Acne Systemic Treatment

Systemic Therapies

• Prescribed for patients with moderate to severe inflammatory acne, with acne that has not responded to topical treatment, or with cases with predominant involvement of the trunk, which is hard to treat topically.
• Include antibiotics, antiandrogenic agents, and oral contraceptives.
  
  Oral Antibiotics
• Useful in decreasing P acnes, free fatty acids in surface lipids and inflammation.
• May take 6 to 8 weeks for improvements to be noticeable.
• Usually necessary to continue treatment for several months, with gradual tapering once disease activity has stabilized or decreased.
• Tetracyclines are the oral antibiotics of choice
• All oral antibiotics should be taken in the absence of dairy products, which decrease absorption of the medication.
• Tetracycline should be taken one hour before or two hours after eating because all types of food inhibit the absorption of this medication.
• Adverse effects of tetracyclines include GI tract upset and vaginal yeast infection.
• Minocycline is an oral antibiotic, which has demonstrated potentially serious, but rare reactions, which include pneumonitis, hepatotoxicity, drug-induced lupus, serum sickness-like reaction, and a severe hypersensitivity syndrome reaction characterized by fever, rash, and internal organ involvement.
• Erythormoycin-another useful drug for acne but may cause gastrointestinal upset.
  
  Antiandrogenic Agents
• Decrease androgen-mediated changes such as sebum production.
• Types: Spironolactone, fultamide, cyproterone acetate, gonadotropin-releasing hormone antagonists and 5 alpha-reductase inhibitors.
• Spironoloactone is the most commonly used and is effective at a dose of 50 to 200mg/day, and may be used with other acne therapies. Side effects include menstrual irregularities, breast enlargement and tenderness, and fatigue.
  
  Oral Contraceptives
• Suppress androgen production and gonadotropin levels, decrease free testosterone via increased levels of sex hormone-binding gobulin in the blood, and inhibit 5 alpha reductase and androgen receptor binding.
• Appear to be most effective with a low-androgen progestin component (i.e. Ortho-Tri-Cyclen)
• Ortho-Tri-Cyclen is approved by the FDA for the treatment of moderate acne in females who: are 15 years or older, have no known contraindication to oral contraceptive therapy, desire contraception, have achieved menarche and are unresponsive to topical anti-acne medication.
• Norethindrone, desogestrel, and levonorgestrel are other types of oral contraceptives.
• It may take 3 to 6 months for improvement to be noted, with slight worsening of the acne early in the course.

  Combination Therapy

  Because acne is caused by many factors and patients often have more than one type of lesion, combination therapy using more than one of the above regimens is often necessary and tends to be more effective than one single therapy used alone. An example of combination therapy is the use of a topical antibiotic in the morning and a topical retinoid in the evening for combined mild inflammatory and comedonal disease.

  More art than science

  Acne is a common disorder with the potential for both medical and psychological complications. Treatment is best accomplished by thorough patient education and support combined with therapy directed at specific pathogenic factors. Acne treatment is more art than science, and multiple factors play a role in therapeutic success, including patient motivation, compliance, and individual response patterns. Combination drug therapy with topical and systemic agents is often more successful than monotherapy. Treatments continue to be refined and should offer patients significant hope for improvement in their condition.