Cystic Acne (cont.)

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Almost all patients with this severe form of acne will require some form of systemic (oral) medication to control this condition. The goal of therapy is to minimize scarring. The choice of drug with which to begin treatment depends on the experience and preferences of the physician and patient. It is often warranted to try oral antibiotics initially (doxycycline [Doryx, Oracea, Monodox], sulfamethoxazole/trimethoprim [Bactrim, Sulfatrim], minocycline [Minocin]) for a limited period of time supplemented by a topical retinoid drug (Retin A, Differin, Tazerotene). Antibiotics probably owe much of their effectiveness to their anti-inflammatory characteristics rather than their antibacterial attributes.

Occasionally, cystic acne in female patients responds to oral contraceptives like ethinyl estradiol/norethindrone (Ortho Tri-Cyclen) along with spironolactone (Aldactone), an antiandrogenic drug.

If this option is not successful, then the patient is started on isotretinoin (Claravis, Amnesteem, Absorica, Myorisan, Zenatane). Patients may benefit from a lower dosage initially, followed by an increase to the standard 1 mg/kg dose after about a month. Patients should remain on this dosage for at least six months to maintain a durable improvement. Rarely, a short course of oral steroids (prednisone) may be necessary to suppress the inflammation during the initiation of therapy.

Patients who are treated with isotretinoin will need to be enrolled in the iPLEDGE (http://www.ipledgeprogram.com) program as will the physician prescriber and the pharmacy provider. This requires monthly visits and laboratory work. Females of childbearing potential must be on some form of birth control and have negative pregnancy tests during the course of therapy because isotretinoin can damage exposed fetuses. There are a variety of other potential side effects produced by the drug. Isotretinoin, however, when used in appropriate patients, is a unique drug in that it offers a safe and effective "cure" for a noninfectious disease.

Singular, individual cysts can develop in association with moderate acne. These isolated cysts often respond to injections of a steroid suspension (Kenalog) directly into the cysts.

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