Based on the latest evidence, important changes in isotretinoin administration are called for—specifically, using a much lower dose (0.25-0.5 mg/kg, divided into 2 daily doses) for a longer period of time.30 While the traditional dosing generally requires a 3- to 5-month course of treatment, the lower dosing can take 6 to 8 months.
Who's a candidate for hormonal therapy?
Any hormone that has antiandrogenic properties can have a beneficial effect on acne.
The most common hormonal therapy is an estrogen-progestin combination OCP.23,31 Progesterone-only OCPs should not be used as they can worsen acne.
In theory, any OCP that contains estrogen can work because of its androgenic properties. The estrogen appears to suppress sebaceous gland activity. OCPs with FDA approval for the treatment of acne include Estrostep Fe (norethindrone/ethinyl estradiol [EE]), Ortho Tricyclen (norgestimate/EE), and Yasmin and Beyaz (drospirenone/EE). With any OCP, the effect is gradual, and it can take 3 to 4 months for patients to see an improvement. OCPs are an excellent choice for women with moderate-to-severe acne or those suffering from hirsutism and seborrhea.
Other hormonal therapies—which are not FDA approved for acne treatment—include spironolactone, cyproterone, and flutamide.24 There is no evidence to support the use of finasteride or cyproterone.
Spironolactone is the most studied and has modest benefits at 100 to 150 mg/d.22 Caution is needed when using spironolactone, as gynecomastia, hyperkalemia, and agranulocytosis are potential adverse effects. It is important to closely monitor the blood pressure, chemistry, and cell count of patients taking spironolactone.
CASE Because Ms. S is sexually active and does not wish to become pregnant, she is a candidate for an OCP. You prescribe a pill containing norgestimate and EE, add a topical retinoid to her regimen, and schedule a return visit in 3 months to evaluate the effectiveness of therapy. If there is little improvement, you will recommend isotretinoin at that time.
Talk to patients about lifestyle modifications
Although the role of lifestyle changes in acne treatment is controversial, there is some evidence to suggest that these modifications are worth considering:
Glycemic load. In Western society, where the typical diet includes foods with a high glycemic index, there appears to be a higher prevalence of acne compared with regions where foods with a low glycemic index (≤55-60) are the mainstay. A low glycemic load appears to reduce both the occurrence and severity of acne.17 Thus, patients who are willing to make dietary changes should be advised to consume foods with a lower glycemic index, such as peanuts and green vegetables.
Dairy. Milk is believed to have an androgenic effect, and dairy products in general have a positive correlation with acne. Thus, a reduction in milk intake has been found to improve acne.18,32 Stress the importance of calcium supplementation for patients whose dairy consumption is reduced or eliminated.
Fish oil. Omega-6 fatty acid, found in fish oil, has anti-inflammatory properties, and an increase in foods rich in omega-3 fatty acid (eg, salmon, sardines, walnuts) has been associated with improvement of acne.17
Probiotics. There is limited evidence for probiotics as a therapy for acne. They do appear to regulate inflammatory cytokines within the skin and to upregulate the IGF-1, both of which influence the formation of acne.10,33
Other treatment options to consider
Injections, chemical peels, and/or laser treatments may be considered as adjunctive therapy or when standard therapies fail.
Steroid injections. This treatment regimen centers around a midpotency steroid that is diluted with normal saline and is introduced into each lesion until the lesion is distended and/or blanched. There are limited data on the use of corticosteroid injections for acne, however, and these injections are reserved for severe cases to reduce inflammation. Potential adverse effects include hyperglycemia, obesity, and Cushing traits.
Chemical peels are used to decrease both inflammatory and noninflammatory lesions, and are typically well tolerated. In one study, more than 95% of patients were satisfied with the results.11,34
Various chemicals have been used, including alpha-hydroxyl acid (glycolic acid), beta-hydroxyl acid (salicylic acid), and Jessner’s solution, with equal efficacy.35-38 Chemical peels can be used on patients with darker skin, but caution is required to avoid dyschromia.39 Other adverse effects include dry skin, crusting, and facial erythema. More adverse effects have been reported with glycolic acid vs salicylic acid.37
Laser therapies include photodynamic therapy—blue light with amino-luvanic acid—and phototherapy (blue light alone).40-42P acnes accumulate photosensitizing porphyrins in the comedones; when the laser therapy is applied, the porphyrins absorb the light source and destroy the bacteria.