Acne Vulgaris: Systemic Therapy

I'm going to cover systemic acne therapies, and before I get started, however, I want to tell you something that I usually forget when I give a talk like this. I usually forget to say exactly what I do with my average patient. My average patient that I treat is on what I call the acne trifecta. When I tell my residents to write the prescription for the trifecta, it is tretinoin, one of the Retin-A variables, and we like the Retin-A Micro when it is available on the formulary. We, of course, are totally dominated by HMOs in Arizona, so we do have to go by formularies, or generic tretinoin is fine. Tretinoin at bedtime, and one of the benzas in the morning, and I like benzaclin, just like Larry does, but it's very expensive and often not covered, so plain vanilla benzoyl peroxide is just fine too. In fact, the major efficacy of benzaclin is still the benzoyl peroxide, the Clindamycin adds some, but is not as potent as the benzoyl peroxide is. And those are the two topicals that I use, and then the third part of my trifecta is doxycycline 100 mg b.i.d., even in the sunbelt, and we'll go back to that. Florida claims to be the sunshine state, but we have to say in Tucson, we have more hours of sunshine than you do here in Florida, and we're at elevation too, so it does a lot more damage to the skin, so we're much more efficacious at damaging skin actually in Tucson than you are in Miami, if that's an advantage. So, we'll go ahead then, and talk about systemic acne therapy.

Yield to Peds

And I agree with Larry completely that this is mainly in the hands of primary care people, we're talking mainly to pediatricians here, so truly in this regard we need to yield to pediatrics. Now, this is my favorite pediatrician, my wife, Kay Hansen, and there is no question that we need to yield most of the treatment, I think, to our primary care colleagues, but we do need to have a partnership, because there are cases I think that need to be referred, and my idea of when they need to be referred at least are all cases of scarring acne where you don't get them better quickly. I don't think there is a single case of acne really in the world that I couldn't help if the patients could keep their appointments, and could get the medications I prescribe for them. And I still see mistakes made where kids are treated ineffectively for months or years before referral is made, so my basic branch point is if it's scarring acne, either get them better quickly, or referred quickly. Again, I think I agree with Dr. Schachner completely that if it's scarring acne, it's time for systemic therapy. I do not start treating scarring acne just topically. I've heard speakers on acne, including Sidney Hurwitz in the past who showed terrible scarring acne that he cleared with topical treatment, but I think it's too risky. I think you risk creating scars if you do that.

For example, this is actually my first patient that experienced serious mood changes on isotretinoin or Accutane, which I believe in, and he really needed isotretinoin, he really needed treatment of his scarring acne.

This is a patient that doesn't have terrible acne, but look, he has scars, he has little scars from papular acne. He still needs systemic treatment. And guess what, he's got a medication which is making his acne worse, it's hydantoin, Dilantin, which is a known "worsener" of acne, but what is the single worst medication that one of your patients might be on that could worsen acne? Well, some of the performance-enhancing steroids could do that, but lithium. And I don't know if I have a disproportionate number of bipolar kids in my practice, but I swear, I run into it so often, I have a kid with nasty acne, I ask him what medication he is on, including lithium, I'll touch on that again when I give the talk on drug eruptions tomorrow, so lithium is probably the one I see most commonly today.

This girl needs serious treatment, like Larry says, oral contraceptives and/or Accutane.

This lady has mainly comedonal acne, but it's pretty disfiguring comedonal acne, and she needs the big-time retinoid treatment, and like Larry said, we should never be able to take pictures like this again. This should be like pictures of smallpox. We shouldn't be able to get any new ones, because this is sinus tract formation, totally untreated scarring acne, we should not be able to have pictures like this again.

This youngster needs seasonal treatment for acne, because it's his football helmet. He's a linebacker, which makes it a lot worse in the fall, but during the spring he hardly needs serious treatment for it.

Oral Antibiotics

We're going to go over antibiotics, and again just to back up what Dr. Schachner said, it takes up to two months, I even go eight weeks before I like to see my patients back, to see an early response, and for all treatments we're talking about, including Accutane. Including Accutane, it takes four to six months to get where you want to be, so this is slow, slow improvement, and remember our teenagers are not really into delayed gratification. They want to be better yesterday. We're saying two to three months to begin to work, that's what I tell the patients. I'm even more conservative than Larry, and four to six months to get maximal benefit, so you do not stop the medication at any point before we talk about it, and you need to not just talk to patients, you need to see them. For example, the troubled teenager with 100 nasty spots on his face comes back to see me after two to three months, they still have 100 red spots, but the red spots now are flat, they're not bulging anymore. That's a marked improvement. I know that, but the teenager doesn't know that, because they look in the mirror and still see 100 bloody spots. That's why you don't make a determination over the phone. You have to see the patient to know.

Tetracycline

We're going to start with tetracycline. I have to say at the outset I have almost abandoned using tetracycline, because it's so hard to use in terms of that empty stomach thing. The dosage is 500 mg twice a day on an empty stomach, it has to be empty, just like Larry says.

You have to take it well before a meal, or well after, and if you think about teenage boys, those kids have tapeworms, they're eating eight times a day. Try to schedule an empty stomach, a half hour to an hour before, or 2 hours after. Most of us couldn't do that, as busy professionals take these, and we expect teenagers to do it, and I don't think it's very likely. That's our biggest problem here, and if you don't take it on an empty stomach, you might as well take it directly to the commode and flush it, and eliminate the middle man, it is just not absorbed. The advantages, however, are that it's cheap, it's well tolerated, and if taken as directed, it's quite effective. This advantage as Larry actually talked about, most of these, the pregnancy contraindication is real, the alleged interference with oral contraceptives is not in terms of evidence-based medicine, it isn't there. There are no studies which corroborate this. There is only one medication, and I'm sure Dr. McMillan knows, and lots of other people, probably only one medication which clearly causes contraceptive failure, one antibiotic, what is it? Rifampin. Rifampin interferes with metabolism of the estrogens, and if you were to get another candidate from the derm literature, it would probably be griseofulvin. The third best candidate actually would not be tetracycline, from just anecdotal reports, it would probably be amoxicillin. So it really is probably, I'm not saying it's a myth, but there is no evidence-based medicine for this, so we should lay off making too big a deal out of it.

What I tell kids - because they hear this, and they hear it from pharmacists, and they hear it from some of their OB's, but even in the OB literature and GYN literature are starting to change in this regard. If somebody gets twitchy about this, and they should be twitchy about all the cyclines if they're twitchy about tetracycline, I tell them this: let's say that tetracycline doubles the pregnancy failure rate. And let's say that the pregnancy failure rate in teenagers at least may be 2% to start with, with oral contraceptives. Let's say it goes from 2 to 4%, and there is no evidence that it does. Would that change your life, if it's 2-4%? And for most of them, and for young women in their 20s too, you got to be ready for an "oops" pregnancy anyway, 2%. So if 4% is the number, will that change your life? And that's how I get around this, but I don't believe that that is the reality issue. The photosensitivity is very different amongst the cyclines, and I'm going to come back to the other cyclines. Tetracycline is a mild photosensitizer. Doxycycline is a potent photosensitizer. Minocycline is not a photosensitizer at all. So, we have to go through that, and the pharmacists do not know this, by the way. They will tell you that all of the cyclines are the same. So you have to actually instruct your patients in that. Because other cyclines are so much easier to use, I have largely abandoned tetracycline, but if a patient comes in on it, and is doing well, obviously I continue that.