Acne is the most common skin disorder seen in the United States, affecting approximately 17 million persons. Acne can persist into mid-adulthood in some persons, and can also present initially in adulthood. Overall, acne affects approximately ten percent of the U.S. population. Acne was the most common reason for visits to dermatologists over the two year period from 1989 to 1990, accounting for 16.6 percent of all visits. Although acne is not associated with severe morbidity, mortality, or disability, it can produce psychological effects. Furthermore, in severe cases, acne can lead to physical scarring
which may exacerbate the emotional effects of the disease.

Severe Acne Treatments

Medical treatment of acne is determined by the extent and severity of disease, prior treatments, and therapeutic goals. Each regimen must be followed for a minimum of four to six weeks before determining whether it is effective. The following table lists guidelines to be used in the treatment of acne.

Clinical Appearance	Treatment
Comedonal Acne - no inflammatory lesions	Topical tretinoin (retin-a) or benzoyl peroxide
Mild to Moderate Inflammatory Acne - red papules, few pustules	Topical tretinoin and benzoyl peroxide and/or topical antibiotic. If acne is resistant to above therapy, add oral antibiotic.
Moderate to Severe Inflammatory Acne - red papules, many pustules	Topical tretinoin; topical antibiotic or benzoyl peroxide; and oral antibiotics
Severe Nodulocystic Acne - red papules, pustules, cysts & nodules	Topical tretinoin; benzoyl peroxide or topical antibiotic; oral antibiotics; and consider isotretinoin

Benzoyl Peroxide and Tretinoin (Retin-A)

Topical keratolytic therapy is recommended as the primary treatment for comedonal acne to prevent new acne lesions as well as to treat preexisting ones. Two classes of keratolytics, tretinoin (retin A) and
benzoyl peroxide, can be used alone or in combination with each other and will control 80 to 85 percent
of acne. Cream preparations of both tretinoin and benzoyl peroxide should be used because they are
less irritating to the skin than gel forms. Tretinoin has a propensity to severely irritate the skin if used incorrectly. To avoid irritation, a low strength Tretinoin Cream 0.025%, or Tretinoin Cream 0.05% should
be applied every other night for one week and then nightly. In addition, because skin treated with tretinoin is more sensitive to sun exposure, sunscreen should be used. Tretinoin should be avoided during pregnancy because of the potential of photoisomerization to isotretinoin, a teratogen. Improvement of
acne after treatment of tretinoin can take six to 12 weeks and flare-ups of acne can occur during the first few weeks due to surfacing of the lesions onto the skin. Benzoyl peroxide is available over-the-counter in various strengths and applications (gels, creams, lotions, or soaps). All concentrations seem to be therapeutically equivalent. Mild redness and scaling of the skin may occur during the first week of use.

Topical Antibiotics

Topical antibiotics decrease the quantity of P. acnes in the hair follicles. However, they are less effective than oral antibiotics because of their difficulty in penetrating sebum-filled follicules. Topical Erythromycin and Clindamycin are similar in effectiveness and can be used once or twice a day. Some percutaneous absorption may rarely occur with clindamycin, resulting in diarrhea and colitis. Topical antibiotics are frequently used in combination with keratolytics and are most useful for maintenance therapy if improvement after one to two months of oral antibiotics is observed.

Oral Antibiotics

Patients with moderate to severe inflammatory acne will require oral antibiotics in addition to topical therapy (Indicator 2). Tetracycline and Erythromycin are the most commonly used systemic antibiotics. Minocycline is also effective with more convenient dosing; however, its cost limits its use to those
patients with severe or recalcitrant acne.

Isotretinoin

The oral retinoid isotretinoin (Accutane) has been very efficacious in nodulocystic acne resistant to standard therapeutic regimens. In appropriate regimens, isotretinoin has resulted in long-term
remission of acne in approximately 60 percent of patients treated. Because of its severe teratogenicity, isotretinoin should be avoided during pregnancy. Side effects of isotretinoin include dryness and scaliness of the skin, dry lips and occasionally dry eyes and nose. It can also cause decreased night vision, hypertriglyceridemia, abnormal liver function, electrolyte imbalance, and elevated platelet count.
Up to 10 percent of patients experience mild hair loss, but the effect is reversible. Because of the seriousness of these side effects, isotretinoin should be reserved for patients with severe acne who
have failed previous therapy (Indicator 3).

How to Take Care of Your Skin?

In order to keep your skin healthy, eat a well-balanced diet that includes plenty of protein foods, fruits and vegetables (fresh if possible) and liquids. If you have a skin problem, such as a pressure sore or a
healing surgical incision, you should increase your intake of protein (lean meats, dairy foods and legumes), carbohydrates (breads, cereals), vitamins A, C and E, and zinc. Extra iron may be needed if you are anemic (see "Anemia" paragraph, right). The skin is served by a large number of blood vessels, and adequate circulation is needed to maintain skin health. You can help ensure a healthy blood supply by considering the following suggestions:

Smoking cigarettes causes blood vessels to get small (constrict) and prevents blood, oxygen and nutrients from flowing to the body tissues.

Edema or swelling caused by fluid collecting in the tissues, usually occurs in a part of the body
that is not moved frequently and is below the level of the heart (i.e., the feet, legs and hands). Skin over areas of edema becomes thin and pale and injures easily because of poor circulation. Edema can be prevented by elevating your legs and hands frequently, performing regular Range of Motion (ROM) exercises and wearing compressive stockings.

Anemia (a decrease in red blood cells). Oxygen is essential for skin health, and is carried by red
blood cells. A decrease in their number means less oxygen gets to the skin, which means that skin cells may become unhealthy or even die. Anemia should be evaluated and treated by your health care provider.

Vascular Disease or a narrowing of the blood vessels, can be caused by diabetes, smoking, high blood pressure or elevated cholesterol. The result is decreased blood flow to the skin. Work closely with your health care provider to manage conditions that can lead to vascular disease and cause skin problems.