What are the treatment options for recurrent acne?

1. COMBINATION THERAPY
FOR RECURRENT ACNE
Peter Nugraha Soekmadji
Department of Dermatovenereology
Faculty of Medicine
Maranatha Christian University
Bandung

2. Conflict of Interest Statement
• NO support or commercial funding for this
presentation or for any products mentioned
here

3. PATHOGENESIS
Bolognia, J., Jorizzo, J. and Schaffer, J. (2012). Dermatology. [Philadelphia]: Elsevier Saunders.

4. PATHOGENESIS
Das S & Reynolds RV. Recent Advances in Acne Pathogenesis: Implications for Therapy. Am J Clin Dermatol. DOI 10.1007/s40257-
014-0099-z

5. CLASSIFICATION
Liao DC. Management of acne. J Fam Pract 2003;52:43–51
Management of Acne Volume 1: Evidence Report and Appendixes. Rockville, Md: Dept. of Health and Human Services (US),Public Health Service;
2001 Sep. Report No.: 01-E019.
Types Definition
Comedonal (noninflammatory) Dilated hair follicles filled with keratine,
sebum & bacteria
Papulopustular (inflammatory) Inflammatory lesion 2-5 mm in diameter
with/without visible core of purulent
material
Nodular (inflammatory) Solid, raised inflammatory lesions > 5 mm
in diameter

6. CLASSIFICATION
Liao DC. Management of acne. J Fam Pract 2003;52:43–51
Management of Acne Volume 1: Evidence Report and Appendixes. Rockville, Md: Dept. of Health and Human Services (US),Public Health Service;
2001 Sep. Report No.: 01-E019.
Severity Comedone Inflammatory
lesions
Total lesions Pseudocyst
Mild <20 <15 <30
Moderate 20-100 15-50 30-125
Severe >100 >50 >125 >5

8. Diagnosis is essential
to avoid recurrence!!!

9. Krakowski AC, Stendardo S, Eichenfield LF. Practical Considerations in Acne Treatment and the Clinical Impact of Topical
Combination Therapy. Pediatric DermatologyVol. 25 Suppl. 1 1–14, 2008
Acne venenata
Acneiform eruptions
Rosacea
Periorificial dermatitis
Gram-negative folliculitis
Demodicidosis
Congenital adrenal
hyperplasia
Polycystic ovarian
syndrome

10. ACNE VENENATA
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
Differential Diagnosis

11. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
ACNEIFORM ERUPTIONS
Differential Diagnosis

12. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
ROSACEA
Differential Diagnosis

13. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
PERIORIFICIAL DERMATITIS
Differential Diagnosis

14. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
DEMODICIDOSIS
Differential Diagnosis

15. Antibiotic misuse is contributing
to increased recurrence

16. ANTIBIOTIC RESISTANCE
Margolis DJ, Bowe WP, Hoffstad O, Berlin JA. Antibiotic treatment of acne may be associated with upper respiratory tract
infections. Arch Dermatol2005;141: 1132–1136
in Singapore

17. ANTIBIOTIC RESISTANCE
Moon SH, Roh HS, Kim YH, Kim JE, Ko JY, Ro YS. Antibiotic resistance of microbial strains isolated from Korean acne patients.
Journal of Dermatology 2012;39: 1–5
in Korea

18. ANTIBIOTIC RESISTANCE
Nakase K, Nakaminami H, Takenaka Y, Hayashi N, Kawashima M, Norihisa N. Relationship between the severity of acne vulgaris
and antimicrobial resistance of bacteria isolated from acne lesions in a hospital in Japan. Journal of Medical Microbiology(2014),
63,721–728
in Japan

19. ANTIBIOTIC RESISTANCE
Goh CL et al. South-East Asia study alliance guidelines on the management of acne vulgaris in South-East Asian patients. Journal of
Dermatology 2015;42: 945–953
worlwide

20. SOUTH-EAST ASIA TREATMENT
GUIDELINES
Goh CL et al. South-East Asia study alliance guidelines on the management of acne vulgaris in South-East Asian patients. Journal of
Dermatology 2015;42: 945–953

21. CLINICAL PEARLS FOR
COMBINATION THERAPIES
• Always check patient compliance to
treatment
• Use multiple agents that affect different
aspects of acne pathogenesis
• Avoid concomitant use of topical & oral
antibiotics
Work Group. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.
Layton AM. Top Ten List of Clinical Pearls in the Treatment of Acne Vulgaris. Dermatol Clin-(2015)-–-http://dx.doi.org/10.1016/j.det.2015.11.008.
Thiboutot D, Gollnick H, Bettoli Vet al.New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in

23. Strategies to prevent
antibiotics resistance

24. RECOMMENDATIONS FOR
TOPICAL THERAPIES
• BPO does not induce resistance
• Avoid monotherapy or long term use of
topical antibiotics
• If topical antibiotic is indicated, add BPO or
topical retinoid
• Prefer topical retinoids + BPO for
maintenance
• Withdraw antibiotics once inflammation is
controlles
Work Group. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.
Layton AM. Top Ten List of Clinical Pearls in the Treatment of Acne Vulgaris. Dermatol Clin-(2015)-–-http://dx.doi.org/10.1016/j.det.2015.11.008.
Thiboutot D, Gollnick H, Bettoli Vet al.New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in

25. Canavan TN et al. Optimizing non-antibiotic treatments for patients with acne: a review. Dermatol Ther (Heidelb). 2016

26. RECOMMENDATIONS FOR
SYSTEMIC THERAPIES
• Tetracylines are more effective than macrolides
• Macrolides use should be limited to those who
can not use tetracyclines
• Erythromycin use should be restricted because
of increasing resistance
• Cotrimoxazole use should be limited to those
who can not use tetracyclines or treatment-
resistant patients
• Systemic antibiotics use should be limited to the
shortest possible duration
Work Group. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.
Layton AM. Top Ten List of Clinical Pearls in the Treatment of Acne Vulgaris. Dermatol Clin-(2015)-–-http://dx.doi.org/10.1016/j.det.2015.11.008.
Thiboutot D, Gollnick H, Bettoli Vet al.New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in

27. Tzellos T, Zampeli V, Makrantonaki E, Zouboulis CC. Treating acne with antibiotic-resistant bacterial colonization. Expert Opin.
Pharmacother. (2011)12(8):1233-1247

28. RECOMMENDATIONS FOR
ALTERNATIVE THERAPIES
• Consider using hormonal agents in eligible
patients
• High glycemic index diet and dairy products
may be associated with acne
Work Group. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.
Layton AM. Top Ten List of Clinical Pearls in the Treatment of Acne Vulgaris. Dermatol Clin-(2015)-–-http://dx.doi.org/10.1016/j.det.2015.11.008.
Thiboutot D, Gollnick H, Bettoli Vet al.New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in

29. Tzellos T, Zampeli V, Makrantonaki E, Zouboulis CC. Treating acne with antibiotic-resistant bacterial colonization. Expert Opin.
Pharmacother. (2011)12(8):1233-1247