Cyproterone acetate reduces sebum production and is usually given in combination with the oral contraceptive pill at a dosage of 12.5 to 50 mg daily during the first 10 to 15 days of the menstrual cycle. It can also be prescribed on its own at a dose of 50 to 100 mg daily from day 1 or 5 of the menstrual cycle and stopped before ovulation on day 14. An improvement is usually seen within three months.
Spironolactone is a safe and effective treatment requiring no monitoring in a young fit and healthy female.25 Treatment can be started with a low dose such as 25 to 50 mg twice daily and then increased to 200 mg daily if the patient has no significant adverse events such as breast tenderness, ‘breakthrough’ bleeding or headache. Improvement in acne may take up to three months. Spironolactone is contraindicated in pregnancy because of the risk of feminisation of the male fetus.
For patients with widespread and inflammatory deep lesions, oral antibiotics, often in conjunction with a topical retinoid, are the treatment of choice. Consider referral to a dermatologist for oral isotretinoin in the following situations:
- patients with severe acne that is unresponsive to treatment
- patients at risk of scarring
- patients with psychological distress as a result of their acne.
When referring for isotretinoin, some baseline investigations can be done, as mentioned previously. The daily dose and duration of treatment depends on the patient’s weight, response to treatment and any side effects experienced. There is no standardised isotretinoin dose, and many dermatologists tend to start patients on a low daily dose and then gradually increase it as tolerated.26 Female patients should be counselled on the need for contraception, as isotretinoin is teratogenic. All patients should be advised to report any mood changes to their GP or specialist and more regular review may be required. In the rare event of psychological distress or a psychiatric disorder resulting from isotretinoin use, consider referral to a psychologist or psychiatrist.27
Acne medication and pregnancy
Topical and oral retinoids are contraindicated during pregnancy because of the risk of birth defects, and tetracycline antibiotics should not be given due to the risk of deposition and staining of the infant’s teeth. Treatment options for pregnant women include topical non-tetracycline antibiotics, azelaic acid, topical niacinamide and topical alpha hydroxy acids such as glycolic acid (Table).28
The following therapies may improve patients’ appearance and be helpful additions to the overall treatment plan. They may also be helpful in treating acne scarring. These treatments include comedo extraction, electrocauterisation, chemical peels, microdermabrasion, intralesional corticosteroids, laser treatment, photodynamic therapy and phototherapy (Table).
Biophotonic light therapy is a noninvasive treatment, used especially for inflammatory acne, whereby a gel is applied to the affected area (either face or trunk) and fluorescent light energy applied to stimulate the skin’s repair mechanisms.
Surgical techniques including punch excision, subcision and trichloroacetic acid cross hatching and filler may be used for acne scarring.