Introduction Acne vulgaris is one of the commonest skin disorders, which dermatologists treat and it mainly affects adolescents, though it may appear at any age. Acne by definition is multifactorial chronic inflammatory disease of pilosebaceous units. Various clinical presentations include seborrhea, comedones, erythematous papules and pustules, less frequently nodules, deep pustules or pseudocysts, and ultimate scarring in few of them. Acne has four main pathogenetic mechanism — increased sebum productions, follicular hyperkeratinization, Propionibacterium acne (P. acne) colonization, and the products of inflammation. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities are designed. Availability of new treatment options to complement the existing armamentarium should help to achieve the successful therapy of greater numbers of acne patients, ensure improved tolerability and fulfill patient expectations. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs. Our aim here is to review the treatment options available with us in the present scenario. Topical therapy Topical therapy is useful in mild and moderate acne, as monotherapy, in combination and also as maintenance therapy. A. Benzoyl peroxide It is an effective topical agent since many years and is available in different formulations (washes, lotions, creams, and gels) The drug has an anti-inflammatory, keratolytic, and comedolytic activities, and is indicated in mild-to-moderate acne vulgaris. Clinicians must make a balance among desired concentration, the vehicle base, and the risk of adverse effects, as higher concentration is not always better and more efficacious. B. Topical retinoids Retinoids have been in use for more than 30 years. Topical retinoids target the microcomedo–precursor lesion of acne. There is now consensus that topical retinoid should be used as the first-line therapy, alone or in combination, for mild-to-moderate inflammatory acne and is also a preferred agent for maintenance therapy. Its effectiveness is well documented, as it targets the abnormal follicular epithelial hyperproliferation, reduces follicular plugging and reduces microcomedones and both noninflammatory and inflammatory acne lesions. C. Topical antibiotics Many topical antibiotics formulations are available, either alone or in combination. They inhibit the growth of P. acne and reduce inflammation. Topical antibiotics such as erythromycin and clindamycin are the most popular in the management of acne and available in a variety of vehicles and packaging. Clindamycin and erythromycin were both effective against inflammatory acne in topical form D. Other topical/new agents Salicylic acid: It has been used for many years in acne as a comedolytic agent, but is less potent than topical retinoid. Azelaic acid: It is available as 10–20% topical cream, which has been shown to be effective in inflammatory and comedonal acne. Lactic acid/Lactate lotion: It is found to be helpful in preventing and reduction of acne lesion counts. Tea tree oil 5%: Initial clinical response with this preparation is inevitably slower compared to other treatment modalities. Picolinic acid gel 10%: It is an intermediate metabolite of the amino acid, tryptophan. It has antiviral, antibacterial, and immunomodulatory properties. When applied twice daily for 12 weeks found to be effective in both type of acne lesions, but further trials are needed to confirm its safety and efficacy. Dapsone gel 5%: It is a sulfone with anti-inflammatory and antimicrobial properties. The trials have confirmed that topical dapsone gel 5% is effective and safe as monotherapy and in combination with other topical agents in mild-to-moderate acne vulgaris. Systemic Therapy Systemic antibiotics Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. There is a significant association between antibiotic used in acne and the incidence of upper respiratory tract infection. Hormonal therapy It may be needed in female patients with severe seborrhea, clinically apparent androgenetic alopecia, and with proven ovarian or adrenal hyperandrogenism. a) Oral contraceptives Estrogen is commonly combined with progestin to avoid the risk of endometrial cancer. Anti-acne effect of oral contraceptive governed by decreasing level of circulatory. b) Spironolactone They functions primarily as a steroidal androgen receptor blocker. It may cause hyperkalemia (when higher doses are prescribed or when there is cardiac or renal compromise), menstrual irregularities. Oral isotretinoin (Roaccutane) as a revolution in Acne treatment Oral retinoid is indicated in severe, moderate-to-severe acne or lesser degree of acne producing physical or psychological scarring, unresponsive to adequate conventional therapy. It is the only drug that affects all four pathogenic factors implicated in the etiology of acne. Although there are many studies, but very large evidence-based study is lacking to confirm the dosing schedule. New developments and future trends are low-dose long-term isotretinoin (Roaccutane) regimens and new isotretinoin formulations (micronized isotretinoin). Side effects include those of musculoskeletal, mucocutaneous, and ophthalmic systems, as well as headache, and central nervous system effects. Most of the side effects are temporary and resolves after the drug is discontinued. Oral isotretinoin is a potent teratogen. Therefore women of child-bearing age require negative pregnancy test before treatment, strict contraceptive measures essential before, during and even 6 weeks post-therapy. Physical Treatment A. Lesion removal a) Comedones Both open and closed comedones can be removed mechanically with comedone extractor and a fine needle or a pointed blade. b) Active deep inflammatory lesions a) Visible light b) Photodynamic therapy. Acne and diet: (Eat Chocolate and Do not Worry) Dietary restriction has not been demonstrated to be benefit in the treatment of acne. The myth that diet affects acne is widespread.., no industrialized societies than in modernized Western populations may be due to lower glycemic index diet, claims one trial. Although not currently recognized within our dermatology, fortunately no relation between Acne and chocolate is there. Conclusion Various topical and systemic drugs are available to treat acne. To overcome this situation a panel of physicians and researchers worked together as a “Global Alliance” and “Task Force” to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne, mostly evidence-based and inputs from various countries which come at last that oral treatment is the best way in executing a treatment for this disease Dr. Ahmed Mansi Dermatology Consultant
