Vol. 27. No. 3


Acne is a tremendously common condition affecting millions of adolescents and adults. Up to 80% of teenage girls and 90% of teenage boys are afflicted with acne. Adult acne, although less common than adolescent acne, is a significant problem for 3% to 6% of adult men and 5% to 12% of adult women. Although the presence of acne does not physically impair patients, it can have a remarkable psychological effect. Thirty to fifty percent of adolescents experience psychiatric disturbances as the result of acne. Studies have shown that acne causes similar levels of social, psychological, and emotional impairment as asthma and epilepsy. Studies have also shown that unemployment is greater among adults with acne than among adults without acne. We as physicians must recognize the significant impairment that acne can have on a patient’s psyche and treat it seriously. To implement effective treatment strategies for patients with acne, a solid understanding of the physiology of the pilosebaceous unit and the pathological events that lead to acne are critical. The pathogenesis of acne is very complex but consists of 4 main factors. These key elements are: (1) follicular epidermal hyperplasia, (2) excess sebum production, (3) inflammation, (4) and the activity of Propionibacterium acnes. Some acne treatments address 1 of the 4 factors of acne formation whereas other treatments address multiple components. A myriad of treatment options ranging from washes, to leave of products, to oral agents, to lasers and light sources exist. It is important that the physician understands the gamut of treatment options so that they can be successfully used. A thorough knowledge of potential side effects and efficacy of each treatment is necessary so that physicians can appropriately educate their patients. This issue will aid the physicians by presenting an up-to-date compendium of therapeutic approaches to treating acne vulgaris.

Antibiotic Treatment for Acne Vulgaris

Emmy M. Graber, MD | Guy F. Webster, MD, PhD, FAAD

Although topical therapies alone can be very effective for milder acne, there are often cases for
which oral antibiotics are needed to control disease. Through both antibacterial and antiinflammatory
effects, oral antibiotics in combination with other drugs such as retinoids and benzoyl
peroxide can be highly effective in the treatment of more severe disease. Patients and their
parents often have many questions regarding the safety and efficacy of long-term antibiotic use.
It is important for the physician to have a thorough understanding of the antibiotics at their
disposal as well as their side effects. Through careful discussion, antibiotic compliance can be
optimized and side effects minimized ultimately resulting in treatment success.
Semin Cutan Med Surg 27:183-187 © 2008 Elsevier Inc. All rights reserved.


Effective Over-the-Counter Acne Treatments

Alan R. Shalita, MD | Whitney P. Bowe, MD

Acne is the most common disease of the skin, yet only a fraction of acne sufferers are
treated with prescription products by physicians. There is, however, a large and expanding
market for over-the-counter (OTC) medications, many of which are not only effective but
also well tolerated and cosmetically elegant. Given the presence of OTC acne medications
on the television, the Internet, and store shelves, patients will be acutely aware of these
OTC remedies and will have questions. Patients will expect dermatologists to advise them
regarding products to use either as a sole therapy or in combination with prescription
drugs. Recently, combinations of OTC acne medications in treatment regimens or “kits”
have gained popularity and appear to have increased patient compliance. Quality-of-life
outcomes from OTC medication use, in at least one study, have demonstrated good benefit.
The most common OTC ingredients include benzoyl peroxide, a potent antibacterial agent,
and salicylic acid, a mild comedolytic and antiinflammatory medication. Other, less-common
OTC ingredients include sulfur, sodium sulfacetamide, and alpha hydroxy acids. Zinc,
vitamin A, tea tree oil, and ayurvedic therapies also are available OTC for acne. Additional
and better studies are needed to clarify the benefit of these latter medications.
Semin Cutan Med Surg 27:170-176 © 2008 Published by Elsevier Inc.


Evidence for Laser- and Light-Based Treatment of Acne Vulgaris

Girish S. Munavalli, MD, Mhs | Robert A Weiss, MD, FAAD, FACPh

Acne is a very prevalent skin disorder, affecting more than 85% of adolescents and often
continuing into adulthood. Active acne and its sequelae, especially permanent scarring,
may cause longstanding psychological or emotional harm in patients. Novel and promising
treatments with laser/light devices (such as blue light, red light, pulsed dye laser, infrared
lasers, light-emitting diodes, and pulsed light) have been reported to have varying degrees
of efficacy for treatment. The authors compiled a summary of evidence-based literature on
laser/light treatment for acne to assist clinicians to more appropriately identify treatment
options, should they choose to supplement current medical antiacne therapies.
Semin Cutan Med Surg 27:207-211 © 2008 Published by Elsevier Inc.


Hormonal Therapy for Acne

Diane Thiboutot, MD | Rosalyn George, MD | Shari Clarke, MD

Acne affects more than 40 million people, of which more than half are women older than 25
years of age. These women frequently fail traditional therapy and have high relapse rates
even after isotretinoin. Recent advances in research have helped to delineate the important
role hormones play in the pathogenesis of acne. Androgens such as dihydrotestosterone
and testosterone, the adrenal precursor dehydroepiandrosterone sulfate, estrogens,
growth hormone, and insulin-like growth factors may all contribute to the development of
acne. Hormonal therapy remains an important part of the arsenal of acne treatments
available to the clinician. Women dealing with acne, even those without increased serum
androgens, may benefit from hormonal treatments. The mainstays of hormonal therapy
include oral contraceptives and antiandrogens such as spironolactone, cyproterone acetate,
or flutamide. In this article, we discuss the effects of hormones on the pathogenesis
of acne, evaluation of women with suspected endocrine abnormalities, and the myriad of
treatment options available.
Semin Cutan Med Surg 27:188-196 © 2008 Elsevier Inc. All rights reserved.


Preventing and Managing the Side Effects of Isotretinoin

Megan Brelsford, DO, LT, MC, USN | Trisha Clarke Beute, MD, LCDR, MC, USN

Isotretinoin (13-cis-retinoic acid) is widely used for the treatment of severe acne as well as
for disorders of conification, for psoriasis, and for skin cancer prevention. As a member of
the retinoid family, it has a wide spectrum of side effects, including reproductive, cutaneous,
ocular, neurological, musculoskeletal, and hepatic. As long as patients are able to
tolerate these side effects, it can be a very effective treatment option. This article examines
both the most common and the most concerning side effects as well as ways in which
providers and patients may best manage them to be able to benefit from isotretinoin
Semin Cutan Med Surg 27:197-206 © 2008 Elsevier Inc. All rights reserved.