Treating Severe Acne

Severe acne is characterized by deep cysts, inflammation, extensive damage to the skin and scarring. It requires an aggressive treatment regimen and should be treated by a dermatologist. Severe, disfiguring forms of acne can require years of treatment and may experience one or more treatment failures. However, almost every case of acne can be successfully treated.

Physical methods and prescription medications that dermatologists use to treat severe acne include:

• Drainage and surgical excision

• Interlesional corticosteroid injection

• Isotretinoin

• Oral antibiotics

• Oral contraceptives

Drainage and Surgical Excision
Some large cysts do not respond to medication and may require drainage and extraction. Drainage and extraction, or “acne surgery” as it is also called, should not be performed by patients. Dermatologists are trained in the proper technique and perform acne surgery under sterile conditions. Patient attempts to drain and extract comedones by squeezing or picking, can lead to infection, worsening of the acne and scarring.

Interlesional Corticosteroid Injection
When an acne cyst becomes severely inflamed, there is a good chance it will rupture and scarring may result. To treat these severely inflamed cysts and prevent scarring, dermatologists may inject such cysts with a much-diluted corticosteroid. This lessens the inflammation
and promotes healing. An interlesional corticosteroid injection works by "melting" the cyst over a period of
3 to 5 days.

Isotretinoin
Isotretinoin is a potent drug reserved for treating severe cystic acne and acne that has proven itself resistant to other medications. Isotretinoin is a synthetic (man-made) retinoid (form of vitamin A) that comes in pill form. It is usually taken once or twice a day for 16 to 20 weeks.

Today, it is the most effective acne treatment available because it is the only acne treatment that works on all four factors that predispose a person to acne - excess oil production, clogged skin pores, P. acnes and inflammation. The remissions achieved with isotretinoin usually last for many months to many years. For many patients, only one course of isotretinoin therapy is needed.

The effectiveness of isotretinoin in treating severe acne is shown in the following before-and-after photos:

While isotretinoin is the most effective acne treatment available, it cannot be prescribed to everyone due to a number of potential side effects—some serious. One of the most serious side effects is the potential to cause severe birth defects in a developing fetus. For this reason, the U.S. Food and Drug Administration (FDA) requires that women not be (or become) pregnant while taking isotretinoin. FDA regulations require women of childbearing age to take 2 pregnancy tests prior to beginning isotretinoin therapy and use 2 forms of birth control for 1 month before therapy begins, while taking the drug and for 1 full month after therapy. It is also important that women not breast feed during this time. Women who wish to become pregnant after taking isotretinoin should talk to their dermatologist and gynecologist about when it is safe to get pregnant after receiving isotretinoin therapy.

Other possible severe side effects that may occur while taking isotretinoin include:

• Severe pain in the chest or abdomen

• Trouble swallowing or painful swallowing

• Severe headache, blurred vision or dizziness

• Bone and joint pain

• Nausea or vomiting

• Diarrhea or rectal bleeding

• Depression

• Dryness of the skin, eyes and nose

• Thinning hair

If any side effect occurs, the patient’s dermatologist or other healthcare practitioner should be contacted immediately because some of these side effects can lead to serious health problems.

While taking isotretinoin, patients are regularly monitored for side effects through follow-up visits. For most people, these side effects are tolerable and not a reason to discontinue therapy before remission is achieved. However, it is important to keep appointments for follow-up visits because monitoring can reveal conditions that a patient might not notice. For example, a patient may not realize a rapid increase in bad cholesterol that is detected through a blood test.

The decision to use isotretinoin should be made jointly by patient and dermatologist. When used with all due caution under close medical supervision, isotretinoin can resolve severe acne that has not responded to other therapy. It has proven especially effective in resolving cystic acne, a severe form of acne that usually does not respond to other therapies.

For a substantial number of patients, one course of isotretinoin therapy is all they will ever need. A small number of patients require more than one course of isotretinoin therapy to control severe acne.

It is important to take isotretinoin as prescribed—even if the skin clears before all of the pills have been taken—to prevent relapse. At the end of an effective course of isotretinoin therapy, all or most of the acne lesion will have cleared. Patients may notice residual erythematous (reddish) macules (flat spots) where acne lesions were present. These macules are not scars, and they will fade in 6 to 8 weeks.

After therapy, patients should continue to follow the Skin Care Guidelines for People with Acne.

Oral Antibiotics
Oral antibiotics have been a mainstay of therapy for severe acne for many years. Like topical antibiotics, oral antibiotics work to reduce the P. acnes population (a contributing factor in acne), which, in turn, decreases inflammation. Treatment with oral antibiotics usually begins with a high dosage, which is reduced as the acne resolves. Over time, the P. acnes bacteria can become resistant to the antibiotic being used to treat it. When this happens, another antibiotic can be prescribed. Numerous studies support the effectiveness of the following broad-spectrum oral antibiotics that are used to treat acne in the United States: doxycline, erythromycin, minocycline and tetracycline. For information about each of these oral antibiotics, see Prescription Acne Medications.

Oral Contraceptives
Oral contraceptives have been shown to effectively clear acne in women by suppressing the overactive sebaceous glands. Oral contraceptives can be used as long-term acne therapy; however, this medication should not be prescribed to women who smoke, have a blood-clotting disorder, are older than 35 or have a history of migraine headaches—without the advice of a gynecologist.

Spironolactone, a synthetic steroid, may be used in combination with oral contraceptives to treat acne in adult females. Spironolactone inhibits androgen production. Side effects include irregular menstruation, breast tenderness, headache and fatigue.

An educational program brought to you by the American Academy of Dermatology.