. Topical
tretinoin in pregnancy is theoretically safe as circulating vitamin A. No
increase in foetal abnormalities has been seen in women using topical tretinoin while pregnant.
Wash the skin
Avoid oily substances
Shampoo the hair daily
Don`t "pop" pimples
Exercise regularly
Don't stop the acne medicine
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