Management

Many different treatments exist for acne including benzoyl peroxide, antibiotics, retinoids, antiseborrheic medications, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and kera-tolytic soaps.[24] They are believed to work in at least 4 different ways including: normalising shedding into the pore to prevent blockage, killing Propionibacterium acnes, anti-inflammatory effects, hormonal manipulation.[citation needed]
[edit] Medications

Benzoyl peroxide

Benzoyl peroxide is a first-line treatment for mild and moderate acne vulgaris due to its effectiveness and mild side-effects (primarily an irritant dermatitis). It normally causes just dryness of the skin, slight redness, and occasional peeling as part of some side-effects.[25] It has been found to be nearly as effective as antibiotics with all concentrations 2.5%, 5.0%, and 10% equally effective.[25] Unlike antibiotics, benzoyl peroxide does not appear to generate bacterial resistance.[25]

Antibiotics

Antibiotics are reserved for more severe cases.[25] With increasing resistance of P. acnes worldwide, they are becoming less effective.[25] Commonly used antibiotics, either applied topically or taken orally, include erythromycin, clindamycin, and tetracyclines such as minocycline.

Hormones

In females, acne can be improved with hormonal treatments. The common combined estrogen/progestogen methods of hormonal contraception have some effect, but the antiandrogen cyproterone in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side-effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case. Along with this, treatment with low-dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.

Topical retinoids

A group of medications for normalizing the follicle cell life-cycle are topical retinoids such as tretinoin (Retin-A), adapalene (Differin), and tazarotene (Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and, in general, have much milder side-effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death life-cycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar, but milder, effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years, but are available only on prescription, so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare-up of acne and facial flushing.

Oral retinoids

A daily oral intake of vitamin A derivative isotretinoin (marketed as Roaccutane, Accutane, Amnesteem, Sotret, Claravis, Clarus) over a period of 4–6 months can cause long-term resolution or reduction of acne. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side-effects (many of which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4–6 months may be indicated to obtain desired results. It is often recommended that one let a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. On occasion, a third or even a fourth course is used, but the benefits are often less substantial. The most common side-effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare-up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated or reduced due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports[weasel words] suggest that isotretinoin may cause depression, but, as of September 2005, there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Because of this, the drug is supposed to be given to females as a last resort after milder treatments have proven insufficient. Restrictive rules (see iPledge program) for use were put into force in the USA beginning in March 2006 to prevent misuse, causing occasioned widespread editorial comment.[26]

Anti-inflammatories

Nicotinamide, (vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be of comparable efficacy to topical clindamycin used for comparison.[27] Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin, and may also, according to a cosmetic company, be useful for reducing skin hyperpigmentation (acne scars), increasing skin moisture and reducing fine wrinkles.[28]

Rofecoxib was shown to improve premenstrual acne vulgaris in a placebo-controlled study, although this drug has since been withdrawn.[29]

Naproxen or ibuprofen[30] are used for some moderate acne cases for their anti-inflammatory effects.

Calendula in suspension is used as an anti-inflammatory agent.[31]