Figure 6 . Fitzpatrick skin type . |
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triamcinolone acetonide 2.5mg / mL may be helpful to quickly treat cases of severely tender , enlarged nodules ; however , this carries a risk of skin atrophy and hypopigmentation .
Refer to a specialist after three months for consideration for oral isotretinoin if there is a poor treatment response to the above regimen . Also consider early referral , regardless of the severity , for patients who have scarring , PIH — particularly in darker skin types ( Fitzpatrick IV-VI , see figure 6 ), or significant psychological distress .
Oral isotretinoin is the gold standard for treatment of severe , nodular , or complicated acne . 26 The mechanism of action is multifactorial , not only reducing sebum production and hyperkeratinisation , but also inhibiting C . acnes and thereby reducing inflammation . 27 While other treatments may require repeat or prolonged courses to control symptoms , the aim of oral isotretinoin is longterm remission after completion of a single course . The most widely accepted practice currently is to prescribe a treatment course with a total
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dose of 120-150mg / kg and to cease therapy once this is reached , even if active acne is still present . With this strategy the daily dose and duration of treatment may vary because of patient tolerability . 27 Microdosing , the process of treating at a lower dose for a greater period and only ceasing treatment once acne has
totally cleared , is a strategy many dermatologists are now employing . This has the added benefit of reducing side effects , but the cumulative dose should still be reached to minimise the risk of relapse .
Flaring of acne may occur up to two months after starting treatment and occurs most commonly in cases of severe nodulocystic acne ; occasionally oral antibiotics such
as erythromycin or systemic glucocorticoids ( low dose prednisolone ) may initially be prescribed concurrently . A low dose treatment introduction is also helpful in minimising risk of flares .
The side effect profile of isotretinoin is broad , but commonly includes skin and mucous membrane
Educate all females of childbearing age about the teratogenic effects of isotretinoin and start them on a reliable form of contraception .
dryness ( causing chapped lips , dry eyes and epistaxis ), photosensitivity , discoid eczema and arthralgia . 28 Side effects are often dose dependent , and intolerable side effects may prompt dose reduction until the patient ’ s symptoms stabilise . There is currently insufficient published evidence to support an association between isotretinoin and mental health disorders such as depression
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and anxiety ; instead , it is postulated that people with acne are already at an increased risk of depression
29 , 30 because of the disease itself . Regardless , in a recent review of the prescribing practices of 654 Australian dermatologists , 91 % did not feel that prior or current history of depression was a contraindication to prescribing isotretinoin . 31 Reports of sexual dysfunction while on treatment have also been published by the UK Medicines and Healthcare products Regulatory Agency ( MHRA ), although these data are limited and require further investigation . 29 Advise patients of the possible association with mental health disorders before starting treatment , and screen for these at each subsequent visit . Educate all females of childbearing age about the teratogenic effects of isotretinoin and start them on a reliable form of contraception . The referring GP may start patients on appropriate contraception before their consultation with the dermatologist .
There are no official guidelines for appropriate blood test
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monitoring during oral isotretinoin therapy ; one approach is to screen patients at the start of treatment and periodically or once the peak dose has been reached . Blood tests include FBC , LFTs , and cholesterol and triglycerides as isotretinoin may rarely cause an elevation of triglycerides or minor liver function abnormalities . In females , a pregnancy test is undertaken before starting treatment and may be repeated periodically during treatment .
Treatment adjuncts
In addition to the alpha and beta
hydroxy acid chemical peels previously mentioned , other procedural modalities have been found to be useful adjuncts in treating acne . These include energy-based therapies and manual extraction of comedones .
Light and laser therapies have been found to be useful in the treatment of acne through various mechanisms ( see table 3 ). 32 A meta-analysis showed that pulsed dye laser , in particular , is effective at reducing acne severity after four or more treatments . 33 Other modalities are not well supported in
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