Benzoyl Peroxide Skincare Product

Usually preferred as a gel product
Dosing:
- Start with lowest concentration and increase strength or application frequency to limit irritation and increase tolerability
- Apply to cool, clean, dry skin no more than twice daily
Common side effects:
- Dryness and irritation
- May bleach or discolor some fabrics
- Patients should wash their hands after applying the product
To reduce irritation:
- Start with the lowest possible strength
- Apply infrequently during the first week
- Increase frequency to twice daily
- Discontinue if irritation persists

Role in acne treatment:
- Increases cell turnover in the follicular wall
- Decreases cohesiveness of cells, leading to extrusion of comedones and inhibition of new comedo formation
- Effectiveness in acne treatment is well-documented
Tretinoin (topical vitamin A acid):
- Availability: wide variety of dosage forms and concentrations
- Dosing: applied once nightly
- Side effects: skin irritation, erythema, peeling, increased sensitivity to sun exposure, wind, or cold
Adapalene (Differin):
- Availability: 0.1% gel, cream, and alcoholic solution
- Dosing: applied once daily at night
- Side effects: minimal irritation
Tazarotene (Acnee free gel, cream, and lotion):
- Availability: 0.05% and 0.1% gel or cream
- Dosing: applied once nightly
- Side effects: irritation, erythema, burning, or stinging
Recommendations for topical retinoids:
- Use as monotherapy for comedonal acne or in combination with other therapies for mixed or primary inflammatory acne lesions

Dosing: applied twice daily on clean, dry skin
Side effects:
- Mild transient erythema, burning, pruritus, and stinging
- Decrease pigmentation, should be used cautiously in people with darker skin due to skin-lightening effects

Indications:
- Moderate inflammatory acne non-responsive to topical therapy
- Nodulocystic acne
Oral Antibiotics:
- Role in acne treatment:
  - Standard of care in the management of moderate and severe acne as well as in treatment-resistant forms of inflammatory acne
- Examples:
  - Tetracycline
  - Doxycycline (Vibramycin)
  - Minocycline (Minocin)
  - Erythromycin
  - Azithromycin
  - Trimethoprim-Sulfamethoxazole (Septazol and Sutrim)
  - Clindamycin (Dalacin C Cap.)
- Dosing:
  - Tetracycline: 250-500mg twice to four times daily
  - Doxycycline: 50-100mg once to twice daily
  - Minocycline: 100mg once daily
  - Erythromycin: 250-500mg twice daily
  - Trimethoprim-Sulfamethoxazole: 160/800mg twice daily
  - Clindamycin: use is limited due to diarrhea
- Common side effects:
  - Candidiasis mainly vaginal, diarrhea
  - Doxycycline: photosensitivity
  - Minocycline: pigment deposition of the skin, mucous membranes, and teeth

Role in acne treatment:
- Indicated for severe nodular or inflammatory acne in patients unresponsive to conventional therapies, for scarring, for those with chronic relapsing acne, and for acne associated with severe psychological distress
- Mechanism of action: decreases sebum production, changes in sebum composition, inhibits P.acnes growth within follicles, inhibits inflammation and scarring
iPLEDGE program:
- Mandatory distribution program in the United States for isotretinoin
- Female patients of child-bearing potential must only be treated with this agent if they are participating in iPLEDGE
- Physician enters the patient's information into the iPLEDGE website
- Dispensing pharmacist interviews patient and verifies patient information on website
- Patient signs a consent form to comply with the program
Dosing:
- Dosage: 1 mg/kg once a day for 15 to 20 weeks, but the dosage may be increased to 2 mg/kg once a day
- If adverse effects make this dosage intolerable, it may be reduced to 0.5 mg/kg once a day
Common side effects:
- Cheilitis, conjunctivitis, irritation, photosensitivity
- Teratogenicity, dry mouth, nose, and eyes
- Increases in cholesterol, triglycerides, and glucose
- Increase liver enzymes and ESR
- Mood disorders, depression, and suicidal ideation
Contraindications:
- Hypersensitivity
- Pregnancy

Routine monitoring of CBC, liver function test, lipid panel at baseline and again after response is established
Because isotretinoin is teratogenic, women of childbearing age are told that they are required to use 2 methods of contraception for 1 month before treatment, during treatment, and for at least 1 month after stopping treatment
Pregnancy tests should be done before beginning therapy and monthly until 1 month after therapy stops
Two negative pregnancy test results are required prior to the initiation of therapy in women of childbearing potential
Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related adverse effects, but intermittent dosing is not recommended
Patients experiencing severe headaches, decreased night vision, or adverse psychiatric events should stop taking isotretinoin immediately

Role of hormones in acne treatment:
- Acne associated with hirsutism, menstrual irregularity, and alopecia as well as women desiring contraception
- Oral contraceptives increase hepatic synthesis of sex hormone-binding globulin, resulting in an overall decrease in circulating free testosterone
- Estrogen-containing oral contraceptives can be useful in the treatment of acne in some women
Currently FDA-approved combined oral contraceptives (COC) for the treatment of acne:
- Ortho Tri-Cyclen (norgestimate with ethinyl estradiol)
- Estrostep (norethindrone acetate with ethinyl estradiol)
Antiandrogens:
- Spironolactone (Aldactone) can be used as an androgen antagonist and is beneficial in acne caused by polycystic ovarian syndrome or adrenal tumors
- Pregnancy must be avoided while taking spironolactone because of the risk of feminization of the male fetus
- Spironolactone is not recommended for males because of the potential for gynecomastia
- Hyperkalemia is a potential dangerous adverse effect from spironolactone
Oral corticosteroids:
- Can be used to treat severe inflammatory acne
- Provide temporary quick improvement

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