A Brief Synopsis of AFPs "Diagnosis and Treatment of Acne"

A brief synopsis of: Diagnosis and Treatment of Acne
STEPHEN TITUS, MD, and JOSHUA HODGE, MD, Fort Belvoir Community Hospital Family Medicine Residency, Fort Belvoir, Virginia
http://www.aafp.org/afp/2012/1015/p734.pdf.
Am Fam Physician. 2012 Oct 15;86(8):734-740

     Acne is an inflammatory disorder of the skin. The pathophysiology starts with an increased production of sebum from the sebaceous glands. Hyperkeratinization of the follicles and colonization by Propionibacterium acnes leads to the inflammatory reaction.  Acne should first be characterized into mild, moderate, or severe, depending on the amount of inflammation, as well as the presence or absence of papules, pustules and nodules.  There is no "best" grading system.  If the patient only has comedones, they can be started on topical retinoid. If it is effective, then they they can be maintained on it. If there is mild inflammatory papules and pustules, they can be given the topical retinoid with benzoyl peroxide.  If it is effective, then need only be maintained on topical retinoid. If it is not effective or the patient has moderate inflammatory papules and pustules, they can be started on the topical retinoids, benzoyl peroxide and topical antibiotics (clindamycin or erythromycin).  Benzoyl peroxide is beneficial here because it reduces the  bacterial resistance of the other antibiotics.  If it is effective, they can be maintained on topical retinoid.
     If the patient has moderate inflammation with nodules or severe inflammation without nodules, the patient can use the topical retinoid, benzoyl peroxide  and oral antibiotics, such as doxycycline, minocycline, or tetracycline. TMP/SMX can be used as an alternative. If it is effective, then they can be maintained on topical retinoid and benzoyl peroxide.  If the patient has severe acne with nodules, the patient can be started on oral isotretinoin. Do to the teratogenicity of isotretinoin, it is imperative that the patient agrees to be on OCP concomitantly. A signed contract is done to impress the importance of this to the patient. They are also given graphic pamphlets to read. If the isotretinoin is effective, then they they can be maintained on topical retinoid, benzoyl peroxide, with or without topical antibiotics.  Topical retinoids have been shown to reduced relapses once oral antibiotics are discontinued.