Management of acne vulgaris by nondermatologists is increasing. Current
understanding of the different presentations of acne allows for individualized
treatments and improved outcomes.
To review the best evidence available for individualized treatment of
Search of MEDLINE, EMBASE, and the Cochrane database to search for all
English-language articles on acne treatment from 1966 to 2004.
Well-designed randomized controlled trials, meta-analyses, and other
systematic reviews are the focus of this article.
Acne literature is characterized by a lack of standardization with respect
to outcome measures and methods used to grade disease severity.
Main outcome measures of 29 randomized double-blind trials that were
evaluated included reductions in inflammatory, noninflammatory, and total
acne lesion counts. Topical retinoids reduce the number of comedones and inflammatory
lesions in the range of 40% to 70%. These agents are the mainstay of therapy
in patients with comedones only. Other agents, including topical antimicrobials,
oral antibiotics, hormonal therapy (in women), and isotretinoin all yield
high response rates. Patients with mild to moderate severity inflammatory
acne with papules and pustules should be treated with topical antibiotics
combined with retinoids. Oral antibiotics are first-line therapy in patients
with moderate to severe inflammatory acne while oral isotretinoin is indicated
for severe nodular acne, treatment failures, scarring, frequent relapses,
or in cases of severe psychological distress. Long-term topical or oral antibiotic
therapy should be avoided when feasible to minimize occurrence of bacterial
resistance. Isotretinoin is a powerful teratogen mandating strict precautions
for use among women of childbearing age.
Acne responses to treatment vary considerably. Frequently more than
1 treatment modality is used concomitantly. Best results are seen when treatments
are individualized on the basis of clinical presentation.